Sexual interest, indicated by sexual arousal, sexual fantasising and masturbation, becomes apparent in females and males during the early teenage years. Then, as sexual interest matures in later adolescence, most individuals develop quite specific erotic fantasies. The ability of humans to create and respond to fantasies seems to play a major role in sexual motivation and in sexual receptivity. Strong and deliberate fantasising through erotic stories, pictures, readings and films may help stimulate this interest. Such strategies may help rekindle sexual interest.

Like most species, humans work up to sexual contact with foreplay that excites both partners. Birds coo, bow and strut. Primates spend hours grooming each other. In most mammals, delicate stimulation of sensitive body parts is an important component of stimulatory activity

preceding sex. Many couples find that taking the time to gently and lovingly play with the clitoris, penis, and the nipples, using the fingers, the tongue or a vibrator, can arouse intensely pleasurable sensations. If arousal takes a long time, accept this and continue the activity only as long as you are both enjoying the experience.

There is some evidence to suggest that techniques of sexual intimacy have changed in recent generations with increases in oral sex in marriage, more variation in foreplay and more experimentation with positions. Some women enjoy deep penile penetration and may achieve this by either the female-astride position, or the man-on-top position with her legs on his shoulders and pillows under her hips. Adequate vaginal lubrication is an important consideration and can be achieved using substances such as K-Y jelly or the new hormone-free Replens which lasts for several days and is not messy. Many women find that post-menopausal hormone therapy helps lubrication.

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The question which is often asked, and rightly so, is: what are the long-term effects of taking these drugs on you and the baby that is conceived? And what are the effects if you have 12 attempts at IVF in an effort to conceive a child?

These questions are not easy to answer at the moment because the first baby born from IVF is only 21. In fact no drugs were used at all to achieve that first success. It was just done with the woman’s natural cycle, taking the one egg that was produced. The doctors had used drugs before with their other unsuccessful IVF patients but felt that this was hindering the success of the treatment.

At the moment it is not easy to say what the long-term effect on the ‘test tube babies’ will be, because they are still growing up. We do not yet know what effects the drugs will have on their fertility, for example.

It stands to reason that bombarding the ovaries with drugs like clomiphene is likely to have a long-term effect on the mother, however. The ovaries are being stimulated in a totally unnatural way and concerns have been expressed about the risk of ovarian cancer. At least one high-profile victim, the late fashion editor Liz Tilberis, believed that her disease was linked in some way to fertility treatments she had had years before.

Ovarian cancer is called the ‘silent disease’ because it is not usually detected until it is well advanced. There are two theories as to the natural cause of ovarian cancer. One is that each time a woman ovulates there is damage to the surface of the ovary which eventually triggers cancer. This is backed up by research which shows that women who ovulate less, such as those who have quite a few pregnancies and also breastfeed, have a lower rate of ovarian cancer. The other theory is that ovarian cancer is triggered by exposure to gonadotrophin hormones which are also used in IVF treatment.

The scientific results are not conclusive and more long-term research needs to be done. Some studies show that there is an increased risk of ovarian cancer for women who have undergone fertility treatment. Others show no risk.

It is wise to be cautious about any fertility treatments you are offered. They should be regarded as a last resort, once you have really tried the alternatives outlined in this book.

Fertility treatments may involve heavy doses of drugs as well as invasive medical procedures. They can be embarrassing and uncomfortable, and can certainly put a strain on your relationship with your partner. They are by no means an easy option, and that is something to think about and weigh up if you are concerned that following my Four-Month Preconception Plan is too demanding.

If you are in your twenties or early thirties you have enough time to complete the Four-Month Plan and wait a few months for the improvements in your health and fertility to become established. What have you got to lose?

If you are older you should start having tests earlier but, by following the Four-Month Plan, you will be in much better shape whatever choices you finally make.

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The most important thing to realize is that you are not alone in trying to cope with this disease. There are many people ready to support you by listening, making suggestions and helping you to make choices about treatment.

Talk to your doctor. Tell her or him you feel alone. There are also self-help groups. The Endometriosis Association (Victoria) is a non-profit group set up to help all fellow sufferers. Do not be frightened to ask for help or advice.

For those entering a new relationship there is the problem of when to discuss endometriosis. You may think that a discussion ‘too soon’ in a new relationship will frighten off a potential partner. For those who suffer from painful intercourse there is the constant worry that a new partner may think that you are frigid or that you just do not find him sexually attractive.

Acceptance

For many of us it is necessary to talk through all of these emotions before we can come to terms with the fact that we do have a chronic disease and that this disease will probably cause disruption to our lives.

There is a light at the end of the tunnel. Once you have come to terms with your illness and accepted that you have a health problem you will feel better — both physically and emotionally.

You are going to face many hurdles and be forced to make choices or come to terms with decisions that will be difficult.

You may have to accept that you may never have children, that you may require further treatment at some stage, that your life may be disrupted at times, and that you will be faced with changes.

Decisions

With acceptance of your condition comes the need to make decisions. These decisions will undoubtedly affect your whole future and you really need to weigh up all your options very carefully. These decisions are going to affect your childbearing, your capabilities and your quality of life. Career and relationships will also be affected.

Understand that these decisions will not always be easy to make or to come to terms with.

As a guide, make sure that you are well informed and consider all your options carefully. Look at the side effects, the advantages and disadvantages, the possible outcomes, and your future.

Take time

Do not be rushed into making a decision. Do not be pushed into a decision that someone else has made for you. You are the one who must decide what you really want and what is best for you. You must list your priorities to include your options, treatment and personal needs. Think ahead.

Ask questions

Help yourself become well-informed by talking to your doctor, attending sessions run by self-help groups and using the resources offered by women’s health services.

Read as much as possible about endometriosis and talk to other sufferers. This will not only keep you well-informed but remind you that you are not alone.

Take control

It is your body and you have to live with your decisions. Carefully consider your doctor’s advice and take into account the information you have read. But remember the final decision should be yours.

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The usual treatment is antibiotics, given in tablet form. If a woman is unwell, or vomiting, initially she may need to be treated in hospital with intravenous antibiotics, then changed over to oral medication when she is a bit better.

The type of antibiotics necessary depends on the bugs which are causing the problem. The usual treatment for sexually acquired PID should include doxy-cycline (for chlamydia), even if the test for chlamydia comes back negative. This is because the test is not always reliable, but we know that chlamydia causes a fair proportion of PID. Specific treatment is also needed for gonorrhoea if it is isolated or strongly suspected. Two broad-spectrum antibiotics, like amoxycillin and metronidazole, are often prescribed. They are particularly useful if the PID is post-surgical, but are also prescribed for sexually acquired PID, to cover any other bugs which may be tagging along for the ride, as they can do. It is very important that the entire treatment course is finished, to ensure that the infection is fully treated.

A vital part of treating any sexually transmitted disease is treating the sexual partner(s), to prevent reinfection and spread. Particularly in view of the increasing potential for damage to fertility with each episode of PID, re-infection is best avoided.

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Birth centres. These are often within a public hospital, but as most run independently of routine antenatal clinics, I will discuss them separately.

In country areas. Public hospital care in country areas is often different, because it is not clinic based, but usually general practitioner or obstetrician based. These doctors will usually see a patient in their rooms, like a private obstetrician, and then look after the woman and her baby in the local public hospital.

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Anal sex

This is the highest risk form of penetrative sex, as it involves tiny tears to the skin of the anus, even when using a lubricant, making it easier for bugs to get into the blood stream. It is also a way that other germs, like hepatitis A and diarrhoea-producing bugs can be spread around. You are not likely to get pregnant from anal sex, but you can catch diseases. Even with a condom it can still be a risky business, but we would recommend that if you do practice anal sex you always use a condom, and plenty of lubricant, and change the condom after it has been in the anus, before the penis goes anywhere else.

Other sex practices

There are other ways of enjoying sexual contact than simply having intercourse. If you don’t want to pass either semen or vaginal fluid from one person to another while still having satisfying ‘sex’, there are other things you can do.

Masturbation, which means manually stimulating sexual organs (clitoris, vagina, penis), is usually done by touching and rubbing. It can also be done with specially designed sex toys, including vibrators and dildoes. As long as everything that touches the genitals is clean, and no secretions are spread from one person to another, it is a (airly safe form of sexual contact. People can masturbate themselves, or couples can masturbate each other. Forms of ‘sex without penetration* (of a penis into a mouth, vagina or anus) are generally safe, and are often very satisfying for couples, as they rely more on touching and communicating than simply on sexual penetration.

By practising these you are DECREASING, not ELIMINATING your chances of catching something. Additional measures, such as both partners having an STD check can help to decrease this chance further.

Completely safe sex

One way to be 100 per cent sure that you will not catch an STD is to avoid sexual contact completely (abstinence). Fortunately there is another method which comes close to 100 per cent. If two non-infected people (who have had thorough STD checks) have a sexual relationship which is truly monogamous (neither have any sexual contact with any other person), their STD risk is negligible.

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Antibiotics do not work on viruses or fungi. There are other drugs which are effective against fungal infections (and some newer drugs which look promising against some viruses), but in reality, we have no drugs which fight the majority of viral infections. The immune system generally takes care of them. This is the reason why your doctor may say ‘it’s a viral infection, so I am not going to prescribe antibiotics’. It is not that the doctor wants you to suffer longer with that headcold, or gastro. It is that antibiotics don’t work at ail on viruses.

If you are prescribed antibiotics for an infection it is important that you finish the whole course, just taking a few tablets and then stopping is more likely to lead to a major problem with antibiotics; bacterial resistance. This is when bacteria undergo a minor change which makes antibiotics less effective, or powerless. Several bugs have developed resistance to antibiotics. For example, gonorrhoea is now often resistant to penicillin, and other antibiotics are needed. There is a real danger that, over time, more antibiotics will become useless if we abuse them. The other reason you should finish the entire course of antibiotics is to fully treat the disease you have. An effective course of treatment requires the right amount of the appropriate antibiotic, for a long enough time to kill the bugs.

Antibiotics can sometimes have unwanted effects, as well as the desired effect of preventing bacteria multiplying. Some of the more commonly encountered problems are nausea, vomiting and/or diarrhoea. The antibiotics can not only upset the bad bacteria, but also some of the good guys, who normally help us digest and absorb food. They can also sometimes irritate the lining of the gut, causing symptoms like indigestion.

Another frequently reported side-effect of taking antibiotics is vaginal thrush (candidiasis), again because of the disturbance to the normal bacterial balance in the gut.

Some people are allergic to various antibiotics, most commonly to penicillins. People can have allergic reactions to all kinds of things, and drugs are a common trigger. If a person has had an allergic reaction in the past to a particular drug it is best to avoid it in the future. There are usually suitable alternatives.

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Premenstrual syndrome (PMS) or premenstrual tension (PMT) as it was previously known, has suffered a credibility problem. Because it is difficult to quantify, or show someone, unlike a rash or an interesting new lump, many people would rather believe it wasn’t there. Similarly, the fact that different people may suffer from different actual symptoms have made it harder for the

medical fraternity to swallow. It is easier to understand a condition which affects people in a uniform manner, not a variety of symptoms.

Symptoms. The different symptoms collectively known to constitute PMS may not all be found in the same individual. They include mood changes, irritability, depression, insomnia, and memory and concentration problems. Physical complaints such as headaches, abdominal bloating, hot flushes, breast tenderness, leg swelling, fatigue and nausea, as well as acne, bowel and bladder problems have all been defined. Lists have been compiled of recognised symptoms, but any combination of many different changes may occur in a particular person.

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