Endometriosis and Chocolate Cysts..

During my first ever ultrasound session, Dr. G had discovered that I had endometriosis, so in this post I will explain in brief what endometriosis is all about. Since I am not an expert, I had taken the information from Obstetrical & Gynaecological Society of Malaysia's website to help you guys understand better.

What is endometriosis?

The dictionary will tell you that endometriosis is "the presence of functioning endometrial tissue where it does not belong". Endometrium is the name of the tissue that lines the uterus. Every few weeks the endometrium thickens to form a comfortable nestling place for the foetus. Normally this is shed during your period and recreates itself again in the next cycle. Sometimes, endometrial cells grow on the outside of the uterus. The body responds by covering these rogue cells with scar tissue. These cells still react to hormones released during the menstrual cycle, so when menstrual bleeding begins, the scar tissue surrounding the cells becomes red and swollen, resulting in intense pain.

Where does it grow?

Common sites for endometrial growth - called implants or lesions - include the ovaries, the fallopian tubes and the bladder as well. In fact, endometrial lesions can be found anywhere in the pelvic cavity, and sometimes in the bowel, intestines, colon, appendix, rectum and on Caesarean and laparoscopy scars as well. In rare cases, endometriosis has been found inside the vagina, on the skin, even in the lung, spine and brain.

Who gets it?

Endometriosis used to be called "the career woman’s disease" because it was most often found in professional women who delayed childbearing but further research has shown that endometriosis can affect any woman during the menstruating years. Symptoms can start with or after the first menstruation, but the disease is rarely found after menopause. Overall, as many as 5-15% of reproductive-age women have endometriosis. Overall, as many as 5-15% of reproductive-age women have endometriosis.

How Common Is Endometriosis?

The actual number of women who have endometriosis is unknown because many women do not display symptoms.However, endometriosis is seen in more than half of teenagers who have menstrual periods that are painful enough to be evaluated further. By and large, endometriosis is very rare before puberty and symptoms of endometriosis usually disappear after menopause.

What causes it? 

The cause of endometriosis remains unknown although several different hypotheses have been put forward. Endometrial cells may be carried up through the uterus into the pelvis during menstruation, or they could have travelled to other parts of the body through the circulatory system. No theory has ever been entirely proven but most experts agree that endometriosis is exacerbated by the hormone oestrogen

Is there a cure for endometriosis?  

No, but the symptoms can be managed through a combination of treatments. Basically you can have either surgical treatment or hormone therapy or both. Hormone therapy works by manipulating the hormones that control menstruation and the swelling of your endometrium and endometrial lesions. The medication can be taken orally or through an injection. Treatment varies depending on whether you are treating pain or infertility. Treatment may include medication to shrink the implants, laparoscopy to destroy implants, or surgery to remove the uterus and ovaries.

What are the symptoms?

The most common symptom of endometriosis is recent worsening of period and pelvic pains which often - but not always - correlate to the menstrual cycle. Pain may be felt before, during or after menstruation, during ovulation, in the bowel during menstruation, when passing urine, during or after sexual intercourse and in the lower back region. Other symptoms, usually during period, may include diarrhoea or constipation, abdominal bloating, heavy or irregular bleeding and fatigue.

Symptoms may remain stable, decrease without treatment or suddenly increase. Symptoms may resolve with treatment and then return later. Often symptoms decrease during pregnancy.

The other well known symptom associated with endometriosis is infertility. It is estimated that 30-40% of women with endometriosis may have difficulties in becoming pregnant. Endometriosis is thought to be responsible for up to 10% of infertility problems.

How is it diagnosed?

An experienced gynaecologist should be able to recognise symptoms suggestive of endometriosis if you are honest about the history and pattern of your symptoms. Ultrasounds, MRI scans, and gynaecological examinations may be performed but the only reliable way to definitively diagnose endometriosis is by performing a laparoscopy and to take a biopsy of the tissue.

Is endometriosis cancer?

Although endometrial lesions are sometimes referred to as "benign tumours" because they "behave" similarly to cancer, endometriosis is not cancer.

Is endometriosis sexually transmitted or infectious?

Endometriosis cannot be transferred from one human being to another. The cause of endometriosis is not yet known but it is not an infectious disease.

Is endometriosis inherited?

The cause for endometriosis is not yet known but research does show that first-degree relatives of women with this disease are more likely to develop endometriosis.

What are some natural ways to manage the pain?

Try a hot bath or heating pad to relieve the pain. Relaxation and breathing techniques often help. Your partner can also play a role in making you feel better, whether it is a lower back massage, leaving you alone for a while or experimenting with different and more comfortable positions for intercourse.

What should I do if I suspect I have endometriosis?

Although there is no cure, health care providers can teach you how to manage endometriosis and live a comfortable and active life. The earlier you detect the disease, the less risk there is to your fertility and reproductive organs as well. The most important thing you can do if you suffer from the symptoms of endometriosis is to consult and seek professional advice from your gynaecologist.

Since my doctor had diagnosed me with Chocolate Cyst, so here's some information on the subject from Women-health-info.com's website for your information.

Chocolate cysts are a particular type of ovarian cyst linked to endometriosis. So called “Chocolate cysts” are well known also as Endometriomas - these are cysts in the ovaries formed by endometrial tissue (tissue similar to the lining of the uterus). Actually the chocolate cyst is the cyst of the ovary with intracavitary hemorrhage and formation of a hematoma containing old brown blood.  The term chocolate cysts come from the physical appearance as these growths are usually comprised of dried blood making them brown in appearance. Chocolate cysts are formed when endometrial tissue (the mucous membrane that makes up the inner layer of the uterine wall) grows in the ovaries. Chocolate cysts are usually filled with old, dark, reddish-brown, sludgy-brown blood, hence their moniker. Chocolate cysts can vary between 0.5 and 8 inches (1.5-20cm) in diameter, and are not necessarily a cause for concern. However, if they rupture, their contents can spill into the ovaries and the pelvic cavity. This can be very painful and can also cause some of the organs in the pelvis to bind together. If this happens with the fallopian tubes and ovaries, it can result in infertility.

Chocolate Cysts
Chocolate cysts are affecting women during their reproductive period and may cause chronic pelvic pain associated with menstrual periods (menstrual cramps, endometriosis).

Chocolate cysts (Ovarian endometriosis) probably start as a surface lesion. This process becomes invasive and the endometriotic lesion internalizes into the ovarian tissue. Once the menstrual flow and debris collect at the site of endometriosis in the ovaries, chocolate cysts form that are filled with chocolate-colored liquid. Actually it is a cyst which represent debris from prolonged cyclic menstruation in an enclosed area (inside of ovary). Chocolate cysts could sometimes attain impressive size, with some documented as large as a baseball or grapefruit that completely obliterate the normal ovary. However, usually there is a well-demarcated separation between the cyst wall and the normal adjacent ovarian tissue.

On a monthly basis, endometrial tissue is produced when a hormonal signal is released preparing the uterus to receive a fertilized egg. When pregnancy does not occur the tissue is shed in the form of a menstrual cycle. Another hormonal release signals this shed of tissue which is effectively released from the body through muscular contractions.

When tissue has grown outside of the uterus this shed is not possible and causes an accumulation of tissue and thus cyst endometriosis occurs.

In general chocolate cysts are not life threatening, they can become such if no action is taken. Chocolate cysts’ rupture could be life threatening and is not something to ignore. In these cases emergency medical service is required.

When a rupture occurs, the contents of the chocolate cyst are released into the body and pelvic cavity. Besides being quite painful (it cannot be unnoticed - could be very strong not-bearable pain) it can lead to further health complications, as the cysts have blood in them and are in the pelvic region.

Chocolate Cysts' Symptoms
Most typical symptoms of chocolate cysts are:

• Painful periods- often starting a few days before, and then lasting for the whole of the period;
• Painful sex (Dispareunia)- typically the pain is felt deep inside and lasts for a few hours after sex.
• Pain in the lower abdomen and pelvic area;
• Infertility - as the passage of the egg from the ovary to the fallopian tube may be blocked.

Chocolate Cysts' Diagnosis
Chocolate cysts can be diagnosed with x-rays or trans-vaginal ultrasounds. Positive results on a blood test called CA125 can also indicate the presence of a chocolate cyst, although ovarian cancer will also give a positive result, so this could be cause for concern. In these cases, exploratory surgery may be necessary to determine the nature of the problem.

Chocolate Cysts' Treatment
When chocolate cysts become a problem, causing pain or infertility, the cyst may be surgically removed. In most cases the chocolate cysts can be removed during laparoscopy - with a small incision and a wand shaped tool minimizing the incision size.  In cases where the cyst is very large occasionally the entire ovary can be removed. Sometimes the cystectomy, or removal of only the cyst could be enough. In other cases, if the cyst is very large, poorly located, or if there are multiple cysts involved, a procedure called an oopherectomy, or removal of the ovary, could be required.

Surgery is not generally considered risky however infection is always a factor and therefore doctors may prescribe antibiotics after the procedure. The point here is that while endometriosis is usually treated by preventing the menstrual, there should also be treatment that restores balance to the hormones, as this can be the root cause.

Some specialists suggest that the permanent cure for chocolate ovarian cysts can be done by natural holistic approach. This works on the assumption that all ovarian cysts are an indication of underlying problems within the body. The solution therefore is not to attack the cysts, but to address these underlying problems and restore the body's natural balance.

Well, I hope the information above was beneficial to you guys especially for those couple out there facing the same problem as I am. I do hope that this wall we stumbled upon will be resolved and we will be on our way again on our journey of trying to conceive.

Ist Ultrasound~~ It's a Dildocam!! Endometriosis Discovered..

My dear hubby and I had went to LPPKN two days after our last hormonal injection to get my first ever ultrasound scan. We had been going to a local GP to get my hormonal injections once in every two days as instructed by Dr. G. When we arrived at LPPKN, the waiting area was already full of couples as usual and we had to wait a while until my name was called in to see the doctor. He had some IUI procedures scheduled that morning so the waiting is a bit longer than usual.

When my name was called, a nurse asked me to empty my bladder before undergoing the scan. After that was done, she ushered me into a small examining room attached to Dr. G's office. There was an examination bed with stirrups and an ultrasound machine at the right foot of the bed behind a curtain. I was instructed to undress from the waist down and lie down on the examining table, with both my legs up in the stirrups. I am not used to being exposed so I felt a little bit uncomfortable and a lot shy. While I was lying down waiting for my doctor to come, the kind nurse talked to me and soothed my anxiety a little bit by telling me how all of this is necessary and how the whole procedure works.

Dr. G came in about 10 minutes later apologizing for running a bit late. He then sat at the foot of the bed and asked me about my injections and was I taking my medications on time as instructed and I confirmed. Then he proceeded to explain about the ultrasound he's about to carry out. It is actually a transvaginal ultrasound which is a type of pelvic ultrasound used to look at the reproductive organs. He will then place a probe which is covered with a condom and gel called a transducer (I am going to call it a dildocam from now on!) into the vagina and the picture of my insides will be seen on the TV monitor attached to the machine. In my case, he's using the probe to check on how many eggs I have produced after being injected with Menonys and measuring each egg's size to foresee the possibility of IUI. After making sure that I understand the procedure, he told me to take a deep breath and went on with it.

The placing of the dildocam was not as painful as the speculum used during my HSG scan (seriously, that one really hurt!!). There was a little bit of discomfort while the doctor was moving the probe left and right. He started on my right side which he said was clear. There were 4 eggs with ideal sizes and the rest were too small. Then he proceeded to my left ovary. He told me that he couldn't see clearly the eggs on the left side. It was as if they were squished behind some large unidentified growth which looked like some cystic growth to him. He probed in a little bit harder and was able to detect the presence of some eggs and got the measurement of those. Then he went back to the unidentified growth and did some more probing. Finally he confirmed to me that it was endometriosis and most probably a chocolate cyst and it was quite a large one too. He took the measurement and announced that the size of my endometriosis was 8cm long.

I was panicking thinking that it might be cancerous but he told me that it was not. Dr. G finished his ultrasound and told me to get dressed and get my husband. My husband came in and Dr. G explained about how he discovered that I had a large endometriosis growing on the left side my uterus. He told us that the scheduled IUI for us was to be aborted because the endometriosis must be removed since it was large. He told us that any endometriosis larger than 5cm must be surgically removed. It the size were smaller than that, usually the cyst will shrink because a growing baby inside the womb will take up space and push the cyst and finally flatten it. Well, in my case, it would not happen. He told us to call and set up an appointment on the first day of my next period cycle because he needed to rescan my cyst to reconfirm his diagnosis.

Dr. G told us not to worry and asked us to start thinking about which hospital we would like to get my operation done since LPPKN does not have the facility to do operations. Since it is a big operation, he advised us to choose carefully and whether we a going to go with Government hospitals (free for Government staffs but need to wait a long time to be scheduled for operation) or private ones (lots of cash needed but can get operated immediately).

I felt quite heartbroken about the abandoned IUI procedure and quite scared and shocked about the cyst. An operation! Oh my, I have to go for an operation to get the cyst removed! At this stage, I didn't have any inkling on what to think and how to react. All I could do was lean on my dear husband for emotional support and words of encouragement. It seems that our path in trying to conceive had stumbled upon a thick wall and becoming more difficult. All we could do was pray to Allah SWT and try our hardest.

Will explain about endometriosis more on my next post. In the mean time, please pray for us.. ( T T )

1st Appointment With Our Doctor..

After waiting out for three months to get an appointment, my husband and I were finally scheduled to see our assigned doctor at LPPKN in February 2009. Our doctor is the head of the clinic and he's a senior specialist in the field of infertility. Let's call him Dr. G. Dr. G is a very warm and friendly doctor but he is also quite frank with facts. I think his characteristics are somewhere between being comforting & nurturing and a no-nonsense-I-will-give-you-the-ugly-truth kind of doctor.

He opened our case file and explained the results of the tests that we did the first time we came to LPPKN. He told me that my hormonal levels were okay but a little bit on the low side. As women age, the level of hormone produced to help in conceiving gets lower and lower. This means that I am currently racing with my body clock. Since I was 31 that year, Dr. G told me that my hormone levels were still considered acceptable. Then he proceeded to explain to us on my dear husband's sperm count and mobility test. He told us that my husband's sperm count and mobility is also a little bit on the low side but still acceptable. Since my hubby has asthma, Dr. G said it is normal for asthmatic people to get such results since some of them have to take medication everyday.

Dr. G then showed us the X-ray film of my HSG scan. He explained about the result in detail relating them with the image. He told me that my tubes are not blocked (thank God!) since the dye flowed through and spilled at both ends, but there seem to be something blocking the dye to spill out entirely all over my uterus. Sort of like when we spill a bucket of water on the floor, if the floor is level, the water should be spreading out and not pool in the middle or any certain spot. Looking at my X-ray film, he told us that it seems that the dye that flowed out of my tubes seem to pool at a spot indicating that something is blocking it to spread and spill all over. But then he told us not to worry so much about it. It might just be my organs or some tissues blocking the dye.

Then he explained about the options of treatment given out by LPPKN which were hormonal treatment for the wife of the husband or both if needed, IUI and IVF. He said that since our hormonal levels and sperm count is acceptable, he would start off our treatment with IUI which has a 5%-20% chances of success in infertility cases. Since we have been married for a long time but wasn't able to conceive all this while, he told us that we would try the IUI procedure a few times, and if those does not succeed, we will then be moving up to IVF. He then prescribed me clomid to stimulate my ovaries and a set of Folliova hormone injectables. I was told to start taking folic acid as well.

The injection set consists of 3 boxes of vials. Each box contains a vial of solution and a vial of powdered Folliova. I was instructed to start the injection the next night, skip a day then another injection, skip a day and the final injection. Every injections must be done at the exact same time. For example, if I injected at 9.00 pm the first night, then the next two injections must be done at 9.00 pm. The doctor told me to see a GP to get my injections since my husband nor I didn't feel that confident yet to do them ourselves. Dr. G then scheduled me to get my first ever ultrasound a week from that appointment day. If everything goes well, I would be scheduled for my Ist IUI two days after that.

After the consultation session ended, we got my medicine and injectables, paid the bill and went home. We followed through the instructions and I got my injections as scheduled at a local clinic and boy, did it burn! Ouch!! With the last pill of clomid and the last injection taken, I was praying and hoping that I would be one of those miracle cases of one-time-IUI-success. Thus, that was the start of the first ever IUI cycle of ours on our journey trying to get a baby. 

The Waiting Game Has Begun..

After successfully completing the HSG scan mission and getting our tests done in November 2008, I had to wait for the first day of my next monthly flow in order to call LPPKN to get an appointment with our doctor. At that time, I really had no idea who our doctor is going to be, whether it's a man-doctor or a woman-doctor. I was hoping to get a woman-doctor. 

The day finally came on a fine December day and I called LPPKN after 2.30 pm like instructed (patients will not get an appointment if they call before 2.30 pm). A nurse picked up my call and asked for my file number (which was written on my appointment card) and told me to hold the line. I think she went to get my file as the line went silent for a few minutes and then when she was back on the phone, she told me the name of our doctor. Gasp! It's a man-doctor! Huhu.. I asked her whether it was possible to get a female doctor but she told me that patients cannot choose since the waiting list is very long and, furthermore, my assigned doctor is one of the best in this field. Hearing that, I accepted and then asked for an appointment date. She went silent again as she checked the doctor's schedule and then announced that my doctor's schedule was already full for that month, so I needed to wait out this cycle and then call the clinic again on the first day of my next monthly flow. 

I was a bit disappointed to hear the news and about having to wait but I had no choice. So I thanked her and hung up the phone. So December went by with nothing happened and then came January 2009. My monthly flow came and I called up LPPKN again after 2.30 pm. The nurse checked my doctor's schedule and told me that my doctor's schedule was full so I had to wait out this cycle too. AGAIN! Uh! Oh! I think the waiting game has begun. So just like December, the month of February went by without any exciting events. 

Then came February. Like a programmed machine, on the first day of my monthly flow, I called up LPPKN again after 2.30 pm to get an appointment. The nurse who picked up my call and checked my doctor's schedule. Then she told me to come in next morning since there was still a slot left for the next day. I immediately agreed and wrote down the date on my appointment card. FINALLY! 

I guess this is what we will be going through in our journey of trying to conceive. I was already feeling a bit frustrated because I had to wait out on two months' cycle just to get a seating with my doctor. But whatever happens, we would just have to be patient with the whole system and pray hard that this does not happen too often.