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If the wall between the vagina and bladder becomes weak it is called a cystocele. If the wall between the rectum (bowel) and the vagina becomes weak it is called a rectocele. If the wall between the pelvis and vagina becomes weak it is called an enterocele. If the main ligaments holding the uterus and top of the vagina in place becomes weak, it is called uterovaginal prolapse, as the womb comes down. It is graded according to the amount of prolapse (grade 1 = the prolapse comes down but does not reach the outside, grade 2 = the prolapse comes out but goes back up, grade 3 = the prolapse stays outside the vagina).

The operation

The operation can be performed under general (asleep) or regional (awake) anaesthetic and takes about 1 hour.

The vagina is opened and the bladder or bowel reflected (moved out of the way). Sutures (stitches) are placed on either side and brought together to strengthen the wall. During the operation, a catheter will be passed into the bladder to drain off the urine (so the bladder doesn’t get in the way of the operation).

If there is uterovaginal prolapse it will be necessary to perform a vaginal hysterectomy at the same time. Although there will be some discomfort following the surgery, this will be controlled with pain killers. The average length of stay in hospital is 1 – 4 days and normal activities can be resumed within 2 – 6 weeks. There should be no problem with sexual intercourse once fully recovered from the operation.

Where a couple have failed to conceive, with no obvious reason for failing to do so, it is reasonable to consider assisting conception. This varies from simple counselling and advice to in-vitro fertilisation (IVF = test tube baby) and intracytoplasmic sperm injection (ICSI = injecting the sperm into the woman’s egg).

Natural fertility

Many couples have unexplained subfertility. By this we mean that our checks on the sperm, the ovaries and tubes are normal. Stress, anxiety and unknown causes are included in this group. There are many doctors and nurses who take a special interest in teaching couples about their biological cycles, so helping them to conceive naturally, without the use of advanced scientific techniques. Ask your GP or gynaecologist to recommend someone if you fall into this category.

Ovulation induction

If the subfertility is unexplained, or if the woman has difficulty in producing eggs on a regular basis, the next step is to consider assisting the ovaries to produce eggs (ova). This can help with the timing of intercourse, and provide reassurance that eggs are being produced.

A woman has a few days around the time of producing the egg (ovulation) when she is fertile.

Types of ovulation induction

The simplest approach is to use a drug called Clomiphene. The main risk of using Clomiphene is the increased risk of having twins, and occasionally triplets. If you require Clomiphene it may be wise to discuss this with your gynaecologist/fertility specialist and ask about monitoring your ovary’s egg producing activity when you are on this treatment. More powerful methods of assisting ovulation include injecting hormones that stimulate the ovaries (e.g. follicle stimulating hormone FSH). As the risk of multiple pregnancy is very high when using these drugs, they should only be administered and monitored by medical staff familiar with their use.

Intra-uterine insemination of sperm

Intra-Uterine Insemination of sperm can be used to bypass normal intercourse, in an attempt to ensure that the sperm reaches the egg. It is typically used where there is unexplained subfertility, or where there are minor problems with sperm production. A sample of the partner’s sperm is specially prepared and introduced into the womb (the uterine cavity) using a syringe and a fine plastic catheter (tube).

A speculum is passed (in the same way as if you were having a smear) and the tube is passed into the cervix (neck of the womb). Intra-uterine Insemination is carried out just before ovulation. It is a procedure, which causes little discomfort and only takes a few minutes.

In-vitro fertilisation (IVF)

This is a more advanced technique. It is expensive, in terms of finance, time, emotion and relationships. It used where there are problems that can’t be solved with a simpler approach (e.g. blocked fallopian tubes), or where the easier steps (see above) have failed to produce a pregnancy.

The woman’s ovaries are stimulated to produce a large number of eggs. Eggs are produced in the ovary in little cysts (follicles). These are collected using ultrasound and a fine needle, just before they would burst out of the ovary. The partner produces a sperm sample and the sperm and embryo are mixed in a test tube. They are then incubated for 36 – 48 hours. If embryos are produced the best are selected and placed in the woman’s uterus (womb). The egg collection and embryo placement will usually take place in a special room in the IVF unit you attend. The woman needs careful monitoring during the IVF programme, with frequent ultrasound scans to check the activity of her ovaries.

Intra cytoplasm sperm injection (ICSI)

Where there is a problem with the quantity or quality of the sperm, intra cytoplasmic sperm injection (ICSI = injecting the sperm into the woman’s egg) may be used to increase the chances of the egg and sperm producing an embryo.

IVF and ICSI success

The treatment is not a guarantee of pregnancy. In a typical unit between a quarter and a third of IVF cycles will be successful. Check out the fertility units in your area and don’t be afraid to compare different units for their success rates.

IVF and ICSI failure

Where a treatment cycle is unsuccessful, the couple will be seen by the clinic and a plan made based on why the cycle failed (e.g. no eggs produce, no embryos produced, embryos produced but no pregnancy, miscarriage). Sometimes this plan involves accepting that a pregnancy will not happen with the couple’s eggs and sperm, and a discussion about using another person’s eggs or sperm will ensue. On other occasions the results will have been very encouraging and a second cycle will be recommended.

Other techniques

Gamete intra fallopian transfer (GIFT) places the sperm (using a laparoscopy) in the fallopian tube, either at the time of ovulation or when the eggs are collected after ovulation induction. There are also a number of modified intrauterine insemination techniques, where the sperm is placed higher in the womb, or in the pelvis.

Learn more about your fertility

Occasionally a catheter is needed to stop the damage caused by the caustic urine on the skin.

This is considered the gold standard for bladder repair, but in the last couple of years has been superseded by insertion of a tension free vaginal tape (TVT, see below).

The operation can be performed under general (asleep) or regional (awake) anaesthetic and takes about 1 hour. The abdomen is opened so that the bladder and the vagina can be visualised. The bladder and vagina dissected free so that sutures (stitches) can be placed in the vagina, beside the bladder. These stitches are then tied to the bone behind the bladder so that the neck of the bladder is elevated, making it more able to control leakage of urine.

Complications

As with all surgery, there are risks, and the benefits of having the operation must always be balanced against the potential harm from the operation. The vast majority of women who have surgery will have very few problems and the operation will result in a great improvement in the quality of the patient’s life. However there are potential complications that you should know about.

The common complications of a colposuspension are infection (bladder infection, wound infection), bleeding (blood transfusion may be required), and bladder damage. If the bladder damage is repaired at the time of surgery, there should be no long term problems.

Antibiotics are given at the time of the surgery to reduce the risk of infection. Anticoaguulants (thin the blood) are usually given to reduce the chance of a clot forming in the leg (we also use special stockings and get you mobilised out of bed early to reduce the risk).

Fortunately the number of serious complications associated with colposuspension are uncommon, but can include life threatening haemorrhage, bowel damage and a clot on the lung. Where a patient has fasted (nothing to eat or drink for 6 – 8 hours before surgery), the risk of an accident with the anaesthetic are very low. The risk of dying from a ‘colposuspension’ is approximately 10,000:1.

Diet and Exercise – the key to maintaining your desired weight.

Nothing terrifies a woman more than the feeling she cannot control her weight. The fact that a woman’s weight often fluctuates through her menstrual cycle can also lead to a feeling of uncertainty as to what foods and habits are causing actual ‘fat’ weight gain as opposed to a temporary ‘fluid’ weight gain. Also muscle is heavier than fat so a lot of exercise can result in a better looking, healthier woman whose weight remains the same. Some women are able to control their weight more easily than others and of course a small percentage of teenagers become disturbingly and unhealthily anorectic because of fears over their appearance.

There are some basic rules which no amount of slimming books and tablets can get away from. Your weight (assuming your body is working normally) reflects the number of calories you eat over the amount of activity and exercise you undertake. Foods do vary in their nutritional value, their calorie count and the level of fullness they provide, which is the key to eating to control or lose weight.

If you try to lose weight by being hungry you will usually end up gaining pounds in the long run (the yo-yo effect), as you scare your body into starvation mode. We are programmed to store fat as in ancient times we did not always get to eat every day. If you starve your body to lose weight and then eat again, your body will immediately store fat in readiness for the next time you starve again. So for instance who skip breakfast are 400% more likely to be overweight, as they train their bodies to store fat.

Exercise

Exercise does not have to be going to a gym every day, but it does involve being active on a daily basis. This can mean some house cleaning, swimming or a good hour or two gardening, or perhaps wearing trainers and walking home briskly from the train station or office rather than taking a bus. Exercise is important for two reasons: you burn calories and if you are active your body handles food differently, preparing some of the food eaten today for the anticipated activity the following day.

Diet

It is vital that you do not scare your body by starving, but it is not essential to be‘stuffed’ with food every time you eat. As a simple rule the ‘meat (including other sources of protein such as eggs, cheese, lentils) fruit and vegetable’ approach provides you with all the nutrients you need for everyday life. Protein (usually contains some fat: we need some for its nutritional needs) tends to fill us up for longer, which is the basic principle surrounding ‘low carb’ diet. While fruit and vegetables (and other sources of complex carbohydrates e.g. whole grain foods and non processed ‘carbs’) are dreaded ‘carbohydrates’ most are good complex carbohydrates,which means they are absorbed more slowly (a good thing unless you are undergoing exercise) than ‘bad’ carbs, such as pure sugar and processed/fast foods.

Low glycaemic index foods (complex carbs) are another way of looking at good and bad carbs. For instance an apple is healthy but apple juice is only good for you in small amounts, as it is processed with most of the fibre removed. A‘smoothie’ with no additives, just fruit and its fibre, is better that pure juice. Oats (broken down more slowly) are generally better than wheat (interestingly wheat and dairy are the most commonly causes of food ‘allergy’ or unpleasant side effects such as bloating or insomnia).

So it is important to eat when you are hungry but avoid too many carbs or processed or‘fast’ foods, in particular processed or high energy carbs, unless you are very physically active. Porridge, a smoothie, omelette are good examples of breakfast foods that will get you off to a good start to the day. A salad with as much protein (but no bread) as you need to feel full for lunch,while in the evening meat (or other protein) and vegetables (only use potatoes, rice and wheat products in proportion to how physically active you are: not very active then avoid or use sparingly), with fruit for dessert. Good chocolate (high cocoa and lower sugar content) has lots of health benefits but do not overdo it! Wine has ‘empty’ calories so should not be avoided but remembered when looking at the overall amount of calories in the meal. Up to 2 units a day has a lot health benefits but too much alcohol can damage your liver and have unpleasant side effects.

At the end of each week/month it is also important to have had a little of everything you like, otherwise you will give up and go back to bad ways!