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Exercise

Please exercise.

In the preceding centuries, tremendous physical activity was required for human survival, and yet, reproduction carried on. Imagine the exhaustion and stress if we had to spend one week hunting or farming with few tools or resources. Yet probably, under these conditions, most women would be able to get pregnant.

Excessive extreme exercise causing weight loss will cause ovulation to stop because the body figures that there are not enough nutrients stored for both the woman and a fetus. If she can just barely feed herself, she can’t feed the growing baby. The same is true for an anorectic. But here we are talking about extreme extreme. Moderate exercise is fine.

Surprising to me, I did come across a paper from Harvard showing that women who underwent moderate levels of exercise had lower pregnancy rates that those who did not. Like we always say, it’s just one paper. I do not really believe it. The Harvard doctors that I know do not restrict moderate exercise.

Exercise is bad if you are taking fertility drugs because the medications make the ovaries grow. Normally the ovaries are about the size of a walnut, and the drugs increase the number of follicles, therefore the ovarian size increases. Sometimes the ovaries can get to the size of plums or even oranges. They hang inside the pelvis. As they become heavier, they become more likely to twist, and this is called torsion. Here the twisting cuts off the blood supply and causes the ovary to choke. This really hurts, and is treated by laparoscopy. Exercise will increase the odds of this twisting. So in this case, exercise is not good.

Exercise increases blood flow to all areas of the body. The uterus and ovaries are organs that would love to get as much blood flow as they could.

Exercise clears you head. Yes, endorphins are released with strenuous activity, and these can help us fell better, but I think it’s more than that. My theory is that it’s not just about increasing the good chemicals; it’s about getting rid of the bad. Increased blood flow flushes away the old stale thought chemicals that are just hanging around causing trouble. Get rid of them.

Even better, do exercise that requires tremendous concentration. This really clears you head. Any sport will do: sailing, golf, soccer, basketball, biking, you name it. Some are more strenuous than others, but they all work. Same thing; flood your brain with fresh blood and new thoughts, lose the waste products.

Exercise builds muscle mass. This is also good. It just makes you feel better if you have a little tone. Even if you think you are fat, the tone goes a long way. It’s healthier to have some tone and muscle. It helps with balance and lowers you chances of getting injured during an accident (falling, for example). And people with a little tone just age better.

Not to mention all of the obvious benefits of upping your cardio-vascular reserve.

I am not an expert in Yoga, although I have happily done it a few times. It’s very good alternative.

So you don’t have time for exercise? Yes you do, make time. If you are tired, go to gym tired, it works just as well. You will sleep better.

If you do decide to take my advice (and the advice of others), go all out. A little exercise once a week is better than nothing, but more is better. You need at least 2 sessions per week of vigorous activity to really make a difference. Don’t start on any aggressive workout without checking with our doctor first, and consider a trainer at least initially.

See disclaimer 5/17/06 and Happy Workout,

Dr. Licciardi

References:

  • Moran LJ, Dodd J, Nisenblat V, Norman RJ. Obesity and reproductive dysfunction in women. Endocrinol Metab Clin North Am. 2011 Dec; 40(4):895-906.
  • Mutsaerts MA, Groen H, ter Bogt NC et al. The LIFESTYLE study: costs and effects of a structured lifestyle program in overweight and obese subfertile women to reduce the need for fertility treatment and improve reproductive outcome. A randomised controlled trial. BMC Women’s Health. 2010 Jun 25; 10:22.
  • Guzick DS, Wing R, Smith D, Berga SL, Winters SJ. Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertil Steril. 1994; 61(4):598-604.
  • Kiddy DS, Hamilton-Fairley D, Bush A, Short F, Anyaoku V, Reed MJ, Franks S. Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome. Clin Endocrinol 1992; 36:105-11.
  • Katz MG, Vollenhoven B. The reproductive endocrine consequences of anorexia nervosa. BJOG 2000; 107:707-13.

Myomectomy

Surgery to remove fibroids is called a myomectomy (fibroids are also called myomas). There are a few different procedures depending on the size and location of the fibroid. Most are removed via laparotomy. This means through an incision in the abdomen that resembles the incision of a cesarean section. This is an incision that goes from left to right, and is sometimes referred to as a bikini incision. If the fibroids are extremely large, a larger incision is required that is made vertically. This gives the surgeon more room to operate inside the abdomen.

Some fibroids can be removed through the laparoscope. Here a small incision (less than an inch) made through the navel and 2-3 other smaller incisions (½ an inch) are made in other parts of the abdomen.

Some can be removed through the hysteroscope. This is the scope that is placed through the cervix up into the uterus. Here fibroids can be visualized and removed by shaving the fibroid piece by piece. It’s an elaborate d and c.

So who gets what?

Almost all myomectomies are performed via the cesarean section style route. Usually this gives the surgeon enough room, and the fibroids can be removed without difficulty. If the fibroids are just too big to be removed this way, the other, larger incision may be necessary. The negative to this is that the scar is bigger and visible to anyone who sees your abdomen.

A very small percentage of fibroids are removed through the laparoscope.
The best candidates for this procedure are the fibroids that are mostly on the outside of the uterus (subserosal). Clearly the advantage of this procedure is much smaller incision size, which translates into less time in the hospital, less post op pain and much less downtime after the surgery. Unfortunately, most myomectomies are not done this way. The reason is that it is a very difficult procedure to do quickly and with minimal blood loss.

I need to say that there may be a rare surgeon out there who can remove a higher percentage of fibroids in this way, but most can not, at least not safely. I have performed this procedure, but pick patients who I know who have fibroids on the outside, almost hanging off the uterus, so that I do not need to make a big cut into the uterus. It is this cutting into the uterus, which is usually necessary, that makes the laparoscopic approach less desirable.

I recently spoke to a renowned surgeon who spends his week traveling throughout Europe performing very advanced laparoscopic surgery. I asked him why he does not perform laparoscopic myomectomy and he told me it’s safer to just make the incision. Laparoscopic surgery to remove an intramural myoma (in the wall of the uterus) can add hours on to the surgery time and has a much greater chance of blood loss requiring transfusion. In addition properly sewing up the uterus after the fibroid has been removed must be done neatly and precisely. This is a difficult, sometimes impossible task through the laparoscope.

Some doctors are getting more experience using computer assisted surgery (sometimes called robotic surgery) and this does make sewing and knot tying much easier. But so far, in most cases, it remains easier to perform a safer procedure through the standard incision.

A little more about fibroids next time, and please read disclaimer 5/17/06.

Dr. Licciardi

References:

  • Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981; 36:433.
  • Laughlin SK, Stewart EA. Uterine leiomyomas: individualizing the approach to a heterogeneous condition. Obstet Gynecol. 2011 Feb; 117(2 Pt 1):396-403.
  • Stewart EA. Uterine fibroids: the complete guide. Baltimore (MD): Johns Hopkins University Press; 2007.