DRY EYE: EMERGING OPHTHALMIC PROBLEM

DR. M. R. JAIN M.S, FICS ( USA), FACLP ( London ) FAMS
MEDICAL DIRECTOR
M. R. J INSTITUTE AND JAIN EYE HOSPITAL, JAIPUR

Dry eye is the most frequent disorder in Ophthalmology. Fortunately, only infrequently it becomes the most severe. Although the condition was recognized as a clinical disorder in the year 1920 and described clinically in the early 1930’s, the greatest amount of information both from an epidemiological and pathogenetic perspective has accrued during the last ten years.

What is dry eye?

Dry eye is a disorder of the preocular tearfilm that results in damage to the ocular surface and is associated with symptoms of ocular discomfort. Dry eye is characterized by instability of the tearfilm that can be due to insufficient amount of tear production or due to poor quality of tearfilm, which results in increased evaporation of the tears.
Dry eye therefore can be divided in two groups, namely
1. Aqueous production deficient
2. Evaporative

Prevalence of dry eye.

No authentic prevalence survey has been conducted in India but it is noted that out of the patients above the age of 30 years attending the outdoor, one out of every five has a complaint pertaining to dry eye. A recent survey conducted in year 2002, based upon a well – characterized population of adult men and women in the USA, identified a prevalence of 6.7 percent in women over the age of 50 and 2.3 % in men over the age of 55.These rates extrapolate to potentially 9.1 million dry eye patients in USA alone.
In women at the age of 50-52 when menopause usually sets in, an imbalance occurs between the oestrogen and androgen hormone due to decrease of androgens after the menopause. Decrease in androgen levels, excites inflammation in lacrimal gland and ocular surface, disrupting the normal homeostatic maintenance of the lacrimal gland and ocular surface.
The factors which has increased the incidence of dry eye can be narrated as under
a. increasing longitivity of the population
b.increased consumption of medication, both systemically and topically which have adverse effect on the production of high quality of tears
c. increased computer use
d. increased contact lens use and cosmetic surgery of LASIK/ LASEK
e better understanding and diagnosis of dry eye.
f possibly, adulteration in the food?

Pathogenesis of Dry Eye

It is an established fact that any lacrimal gland damage would result in decreased tear flow. This leads to decreased washout of the tear surface debris and bacterias as well as increased presence of inflammatory cytokines and decreased growth factors to maintain ocular surface integrity.
Almost all tear flow is due to a reflex mechanism due to stimuli from cornea sending impulses to the brain and to the lacrimal gland. Any thing which disturbs corneal sensations like hormonal imbalance, contact lenses, LASIK surgery or any other trauma to the eye, may it be surgical or accidental.

The aqueous deficient dry eye (keratoconjunctivitis sicca) is a disturbance of the neuro-humoral interaction of the ocular surface which interrupt secretomotor nerve impulses to the lacrimal gland that results in inflammatory suppression of aqueous secretion, a necessary component of the tearfilm, with subsequent damage to the ocular surface, producing symptoms of ocular irritation and discomfort. The evaporative dry eye is a disturbance of the stability of the tearfilm, which is usually due to abnormalities of Meibomian gland secretion or abnormal eyelid position and movement. Both types of dry eye results in damage to the ocular surface and symptoms of ocular discomfort and impaired visual function.

Tear Film
It comprises of three layers
Outer Lipid layer
It is formed by the oily secretion of Meibomian glands. It acts as a lubricant and prevent evaporation of tears.
Middle Aqueous Layer
It is the main tear fluid liberated from lacrimal gland and Accessory glands. It contains proteins, immunoglobulins, lysozyme, lactoferin and betalycin. It provides moisture to the eye, nutrition to the cornea and antibacterial activity. It provides the epithelial cells with glucose, oxygen and growth factors. It flushes out the debris and organisms from the corneal surface and drains into nasolacrimal canal.
Inner Mucous Layer
The innermost mucous layer of the tear film forms a highly hydrophilic wetting surface over the hydrophobic epithelial surface of the cornea and conjunctiva. The mucous also reduces the surface tension between the lipid layer of the tear film and the water layer, thus contributing to the stability of the tear film.

Classification Based On Etiology

1. Age Related. Lacrimal secretion begins to decrease after the age of 30 years. At the age of 6o, we reach the borderline between the production and need. At the age of 90, almost all persons have dry eye.
2. Hormonal. At the age of menopause almost every women develops dry eye either mild or moderate. Recent research has shown that it is due to lowering of androgen levels produced by the ovaries. Men develop dry eye related to hormones with less frequency and intensity than women.
3. Pharmacological. There is adverse effect on production of tears due to preservatives in teardrops used for long period. Glaucoma patients are more prone to this problem due to prolonged therapy.
Systemic drugs like antidepressants, antihypertensives, antihistaminics, anticholinergics, antipsychotics, angiolytics, antiparkinsonians, diuretics and hormones too can cause dry eye.

4. Immunological: This is related to autoimmune reaction in exocrine glands affecting outside body secretion like secretion of tears, saliva, sweat and vaginal secretions. The Sjogren’s syndromes are those in which patient’s immunological system attacks its own exocrine glands. Rheumatism, cicatricial pemphigoid and erythema multiform can lead to Sjogren’s syndrome.
5. Infection. Chronic infection of conjunctiva can affect mucous secretion leading to mucin deficiency and infection of lacrimal glands can affect aqueous secretion. Inflammation of lids may affect oily secretion. Any of the component if affected, tearfilm is disturbed.
6. Hypo nutrition. Avitaminosis A, and alcoholism that leads to poor intestinal absorption may give rise to dry eye.
7. Traumatic: Any trauma to the eye may it be accidental or surgical, can precipitate dry eye. Major surgeries like removal of tumour etc has more chances to cause dry eye. Cataract or glaucoma surgery too can be responsible especially in older persons.
8. Neurological.
a. Post LASIK. Lasik leads to the development of temporary dry eye in about 4 percent of patients. The Lasik induced dry eye tends to resolve approximately within 6 months.

b. Contact lens wear. Contact lenses when worn for prolonged period, affect corneal sensations and hence decrease tear secretion.
9. Defective glands. Responsible for aqueous, mucin and lipid secretions.
10. Inability to utilize tears. There is normal production of tears but cornea is unable to use them due to:
a. Epitheliopathy or corneal dystrophy, which decreases corneal, wet ability.
b. Due to lipid defect the lids are unable to circulate the tears over the entire ocular surface (lid paralysis, ectropion, lagophthalmos)
Symptoms
Dry eye patient can present any one of them or multiple symptoms:
Itching, burning, irritation, pain, discomfort. There may be pain and photophobia and blurred vision that improves with blinking. There is usually stringy ropy mucous discharge, which can increase in the afternoon. The discomfort in the eye usually increases while reading, watching T.V or working on the computer. At times there may be excess of watering, specially during breeze.
All these symptoms are exaggerated during dry and windy conditions.
Some of the patients give a typical history of desire to frequently sprinkle water into the eyes.
Signs

Tear Lake. Normally at the lower lid margin there is there is concave tear meniscus of 0.3 to 0.5 mm, which is called Tear Lake. In dry eye it is usually less than 0.1mm.
Debris. There is increased debris in the decreased tear lake. Mucous threads may be seen.
Other Signs. Redundant conjunctiva, injection of the conjunctival vessels, and sometimes mild chemosis may be present. In advanced cases, the conjunctival and corneal dryness may be very evident.
Staining.

1. Fluorescein stain. Fluorescein may stain any denuded area of corneal epithelium. The reduced tear lake could easily be appreciated with fluorescein.
2. Rose Bengal Stain. Rose Bengal (solution 1 % or strip) stains the damaged devitalized epithelial cells of the conjunctiva and cornea. It can detect even mild cases of Keratoconjunctivis Sicca (KCS) by staining the palpabral conjunctiva in the form of two triangles with their base towards limbus..
Tear Film Break Up Time. (TBUT)
It is a quantative measurement of tear film stability. A mucous deficiency results in beading of the aqueous tear around the small amount of available mucous on the epithelial surface and reduction of TBUT.
Diagnosis.

Diagnosis is most often based on the complaint of the patient without any evident cause in the eye. Quite often, persistent fishing for ropy mucous discharge is very classical and so is the importance of the complaint of increased discomfort in dry and windy environment.
Diagnostic tests mostly employed are as under
a. Shirmer Test. The test is used to quantitatively measure the tear secretions by the lacrimal gland, and should be done before any other examination as the manipulation of the eyelid and eye can alter the results of the test.
Shirmer I Test. Is used to measure tear secretion rate without anesthesia.
Shirmer II Test is done similar to Shirmer one but after instillation of anesthetic drops.
Other employed tests are :
a. Tear Function Index (TFI)
b. Fluophotometery.
c. Tear Osmolarity.
Treatment

Conservative
1. Patient Information. Patient must be educated and fully informed about the disease as well as he must be explained the limitations of medical management. This maintains the patient’s confidence in your line of treatment.
2. Controlling the surroundings. Special stress must be put to control the surroundings to minimize the severity of the condition.
a. Still Air. Patient must avoid sitting facing direct flow of air from air conditioners, ventilators, windows or fans. It is better that patient avoid sitting in front of door in a room. While driving car, the car window must be closed and the patient should use glasses. Car A.C. wind should not blow directly on the face.
b. Humid Air. Even if there is no refractive error, patient must wear glasses. Just by wearing spectacles, the humidity between the eyes and the spectacles rises by 2 %. Spectacles with side panels and moist chamber may be reserved for more severe cases. Humidifiers must be used in the rooms. There are air-conditioners available with attached humidifiers.
Special glasses with moist inserts ameliorate severe dry eye symptoms. The moist inserts on the side panels increase the ambient humidity, resulting in a decrease in the tear evaporation from the ocular surface. Another type of moist chamber is obtained more easily and less expensively by using swimming goggles. The most favorable range of relative humidity for minimizing tear evaporation is reported to be 40% to 50 %. Wet gauze mask is an alternative treatment modality.
c. Pure Air. Polluted air is very harmful for dry eye patients. Palpabral aperture must remain open as little as possible. Closed window in the car, helmet with a shield while driving scooter and covering your eyes with goggles while driving bicycle gives some relief. While reading books, the book should be kept as close to chest as possible so as to have minimum palpabral aperture. While looking down, ocular surface exposed to the air is just 1 square centimeter, whereas while looking straight, 2.0 sq. cm. and while looking up, 3,0 sq. cm.
Computer Vision Syndrome. While looking at the monitor, the eyes have the tendency to stare at the screen thereby reducing the blink to about 6-7 blinks a minute. If the computer is at a higher level than the eye, there is further increased evaporation of tears. To avoid computer vision syndrome, one must keep the computer at the lower level than the eyes and a habit must be formed to blink about 10-12 times per minute. When working for long period, one must close the eyes for some time or use some artificial teardrops.

Medical Management

Tear Substitutes.

Tear substitutes are the mainstay in the medical management of dry eye. Variety of tear substitutes is available. Hypotonic non-viscous solutions counteract the hyper tonicity in dry eye syndrome and can last up to two hours. Viscous solution contains cellulose as their base and thus last longer. Preservatives are added to increase the shelf life and the stability of the solution. The commonly used preservatives include benzalkonium chloride, thimerosal, and chlorhexidine. In spite of their low concentration, they can produce toxic effect on the cornea and conjunctiva and adversely affect the dry eye condition.

THE use of unpreserved collyria, and more recently preservatives that are transient or which rapidly oxidize to non-toxic compounds upon exposure to air and the ocular surface, has become routine for those patients requiring more than three or four lubricant drops per day. The tear supplements have focused on maintaining a hypotonic collyrium with normalization of electrolyte concentration to combat the damaging effects of hyper tonicity.

In India, preservative free tear substitutes used are :

Refresh Tear Drops (Allergan),
Gen Teal drops (Novartis) ,
Eye Mist Drops (Avesta) ,
Tear Drops (Milmet)
Celluvisc 1 % (Allergan)
Refresh Liquigel (Allergan)
Tear substitutes are instilled in the eyes 3- 6 times a day
depending on the severity of the condition. If necessary, Refresh
Liquigel or Celluvisc is instilled at bedtime.
Androgens

Role of androgen as a therapy is yet not well established though it is known that in females, lack of Androgens play important role in its etiology.
Topically, androgenic supplementation of artificial tears, appears to lower the Osmolarity of patient’s tears either by retarding evaporation or possibly stimulating tear secretion.

Tear Stimulants
Tear stimulants have as yet not proved very useful.
Recent trials with purinergic P2Y2 agonist has reached phase three trial in USA. The medication designated diquafosol tetrasodium (Inspire Pharmaceuticals, USA) has been extremely well tolerated and increases tear film volume and mucin content. The pharmacological action is to increase fluid transport across the conjunctiva and stimulate mucin release from goblet cells.

Cyclosporine A

Looking to the immunological aspect of the disease, cyclosporin A in the form of topical drops (0.005 %) is being used in moderate to severe form of DES to treat inflammation of the ocular surface and lacrimal gland. The drops are instilled twice a day and the beneficial results are observed within four to six months. The drug may have to be used for whole life. Cyclomune is an immunomodulator. It selectively suppresses lymphocytic functions involved in a disease without actually suppressing the entire immune system. It inhibits T helper cells that are known to cause inflammation of the ocular surface and lacrimal glands in patients with dry eye. The main indication for the use of Cyclomune is surface staining of the cornea. Instillation of drops is associated with stinging sensations, which gradually decrease.
Cyclosporine drops are marketed by Allergan as Restasis in USA and by Avesta in India as Cyclomune

Meibomitis.
A recent study in USA has shown that about 38 % patients with dry eye has concurrent Meibomian gland involvement. Hot wet compresses, betadain scrub, eyelid massage and oral tetracycline or doxycycline, may treat Meibomian inflammation.

Topical Steroids (Soft steroids)

Topical steroids are being tried in some of the resistant or advanced cases of dry eye or in patients who have severe itching. Lodeprednol etabonate 0.2 % is a good choice for long-term use. It is soft steroid that is activated by enzymes as it passes through the cornea. It seems to have very little effect on IOP. It is marketed as Alrex by Bausch & Lomb
Mucolytics.
Topical 5 percent Acetylcysteine drops are recommended for instillation four times a day. It is effective in eyes with excessive mucous.
Future Therapies.
Apart from tear substitutes, anti-inflammatory therapy, androgen hormone replacement, and tear stimulant diquafosol tetrasodium may form main therapeutic measures. Herbal supplements such as oil of primrose and flax seed oil are reported to be help in relieving symptoms of dry eye and Meibomitis. Essential fatty acids of omega 3 and specially omega 6 category as food supplements are showing some promising results.
Surgical Management

A. Canalicular Obstruction by Punctal Plugs
It is a simple procedure that decreases the tear drainage markedly and improves the qualitative and quantitative component of tears. A decrease in osmolarity of the tears is noted. Improvement can be seen by Schirmer and TBUT test.
B. Punctal Patch Technique This is most efficacious surgical technique for long lasting occlusion of the lacrimal drainage system. In this technique a raw area is created surrounding upper and lower puncta. A piece of bulbar conjunctiva is taken and transplanted to the punctal wound with its raw surface in contact with the lid and sutured to it with four 9. 0 stitches.
Summary

Dry eye disease appears to be on increase due to multiple factors. Inspite of great advance in understanding and diagnosing the disease, the disease remains a challenge to medical profession. Preservative free drops have significantly improved the quality of life of dry eye patients. Anti-inflammatory therapy, androgen hormones and tear stimulant, namely, diquafosol tetrasodium and probably some herbal drugs hold great hope for a DES patient.

The procedure ‘LASIK’ for correction of refractive errors has now become very familiar. This laser correction of vision has changed the lives of millions for the better.
For more than a century, spectacles have provided good vision for people with almost all kinds of refractive errors. Spectacles are still the first option to start with. Many individuals have even used them in distinctly different styles and shapes and made them a part of their identity.
For those who were looking for alternatives, contact lenses provided the break, to show off their faces without spectacles.
More and more people are on the lookout for a ‘permanent’ solution for their refractive errors. LASIK is being offered as a magic cure by some commercial outfits. A lowdown on the pros and cons of this refractive surgery procedure shall help one to make an informed decision, whether to go for it or not.
Refractive surgery for vision correction has made tremendous advances since its start as radial keratotomy, or RK. The concept was first used in the early 1960s by Sato in Japan. The original procedure, however, didn’t work for most people.
RK is the earliest form of vision correction surgery. It was perfected in the 1970s by the Russian ophthalmologist Fyodorov and was first performed in the United States in 1978.
Today, several different options exist to help the majority of people who wear glasses or contact lenses reduce their dependence on their corrective lenses. In almost all cases, refractive surgery is elective and cosmetic.
Vision correction surgery can benefit people with myopia (nearsightedness), hyperopia (farsightedness), and astigmatism (vision distortion due to variation in corneal surface in different meridians).
[Vision correction surgery will usually not benefit people with presbyopia (defective near vision). This condition affects all people older than 40-45 years. In presbyopia, the lens loses its ability to change shape and thus focus the eye for near vision. A further refinement to LASIK, called multifocal LASIK, is undergoing clinical trials and may be available very soon]
Not every person requesting laser vision correction is a candidate for the surgery. Factors, such as very high refractive errors, certain ocular diseases, and certain medical diseases, may prevent a person from being a candidate for refractive surgery.

Minimum criteria for LASIK could be:
Age 18 years or older for myopia or hyperopia
Age 21 years or older for astigmatism
Stable refraction for at least 1 year
There are three main steps to the procedure:
1) Creation of a corneal flap, using a microkeratome
2) Corneal stromal ablation, using excimer laser
3) Replacing the corneal flap

The Risks
As with any surgical procedure, complications may occur. In laser vision corrections, complications may occur during the procedure (intraoperatively) or during the healing period following the procedure (postoperatively).
Complications during the procedure mainly occur during the creation of the flap with the microkeratome. These include incomplete flaps, irregular or small flaps, buttonholes, decentered flaps, or free flaps. When these complications occur during surgery, the procedure is stopped, and the flap is put back in place. The flap is then allowed to heal for 3-6 months. After this healing period, the procedure may be repeated and the flap may be recut.
Early complications after the procedure include dislodged flaps and flap folds. Folds can be described as macrofolds and microfolds, which can cause visual distortion. Dislodged flaps and macrofolds require that the flap be lifted and repositioned, thus eliminating the folds.
Other complications include interface debris (debris between the flap and the lasered cornea), epithelial downgrowth into the flap, epithelial defects, or corneal abrasions.
Infection of the cornea (infectious keratitis) and inflammation can also occur. Infections are rare but very serious if they do occur.
Refractive complications include undercorrections or overcorrections, which may require additional laser correction (an enhancement procedure) and decentered laser ablation, which may require retreatment or the use of a hard contact lens.
Laser vision correction could also induce astigmatism. Halos and glare, especially at night, may occur after the procedure. They are common after the procedure but usually get better gradually.
Regression of the procedure may occur and would require additional laser treatment or the use of glasses or contact lenses.
After the surgery, dry eye symptoms are the most common complaint. Dry eyes following LASIK may occur due to a decrease in corneal sensation because the microkeratome cuts through the superficial corneal nerves. This may result in a decreased blink rate and, thus, a decrease in rewetting of the eye. Improvement occurs with the use of artificial tear lubrication and with time.

Every person who is considering LASIK must undergo a complete eye examination prior to surgery.
During this examination, the corneal thickness will be measured with a device called a pachymeter. Adequate corneal tissue remaining after the procedure is extremely important. If the cornea is too thin, LASIK may not be able to treat the refractive error without thinning the cornea too far, inducing a complication.
A map of the corneal surface, called topography, is performed to rule out any corneal problems that may lead to a poor result with the surgery, such as keratoconus. The size of the pupils in light and dark will be measured. People with large pupil diameters in a dimly lit room may not be good candidates for the LASIK procedure.
The refractive error will be checked prior to dilation of the pupils and again after dilation. This helps ensure that the refractive error is stable. A glaucoma test and a thorough retinal examination are also performed at this visit.
During the Procedure
The procedure is performed on an out-patient basis. It takes about 10 minutes to perform for each eye. Both eyes are usually done during the same procedure, although there may be times when the patient or the surgeon prefers to have each eye done at different times.
Prior to the procedure, most people will be given medication for relaxation. The eyes are anesthetized with topical anaesthetic drops prior to the procedure. The eyes are cleansed, and drapes are applied to the eyelids to cover the eyelashes so they cannot interfere with the procedure. The eyelids are held open with an eyelid retractor.
An instrument called a microkeratome is used to create the LASIK flap. Initially, a small mark is placed on the cornea to help realign the flap at the completion of the procedure. A suction ring is applied to the eye, which may cause a pressure sensation. The microkeratome creates a flap in the anterior cornea at about 20-25% of its depth. The flap is then retracted back, exposing the corneal stroma or inner layer of the cornea.
Next, the laser is used to resculpt the corneal surface. The laser portion of the surgery can take several seconds to several minutes to complete. During this time, the patient has to look continuosly at a target, such as a flashing red light or a flashing green light. The laser itself is invisible, although ne can hear a loud tapping sound when the laser is firing.
In myopic corrections, the laser works to flatten the central cornea. This allows light rays to focus onto the retina, reducing myopia.
In hyperopic corrections, the laser is used in the peripheral cornea, causing a steepening of the central cornea, which allows better focusing of light rays onto the cornea.
Once the laser portion of the procedure is completed, the flap is returned to its original position on the cornea. Through the natural characteristics of the cornea, the flap will seal itself in place after a few minutes. Usually, the flap is allowed to dry for approximately 3 minutes prior to removing the lid retractor. At the end of the procedure, antibiotic and anti-inflammatory drops are put into the eyes.

After the Procedure
As with any surgery, some discomfort is expected following LASIK too.
Immediately following the procedure, antibiotic drops and steroid drops will be placed into the eyes. The flap will be checked under magnification (using slit-lamp) to be sure it is smooth and wrinkle-free with no debris under it. Finally, protective eyewear, such as goggles or shields, will be placed on the eyes to protect them. With the goggles in place, one will be less likely to rub the eyes, which may cause dislocation of the flap.
The hours following the procedure can be more uncomfortable than the procedure itself.
Immediately after surgery, one may experience just a small amount of scratchiness of the eyes, or tears and burning sensation. These symptoms usually go away in about 6 hours. Your surgeon may encourage you to take a nap after the procedure. Taking a nap will help you through the most uncomfortable part of the healing with minimal discomfort.
Immediately after the surgery, most people will notice an improvement in their uncorrected visual acuity. The vision may appear rather smoky, as if one is looking through a smoke-filled room. The vision will stabilize in about 1 week.
The Good News
Almost all of the complications of LASIK are due to the complexity of the first step [unpredictable results during use of the microkeratome (the ‘blade’) and variations in surgeons’ skills].
The arrival of the Femtosecond laser has automated this step completely, without the need for a microkeratome.
The results are wonderfully better and more and more centres are beginning to offer this new procedure to their patients.
This type of LASIK is now marketed as All Laser LASIK or iLASIK (meaning intraLASIK, from a manufacturers name for femtosecond laser) or Blade-Free LASIK.
The flip side though, is the very high cost of this new technique, which is expected to come down in due course.

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Divorce happens and there can be many irreconcilable differences. Many divorces take place due to so many reasons but here we are going to discuss a one major reason for the breakdown. If we can understand this problem while we are still married than maybe we can somehow save the relationship or find adequate professional help. In this article I will attempt to discuss this reason for divorce.

Sex

Sex has always been the one of the major reason for the marriages to breakdown. It’s either no sex, to little sex, or too much sex, lack of knowledge concerning sex, or sex with the wrong person. It still amazes me how many people get married and have very little comprehension concerning sex. This doesn't mean people need to experiment before marriage to be able to please their partner. It means they need to read and discuss it with each other find out what pleases the wife and she find out what pleases her husband.

Fear and not knowing can cause problems in the marriage. Also, forcing the one partner to perform in a way which they dislike or are just not into it. The one thing that will help in this area is to communicate with each other. I suggest that each partner should discuss the matter with each other and read the book "The Act of Marriage" by Tim Lahaye.
So if any body of you or both of you are facing any type of sex problem kindly try to solve it mutually, if your efforts are not working to solve it then never hesitate to take professional help from a good qualified sex therapist.

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From vary long time in India, sex in marriage is often something which is brushed aside and joked about. But now we have to take this matter seriously because this is deeply related with our marriage, love, health and vary important for a healthy vibrant relationship.
Marriage and sex problems can easily arise in a marriage where these things are not given the priority they deserve. How much importance is placed on them depends in part on each partner's views and personality. For some people the idea of a sexless marriage is unthinkable. For others, it may be a trade off in an otherwise happy relationship. The key of course, is making sure that both partner’s views are in synch.
Sexual problems in marriage should never be waived off or made fun of. Your spouse may be self-conscious of the issue already, and highlighting it unnecessarily will not help resolve the problem. Instead, married couples need to work together to create solutions and, if necessary, accept reality.
However, some people who experience sex problems like erectile dysfunction, hormonal imbalance, loss of desire due to a temporary condition (such as illness or pregnancy), inability to achieve orgasm, premature ejaculation etc, find the impetus to maintain their marriage very difficult.
Having an active, sexy marriage helps couples to feel connected at a deeper level, beyond words and ideas and day to day problems. Having difficulties in the bedroom is definitely something to talk about and should be resolved as quickly as possible.
In the-fast changing social scenario setting out new standards for man-woman relations, the Honorable Supreme Court of India on 21 March 2006 ruled that a wife can seek divorce for husband’s sexual incapacity and his failure to consummate the marriage due to such a physical handicap.
However, if you are having problems, you may want to seek professional help, so need not to worry about this because, now a days a few good sex clinics are there, those are giving all the services like consultation, examinations, diagnosis, sex counseling for couples and singles, sex therapies and treatments of sex problems to get you out of these sex problems and have the best possible sex life.
Further more, statistics show that most people who attend some kind of sexual therapy from qualified doctors can actually improve their marriage as well as their health. Almost 93% of those who have undergone sexual therapy have significantly improved their married life.
Marriage experts agree that healthy sexual activity can save marriage from divorce (divorce due to sex problems). Getting sex help isn't something you need feel embarrassed about, especially if it leads to the best possible sex life.

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OK, so you want to have a baby. Your chances of succeeding are excellent: About 85 percent of all couples who try to conceive will do so within one year. (After one year, couples are considered infertile.) Twenty to 22 percent will get pregnant within the first month of trying. There are some obvious rules to this game. The first is that you and your partner need to have sexual intercourse, with the penis in the vagina. The penis must ejaculate inside the vagina, depositing sperm near the cervix, the mouth of the uterus. In addition, intercourse must occur at or around the time of ovulation. There are also a lot of misconceptions and old wives' tales surrounding this issue. For example, it is not necessary for the woman to achieve orgasm in order for conception to occur, according to Paul A. Bergh, M.D., an assistant professor of obstetrics and gynecology in the Division of Reproductive Endocrinology at Mount Sinai Medical Center in New York. Bergh explains that the fallopian tubes, the tubes that carry the egg from the ovary to the uterus, actually draw the sperm inside, coaxing them to unite with the egg. This occurs with or without orgasm, he says. The following tips will help increase your chances of getting pregnant. Also refer to "When and Why to Seek Help" for a list of conditions that should prompt you to see a doctor before your year of trying is over. Good luck!

Get a physical.

Before spending a year trying to get pregnant, it's a good idea to have a thorough physical examination, according to Sanford M. Markham, M.D., an assistant professor of obstetrics and gynecology at Georgetown University Medical Center in Washington, D.C. "Make sure that there aren't any physical problems, such as masses or cysts in the pelvic area," he says. "Your doctor should also treat any low-grade vaginal infections that you might have. He or she should also check for sexually transmitted diseases." Other conditions that can interfere with pregnancy are ovarian cysts, fibroids, and endometriosis, an inflammation of the lining of the uterus, Markham says.

Have sex around the time of ovulation.

The woman's egg is capable of being fertilized for only 24 hours after it is released from the ovary, according to Richard J. Paulson, M.D., an associate professor of obstetrics and gynecology and director of the In Vitro Fertilization Program at the University of Southern California School of Medicine in Los Angeles. The man's sperm can live for between 48 and 72 hours in the woman's reproductive tract. Since sperm and egg must come together for an embryo to be created, a couple must try to have sex at least every 72 hours around the time of ovulation (see Extra! Extra! - "Methods of Ovulation Prediction") in order to hit the mark, Paulson says. "Every 48 hours is even better," he says. However, he adds, the man should not ejaculate more frequently than once in 48 hours, since that may bring his sperm count down too low for fertilization.


Men should ejaculate every two to three days.

Along with the advice to have sex no more often than once every 48 hours, men should also try to ejaculate at least once every two to three days throughout the month, says Bergh. Men need to keep ejaculating to keep up their sperm supply, he adds.

Maintain a healthy lifestyle.

The best way to enhance your chances of getting pregnant is to maintain an all-around healthy lifestyle. This goes for both men and women, says William C. Andrews, M.D., executive director of the American Fertility Society and professor of obstetrics and gynecology at Eastern Virginia Medical School in Norfolk. "A healthy lifestyle will also help ensure the quality of your offspring," Andrews says.

Try to eliminate stress.

"There is little doubt that severe stress will interfere with reproductive function," says Paulson. "At the simplest level, stress will take away your libido. At the extreme, the woman may stop menstruating. Although studies in men are lacking, it is quite likely that a similar effect may occur."

Keep the testicles cool.

Exposure to extreme heat can be the death of sperm--literally. (That's why the testicles are outside of the body--to keep them cool.) Bergh's advice for maintaining the proper temperature is to wear boxer shorts (if you find them comfortable) and to avoid hot tubs and whirlpools. Taxicab and truck drivers will benefit from the use of a beaded seat mat that allows air to circulate. "There was an old Indian fertility ritual where the men used to dip their testicles in cold water," says Bergh. "They had the right idea." Varicose veins in the testicles can also interfere with temperature regulation. If you have these, see a urologist, Bergh suggests.

Take your time in bed.

It's not a bad idea for women to stay lying down for half an hour after sex, to minimize any leakage of sperm from the vagina, says Markham. Although staying in bed for a while may not make a tremendous amount of difference (sperm are strong swimmers), it certainly can't hurt. "Just stay in bed and take it easy," he says.

Try elevating the hips.

Placing a pillow under the woman's hips after intercourse may prevent sperm leakage, says Bergh. Although this is not proven to have any effect, it can do no damage, he says.Don't smoke. Smoking has been shown to lower men's sperm count and to impair fertility in women, according to Paulson. "There is nothing that has been looked at that smoking has not had an impact on," he says. His message is clear--don't do it. Also, if a woman does become pregnant, cigarette smoke--even in the first few days after conception--may be harmful to the developing embryo. So, the sooner you can quit, the better.

Eliminate alcohol and drugs.

Hormones can be thrown out of balance with drug abuse and high alcohol intake, says Paulson. This holds true for men and women. Even marijuana smoking can impair fertility. "Marijuana smoking has been associated with increases in prolactin, a hormone which can cause milk secretion from the breasts of both men and women. This can have deleterious effects upon reproduction," he says.

Eliminate medications.

Many medications, including common over-the-counter analgesics, can impair fertility, according to Markham. "A lot of things can inhibit ovulation and conception," he says. "It can be helpful to eliminate all medications." Be sure to check with your doctor before discontinuing any prescription medication, however.

Avoid lubricants.

Certain gels, liquids, and suppositories for lubricating the vagina may impair the sperm's ability to travel through the woman's reproductive tract and fertilize the egg, according to Markham. He recommends consulting a physician for a list of those that are not detrimental.

Try the missionary position.

This is another old wives' tale that can't do any damage and may do some good, according to Bergh. The missionary position, with the man on top, seems to be a good position for minimizing sperm leakage from the vagina.

Don't ruin your sex life.

One mistake many couples make is worrying so much about being able to conceive that it takes over their lives, says Andrews. "Don't be too mechanistic about it," he warns. "With a reasonable frequency of intercourse, a loving couple will tend to hit the right day. People sometimes make it an ordeal, rather than an expression of love. It can become so stressful that it is counterproductive."







PREMENSTURAL SYNDROM

PREMENSTRUAL SYNDROME - 11 Ways to Ease the Discomforts

You've heard the joke before. A woman flies off the handle at work or at home and everyone around her chimes in with, "It must be that time of the month again." The joke, of course, misses the point that women, at times, actually do get upset by their demanding husbands, whiny kids, and stressful jobs. For some women, however, the joke holds more truth than they'd like to believe. For these women, "that time of the month" really is a period of emotional imbalance, anger, depression, and anxiety. Situations that they normally cope well with suddenly become insurmountable. And the energy and health they enjoy most of the time give way to fatigue, achiness, and weight gain almost overnight. These women have what is known as premenstrual syndrome, or PMS, a condition that has no known cause and no complete cure. But research into the topic has brought about several theories as to what may make some women more vulnerable to PMS. "The two most widely held theories, neither of which has huge support, include an ovarian hormone imbalance of either estrogen or progesterone and a brain hormone change or deficiency," says Harold Zimmer, M.D., an obstetrician and gynecologist in private practice in Bellevue, Washington. Zimmer stresses that no single cause of PMS has ever been proven and that much of the research is contradictory. Whatever the cause, the symptoms can include anxiety, irritability, mood swings, and anger; indeed, these symptoms occur in more than 80 percent of women who suffer from PMS. Other symptoms may include sugar cravings, fatigue, headaches, dizziness, shakiness, abdominal bloating, breast tenderness, and overall swelling. Much less common are depression, memory loss, and feelings of isolation. The symptoms, and their severity, vary from woman to woman. "Symptoms are definitely cyclic, and that is one of the main criteria for diagnosing this condition. And the symptoms generally disappear with the onset of the woman's period," says Phyllis Frey, A.R.N.P., a nurse practitioner at Bellegrove OB-GYN, Inc., in Bellevue, Washington. "It's often the emotional symptoms that bring people in to the doctor," she adds. As for what you can do to relieve the discomfort of PMS, there are several home remedies. And according to Zimmer, the home remedies probably work as well as, or better than, the medical remedies available. Here's what you can try:

Maintain a well-balanced diet.

Include lots of fresh fruits and vegetables, starches, raw seeds and nuts, fish, poultry, and whole grains. "It is just sort of common sense dietary measures," says Zimmer.

Go easy on sugar.

Your cravings for sugar may be strong during this time, but giving in to the sugar craving may make you feel even worse and can intensify your feelings of irritability and anxiety. To make fending off your sugar cravings a little easier, try keeping healthy snacks readily available and keeping sugary foods out of the house--or at least out of your reach. If you can't give up the sweets completely, try eating only small amounts at a time, and opt for things like fruits or apple juice that can help satisfy your sugar craving and provide nutrients.

Eat small, frequent meals.

You don't want to go long periods without food because that can potentially intensify your premenstrual symptoms as well, says Zimmer.

Avoid alcohol.

Both Zimmer and Frey stress that alcohol will only make you feel more depressed and fatigued. Alcohol also depletes the body's stores of B vitamins and minerals and disrupts carbohydrate metabolism. It also disrupts the liver's ability to metabolize hormones, which can lead to higher-than-normal estrogen levels. So if you need to be holding a beverage at that party, try a nonalcoholic cocktail, such as mineral water with a twist of lime or lemon or a dash of bitters.

Cut down on caffeinated beverages.

These include coffee, tea, and colas. Caffeine can intensify anxiety, irritability, and mood swings. It may also increase breast tenderness. Try substituting water-processed decaffeinated coffee; grain-based coffee substitutes such as Pero, Postum, and Caffix; and ginger tea.

Cut the fat.

Eating too much dietary fat can interfere with liver efficiency. And some beef contains small amounts of synthetic estrogens. Too much protein can also increase the body's demand for minerals. Opt for smaller servings of lean meats, fish or seafood, beans, peas, seeds, and nuts. Use more whole grains, rice, vegetables, and fruits to fill out your meals.

Put down the salt shaker.

Table salt and high-sodium foods such as bouillon, commercial salad dressings, catsup, and hot dogs can worsen fluid retention, bloating, and breast tenderness.Practice stress management."Learning to control and reduce your level of stress has a great effect on reducing the symptoms of PMS," says Zimmer. Try joining a stress-management or stress-reduction program at your local hospital or community college; learning biofeedback techniques; meditating; exercising; or doing anything that helps you to relax and cope with stress.Try not to plan big events during your PMS time."I don't like to encourage my patients to plan their lives around their menstrual cycle, but if they have the option of planning a big social event at some time other than their PMS time, it would help them out to do so," says Zimmer. "The increased stress of the event will only make the PMS symptoms worse," he adds.

Exercise aerobically.
"Besides being a great stress reducer, aerobic exercise triggers the release of endorphins (the natural brain opiates) and produces a 'runner's high,'" says Zimmer. "Good forms of aerobic exercise include running, stair-stepping, bicycling, or taking an aerobics class," he continues. "The social environment of a health club can also make you feel better by encouraging you to interact with other people," he adds. He also goes on to say that increasing the pelvic circulation can help to rid the body of some of the bloating associated with PMS. Try to exercise for 20 to 30 minutes at least three times a week. If you are too fatigued to exercise during the actual PMS period, don't. Doing so the rest of the month should help in itself.

Talk it over.

Try to explain to your loved ones and close friends the reason for your erratic behavior. "One of the biggest stresses on a woman during this time is family. And it's not only the stress of feeling bad when she flies off the handle at someone, but also of having to apologize for her behavior later on," says Zimmer. He recommends enlisting the aid of your family and close friends by asking them to understand what the problem is and to realize that when you lash out at them you are not as in control as you would like to be. "If your child is really acting out and yelling at you for something during your PMS time, you might remind him that this is not the best time for him to be getting you angry. Hopefully, he'll see this as his cue to go outside and play," Zimmer explains. "You have to walk a fine line, though, and not begin using PMS as an excuse to be nasty to people," he adds. If the emotional symptoms are causing problems in your relationships, consider getting some counseling from a mental-health professional. Ask your physician to refer you to someone.