Conceiving
1. If patients are able to have occasional intercourse it is best to time intercourse around ovulation to maximize the chance of getting pregnant. Ovulation usually occurs mid-cycle, for example on day 14 for people with 28 day cycles. They can also choose to use an ovulation test kit to optimally time intercourse.
2. If insertional intercourse is not possible, patients can try self-insemination. This technique involves purchasing a syringe or turkey baster. The partner ejaculates into a sterile container and the semen is drawn up into the syringe/baster. The syringe with semen is inserted into the vagina to facilitate insemination. Ideally, insemination is carried out at the time of ovulation.
3. Another alternative is to seek out the assistance of a Fertility Clinic. These centers offer insemination under sedation or general anesthetic in British Columbia. Referrals are required.
Olive Fertility Centre 🔗oliverfertility.com
Contact Dr Beth Taylor at ✉ BTaylor@olivefertility.com
Pacific Coast Reproductive Medicine 🔗pacificfertility.ca
Contact Amanda at ✉ ACullen@pacificfertility.ca to arrange for a consult to discuss options.
What if they are on neuropathic medications?
Patients with spontaneous/unprovoked vulvodynia may benefit from systemic therapies. Commonly used medications include tricyclic antidepressants and gabapentin.
These medications are FDA risk category C.
If patients cannot discontinue these medications, they should discuss with their obstetrical care provider or maternal fetal medicine physician pre-conception to review risks and benefits.
Pregnancy
Ensure your patient sees an obstetrical care provider who is vulvodynia-aware, or open to learning about the physical and psychological impact of vulvodynia on pregnancy, labour, and delivery. There are a few common concerns that patients with vulvodynia have during pregnancy.
1. Transvaginal ultrasounds. For patients with vulvodynia, the transvaginal ultrasound may be painful and traumatic. If a transvaginal ultrasound is required, it is important to have a discussion with the patient to answer questions and discuss options for reducing anxiety during the exam.
2. The Group B Streptococcus test at 35 weeks gestation. This test can be done via self-swab for patients with vulvodynia.
Labour and Delivery
On its own, vulvodynia is not a reason to plan an elective cesarean section. There is no evidence that a vaginal delivery will worsen or improve vulvar pain longterm.
It can be helpful to review and emphasize pain relief options for vaginal delivery, including an early epidural. After an informed discussion, if a patient desires, they should be allowed to plan an elective C-section.
It is essential to remind the patient that they are empowered to make their own decisions throughout labour and delivery (e.g., decisions about pain management, c-section deliver, etc.).
Because patients with vulvodynia are likely particularly sensitive to vulvar and obstetrical pain, it can be helpful for patients with vulvodynia to work with their healthcare team to ensure a trauma-informed approach to labour and delivery.
Postpatrum
Lactational amenorrhea can cause vulvovaginal atrophy due to estrogen suppression. During this time, patients may benefit from topical estrogen therapy applied to the vulvar vestibule to decrease provoked pain.