HEART ATTACKS IN WOMEN

 

Heart attack is the commonest cause of death in women after sixty five. As many women die of heart attack as men at this age. 26.8% of women die of heart disease as compared to all cancers, which is 26.7 %. Sudden grief in women often results in heart attack. I have personally seen two examples of this among my friends. Women’s symptoms of a heart attack are slightly different to men.  They are often resting as opposed to men who are active at the time. They can experience unexplained anxiety, pain in the jaw, back ache, chest discomfort, abdominal pain and even mild flu like symptoms. The reason for these include conditions such as; high blood pressure, diabetes , high (bad) cholesterol(LDL), low (good) cholesterol (HDL), smoking, and high BMI. Even more important than the BMI is abdominal girth as this indicates visceral fat that is the fat inside the body organs. The abdominal girth measured at the level of belly button, should be less than 35 inches, or 89 cms. There can be fast and irregular beating of the heart. There is swelling of the feet if there is associated heart failure. Other conditions that can cause a heart attack are HIV, depression, inflammatory diseases, rheumatoid arthritis, Lupus. Cardiac arrest and aneurysm (Dilated Blood Vessel), high blood pressure during pregnancy and gestational diabetes are also risk factors for heart attacks in women. Women often ignore their symptoms if they are; having chest discomfort or pain, pain in the arm or jaw, sweating, suddenly feeling unwell or fainting. Do not ignore these symptoms. Seek urgent medical help. A dose of Aspirin can be lifesaving. Take it only after you have spoken to your medical adviser. Make sure you are not allergic to it.  For urgent diagnosis an ECG (Electronic heart monitoring) is done. Cardiac Markers are also tested in the blood, they give a good indication of what is happening. Cardiac Markers are repeated to assess the progress. An Ultrasound, chest X-ray, Coronary Angiogram or CT Coronary angiogram is performed to assess the blood vessels of the heart.  Other tests  to assess the general condition such as a full blood examination, inflammatory markers, kidney, liver, thyroid functions and blood electrolytes (Sodium, potassium) are all done. The patients are stabilized, cardiac rhythm is controlled. The final treatment depends on the findings. Either an angioplasty is performed by open heart surgery (changing the blocked blood vessels) or stents are put in the blocked blood vessels. This depends on the severity and degree of blood vessels involved. Both the procedures are very safe. Some researchers believe if early in menopausal life a women takes or given HRT, it is protective against heart attacks in later life. However one cannot be given HRT to protect repeat attacks. In summary it is good to know that, there are lots of solutions for heart attacks. Do not ignore the symptoms if they seem cardiac, as many women get heart attacks as men, after menopause. There is some protection by HRT if one has taken it at the right age, early in menopause. Improve your life style factors. Quit smoking, limited alcohol, watch weight and abdominal girth, regular exercises, cut down your stress levels and be happy. Change of life style factors will take you a long way to protect you from heart attacks.

VEGAN DIETS

 

In our Current world it is becoming popular to try and consume non meat diets. One such diet is called Vegan. It is estimated that in America there are 6.5 million people who are Vegans as opposed to India where the majority are all Vegetarians. The difference is that Vegans do not use any animal products which include milk and milk by products, eggs, fish, or poultry. One well known person in the world who is vegan is Bill Clinton. Using Vegan food is very good for the environment. It takes 100 times more water to produce 1lb of protein from animal than 1lb of protein from plant source. It is good as in some parts of the world we are getting short of water. Vegan diets are useful for weight loss, preventing many diseases, such as heart, diabetes and cancers.  Vegan can get their supply of Vitamin B12 from fortified plant milk and cereals it is important to make sure one gets adequate vitamins from other sources that one cannot get in a Vegan diet. The other vitamin which lacks in a Vegan diet is Vitamin D. For this it is best to sit in the midday sun for about half an hour at least three times a week, to get the UVR rays, as it turns the skin cholesterol to vitamin D. Vitamin D deficiency can cause bone pain, fatigue, muscle weakness, mood changes and even depression. B12 deficiency can also cause this. The other side effects of B12 are red tongue mouth ulcers, tingling and numbness and instability in walking. The other deficiency in a vegan diet is Omega 3. This is very important for body function, cell membranes, hormone production, contraction and relaxation of arteries, blood clotting regulation, decreasing inflammation in the body and heart function.                                                                                                 This can be obtained from flaxseeds, chia seeds and walnuts. These little seeds can be eaten with salads or cereals. The protein sources for vegans are dried peas, chickpeas, kidney, fava, black, and   adzuki beans. These sometimes are hard on GIT and cause bloated feelings and dehydration, it is best to hydrate the beans well when cooking. Eat in proportion. There are some Indian spices when used with lentils and beans help in preventing bloating.

Vegan diets over all, are very useful for individuals, hip pocket and environment; please take care of missing elements such as VitaminB12, Vitamin D, and Omega 3’s.

PREGNANCY IN WOMEN WITH DIABETES

 

Diabetes currently is one of the very serious problems in the world. About 1 in 11 people suffer from diabetes. There are 3 types of diabetes, type1, type 2 and gestational diabetes. The women who are pregnant with diabetes are type 1 or 2. Gestational diabetes is what develops for the first time in pregnancy. Women with diabetes often find it difficult to get pregnant. Uncontrolled diabetes during Pregnancy causes many problems, higher risk of miscarriages, increased foetal abnormalities, macrosomia (big baby) difficult birth, shoulder dystocia, foetal death, and a few others. In view of all this it is very important to have your diabetes under control. Make sure you are taking high doses of folic acid (400mcg daily), for one to two months prior; which helps to prevent foetal abnormalities. Once you get this sorted also make sure your BMI is ok.  This often is not easy but try to exercise regularly.  Find a diabetic specialist, who specialises in pregnancy with diabetes, a dietitian and may be a Physiotherapist. Have a long term glucose test called HbA1c tested it should be 7% if you have type 1 diabetes and 6% if you have type2. In addition you should have all your systems checked that are effected by diabetes, blood pressure, eyes, nerves, and kidneys. It is important to have a pregnancy ultrasound to have precise dates and make sure the pregnancy is normal. An ultra sound is done at 12 weeks, like in any pregnancy, for any genetic abnormalities. An 18 to 20 week ultrasound needs to be done for foetal anatomy and any foetal abnormalities. Maternal blood pressure is watched in women with blood pressure, for mother’s health and adequate foetal growth. In women who have been on Metformin it is discontinued, and replaced with Insulin if required. Women with type 1 diabetes require slightly less insulin in the first trimester. The routine blood tests, full blood examination, blood group, Hepatitis B and C, Syphilis, HIV, latest cervical screening, cervical culture and any other specific tests to the situation are all done.

Regarding the management life style changes are emphasized, regular exercise, stop smoking, no alcohol. Oral antidiabetics are not generally used as they cross the placenta. Women are supposed to maintain and manage their own blood sugars fasting 5.3mmol/L (95mg/dL), one hour 7.8/mmol/L (140mg/dL), two hours 6.7 mmol/L, (120mg/dL). AIC level to be maintained at 6to 6.5 %in type 2 and 7% in type 1 diabetes. This is done every month during pregnancy. It is more important to control blood sugars than A1c. In those women who use the pump, it is also required to test the pre-prandial blood sugar before using the bolus dose of insulin. It is best to leave the insulin management to a diabetic specialist. If the women are getting too many hypoglycaemic episodes, A1c can be relaxed to 7%. A well maintained diabetes prevents preeclampsia.

The most important decision to make in diabetic women is when and how to deliver these women. It is complex in all situations, depending on how well the diabetes is controlled, what facilities are available, what personal are there such as anaesthesiologist, neonatologist and a women’s personal situation. If it is a well controlled diabetes, there are no complications, no foetal compromise, not a big baby, favourable cervix, then it is good to induce at 39 weeks. It is good to have a neonatologist standing by, as babies often require help. Depending on the other factors, induce between 37 to 39 weeks. Never let them be overdue. If there is a situation which require a caesarean section, go ahead and do it.

In the postpartum period the need for insulin decreases so be watchful. Lactation is the best way to feed the babies, they need support as well. They can often get neonatal jaundice. It is important to watch the baby for obesity and diabetes as they grow. In fact this can be transgenerational. Advise all women about contraception.

GESTATIONAL DIABETES: SCREENING DIAGNOSIS AND MANAGEMENT

 

Diabetes mellitus an ever increasing disease in the world. It is a chronic disease causing high blood sugars. These cause changes in the big and small blood vessels finally leading to multi organ disease e.g. brain, eyes, heart and kidneys. Type 1 diabetes occurs in children who never produce insulin. Type two occurs in adults and at present it is occurring in epidemic numbers, 1 in 11 people. This increase is in adults. So much Diabetes in the world is due to our life style factors, affluence, and lack of activity even if we have to go to the local post office we take the car. Exercise physical activity transport and too much socialization. Type 3 diabetes is gestational diabetes occurring in women for the first time during pregnancy. This happens in about 7% of women. It becomes type 2 diabetes in large numbers of females depending on their life style, subsequent pregnancies, and weight gain. Pregnancy is classified as dibetogenic. With the increasing numbers of obesity in the world, diabetic pregnancy is increasing in parallel. This is referred as Gestational Diabetes Mellitus (GDM). This has its own problems, increased blood pressure causing a complication called preeclampsia of pregnancy, big babies (Macrosomia) causing need for caesarian section or difficult deliveries, shoulder dystocia (difficulty with delivery of shoulder), intrauterine fetal deaths and so on. With these happening, the World Health Organization (WHO) decided to screen all pregnant women for diabetes during pregnancy.  Those at higher risk are screened on the first visit, others at 24 -28 weeks because the need for insulin during pregnancy increases at this time. (It is also referred as Insulin resistance meaning body’s inability to use Insulin correctly.)  Blood glucose increases in blood, not being absorbed by the body cells, muscles, fat, and liver. The main cause for this is obesity and lack of activity

Why does the need for insulin increases during pregnancy. This is due to hormones produced by the placenta to help with the fetal growth and development. These hormones are estrogens, human placental lactogens, growth hormones and cortisol. These interfere with the body using insulin effectively. It collects in the blood instead of being absorbed by the cells. This is called Insulin resistance as already mentioned. Initially the placenta is able to produce more Insulin. But in the end this fails. Insulin resistance becomes high and GDM starts. The risk factor for GDM are previous GDM, BMR over 25 Kg per sqm, family history of Diabetes in the first degree relative (Mother, Father Etc.) poor obstetric history, previous fetal death, polycystic ovarian syndrome, big baby more than 4 Kg in weight, nationality: Chinese, Indian, Pacific Islander and Blacks and many others. The screening is started on the initial visit in these high risk women.

Different centers around the world perform the diagnosis by different technical details and consider slightly different normal values. Generally a glucose tolerance test (OGTT) is done. Blood is taken while fasting, then 75 mg of glucose solution is given to drink in 5 minutes. After this 3 samples of blood are taken for glucose in I hour, 2 hours and 3 hours .These values should be

1, 5.1mmol/L (92mg/dl)

2,10mmol/L (180mg/dl)

3, 8.5mmol/L (53mg/dl)

If any value is above the normal, a diagnosis of GDM is made. This differs in different centers in different places which creates confusion. In the past and in some places these values were slightly different fasting 5.3 mm/l. 2 hours 8.6 moll/L.  One has to go by what the local value and criteria are. Some places recommend two abnormal values, WHO recommends universal screening of all women at 24-28 weeks of pregnancy as currently GDM is increasing in tandem with obesity in the world. This is due to our prosperity and poor life style factors. GDM causes Diabetes type 2, in future years of life. It is recommended to screen for GDM on first antenatal visit if there are risk factors for diabetes These are obesity, BMI more than 25kg per sq. mtrs, family history of first degree relative with diabetes, previous stillbirth, shoulder dystocia, macrosomia baby bigger than 4000gm, ethnicity (Chinese, Indians, African Americans, Hispanic), age older than 35, weight gain of 11lbs since age 18 years.

GDM effects Pregnancy by maternal complications such as high blood pressure, preeclampsia, difficult delivery, need for induction, and caesarian section. It also causes big babies (MACROSOMIA), fetal abnormalities, still birth, shoulder dystocia (difficulty with the delivery of the shoulder) nerve palsies, fractures. These babies have hypoglycemia at birth and hyperbilirubinemia (neonatal Jaundice) these babies grow to be obese and hyperglycemic, develop diabetes later in life.

HOW to deal with GDM

Good management results in good results.  It is worthwhile to involve a diabetic physician a dietitian and may be a midwife. Proper care may, prevents preeclampsia, macrosomia, shoulder dystocia, any fetal injuries, need for induction or caesarian section. One basic rule in women with GDM is never let them go over due dates.

Glucose monitoring

Women should start monitoring fasting and 1- 2hours post prandial blood glucose the values accepted differ, 5.3 mmol/L(latest 5.1). 2hours 6.7 mmole/L.

The simplest treatment starts with life style changes, diet on the advice of a dietitian. Low GI carbohydrates are advised. Regular exercise, walking is best.

One recent  research has suggest that an  active exercise program in  the first trimester of pregnancy including walking, low impact aerobics, stationary bicycle and swimming can reduce the risk of GDM. If life style changes and diet alone cannot change the  blood sugars as desired, then some pharmacological drugs are added. Metformin is one such oral drug .  It is only used in some countries not in most. Insulin is the preferred drug treatment. Insulin is used when diet and exercise does not control diabetes as desired. 0.7 to 1, unit of Insulin is started per kg body weight of the women in question. Half of this dose is given as long acting Insulin last thing at night. The other half is given in three divided dosage as short acting Insulin with three meals, sometimes they can have some hypoglycemia in the middle of the night but it is not frequent or very severe. These dosages are adjusted as need be in each individual woman until the blood sugars are at the desired level as mentioned.

Special fetal care is provided for mothers who have GDM.  This can involve regular fundal height assessment fluid around the baby and fetal heart. This can be assessed by the clinician particularly an experienced one. This is often done by ultrasound as well twice weekly or weekly by biophysical profile from 32-34 weeks on wards. Depending on how well is your GDM is controlled. And if you are on Insulin. This includes fetal heart monitoring as well.  Fetal weight is estimated by ultrasound these days.

The other very important decisions are when and how to deliver this woman. If the GDM is well controlled by diet and exercise they can have a normal birth at term. Do not allow them to go past the due dates. Women are induced between 37-39 weeks if any other complications are present or DGM is not greatly controlled. If the fetal weight assessment is 4500g a caesarean section is advised[AP1] [AP2] [AP3]  they are made aware of limitation of weight assessment, particularly if they have a high BMI themselves.

During labor fetal heart monitoring is done continuously. Mother’s blood sugar is maintained by intravenous glucose and Insulin as required.  A pediatrician is invited to be present for delivery to look after the baby as they can have hypoglycemia or acidosis. Mother’s insulin is often not required after delivery. An OGTT is performed for the mother 6-12 week’s post-partum. Women are advised to breast feed as this is best both for the mother and the baby as it helps with minimizing weight gain. It is best to avoid weight gain and be active as this helps not getting Diabetes in future. An OGTT needs to be performed every year, some say every 3 years which I think is not enough. It is best to avoid too many pregnancies but that is individual choice.

We have very good news for the future, worked out by some great research scientists. They have found that the Tymus gland in our body involved with our immune system has a big role in pregnancy by producing cells called  TREGS via Rank are deficient in women who suffer repeated miscarriages and GDM . They also been trying to use them in clinical trials, so we can get rid of two very big problems in women. Great news.

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CASUSES OF PAIN DURING MENOPAUSAL YEARS

 

Once the periods finish in our later years of life women generally feel very happy. Once you have not had a period for one   year it is called menopause. It is a normal phase in our life cycle, it does mean that we cannot have a pregnancy any more. We feel excited that the menstrual aches and pains will go away, but different types of problems raise their hands, just before the periods completely stop.

In the peri menopausal years, i.e. just before menopause, our periods become erratic due to lack of regular ovulation. When this happens the period that starts after a long cycle is often very heavy and painful. For the control of these irregular periods woman are often given the normal oral contraceptive pill or some special pill which regulates the cycle, stops too much bleeding, stops hot flushes and are also contraceptive, so it is great for relief of this particular situation. The other pain you may continue to have is pain due to migraine. This may be the same as you used to have. It is variable, sometimes it goes away with menopause, or it can start for the first time after menopause. Your GP or Endocrinologist will be able to help. The other important cause of pain is ovarian pains. These could be due to preexisting problems such as residual ovary syndrome after hysterectomy or less often endometriosis, adenomyosis (this is the endometriosis of the uterus) polycystic ovaries. It is nor rare for a cyst to appear de novo in the ovary. The clinicians have to be very careful about these as they can often be cancerous and need proper work up to exclude or confirm this diagnosis.  The extent of treatment will depend on the nature of the cyst.  One very common cause of pain during menopause is what is called fibro myalgia which signifies pain all over our bodies, why we do not know or understand. We live on pain killers, maybe massage and whatever variable treatments. More common causes of pain like in both sexes are different types of arthritis. Women also get some different types of pain due to osteoporosis. This does not cause serious pain except for stress fracture of the spine, or  fractures of the bones, such as hip, and wrist or and  anywhere else such as an ankle. More serious causes of pain are cardiac.   Pain due to cardiovascular disease, venous thrombosis. Never ignore them. One of the commonest cause of death in post-menopausal women is cardiovascular disease. Cardiovascular pain can also imitate shoulder, jaw pain and often stomach pain like an ulcer pain. Please seek medical advice should you feel any of these pains as this requires special investigation. During menopause the immunity decreases that results in infections, these surely cause pain. One such infection at this time is shingles. This is caused if a woman has suffered chickenpox in the past. It appear in the torso like a vesicular rash and is very painful. This is infectious in the air and by symptoms touching.  Until a crust forms on the rash women need to be isolated for ten to fourteen days. Treatment involves pain relief and antiviral such as acyclovir.  If left untreated it can cause fatal complications, such as a stroke, pneumonia, encephalitis (inflammation of the brain). It can also cause blindness if it occurs near the eye.

Management of these pain problems is self-care, exercise, correct diet, humor, group activities, fun, and regular clinical advice.

POST MENOPAUSAL ENDOMETRIOSIS

FREQUENCY, DIAGNOSIS AND MANAGEMENT

Endometriosis a common gynaecological disorder occurring in 5 to 10% of the female population. It is a disease that affects younger women during their fertile life. It is supposed to be oestrogen dependent and therefore subsides after menopause. However it still occurs in 2.5 % of post menopausal women. Now there are millions and millions of postmenopausal women, and thousands are with Endometriosis, thus the gynaecologists often come across them. In recent times management of postmenopausal endometriosis is being considered. There is no clear cut pathogenesis on endometriosis. A very old retrograde menstruation theory does not explain all situations. In some case endometriosis has been seen in some 60 to 70 year old women, without any previous history. These lesions are deep, adhesive and sometimes far off from the pelvis. Besides retrograde menstruation, the other factors can be familial predisposition, genetic and epigenetic factors. It can also happen because of coelomic metaplasia, (meaning the bowel epithelium changes into endometriotic tissue) It can also arise from foetal remnants or abnormal oestrogen production from non ovarian tissues. Perhaps immune deficiency also plays a role it is believed that a hormone called Aromatase can convert the local testosterone into oestrogens and a de novo endometriosis arises. Levels of this hormones are higher in postmenopausal women . This can happen more often in obese women. No single theory can explain endometriosis especially when it happens for the first time. It often happens away from the pelvis on non gonodal (not gonads) such as, organs, kidney, ureter (the tube that connects the kidney to the bladder), appendix and bowel. Very rarely it is even reported on the skin. HRT is often responsible for postmenopausal endometriosis especially if oestrogen only therapy is used. Phytoestrogens (oestrogens from plant sources), these are over the counter drugs and their irregular use can reactivate endometriosis in post menopausal women who had it in younger years. Previous endometriosis can even become malignant if oestrogen only therapy is used in hysterectomised post menopausal women.

When women suffer, with pelvic pain, dyspareunia, Dyschezia (pain on bowel movement), abnormal bleeding, and known to have had endometriosis, has had surgical treatment, even if no history of endometriosis, always keep endometriosis in mind. Now if a woman is still having hot flushes, foggy head, lack of sleep and requests treatment for her problems; what can be offered to help her? After looking at her basic previous history, tests such as, a pelvic examination, cytology basic blood tests, maybe an ultrasound, a laparoscopy, if the pain is significant. If there are any significant findings, such as cysts on the ovary and deep infiltrating endometriosis, surgical treatment is advised. If there are no surgical findings medical treatment can be offered. This can be in the form of oestrogens, progesterone, and modified oestrogens called SERMS (modified oestrogens which act differently on different organs). If she still has her uterus and has recently become postmenopausal, concerned about pregnancy, she can try an oral contraceptive pill. Use a pill that best suits her. She can also try a group of hormones called GnRH analogues (these can lower the sex hormone levels). Tibolone, a synthetic steroid which acts as oestrogen, progesterone and testosterone, is a very useful drug. It helps with hot flushes, decreased libido and is very easy to take. It is a useful HRT for postmenopausal with endometriosis. It has a slightly increase risk of DVT.

Postmenopausal endometriosis is mostly recurrence or continuation of premenopausal endometriosis however there are cases reported which seem to arise new. There pathophysiology is difficult to understand.  Beside the explanations mentioned earlier it is also believed that an inflammatory  small cell protein involved in cell signalling called interlukin  play an important role by allowing ectopic endometrial cells to implant in different places and help them to grow. It is also suggested that stem cells modify as endometrial cells.

Conclusion: - Postmenopausal endometriosis is known to occur in about 2.5% of this group of women. It should always be kept in mind when postmenopausal women present with symptoms of pain and / or abnormal bleeding.

Since the postmenopausal endometriosis can be malignant, they can be surface ovarian cancers, endometrial and clear cell cancers; surgical treatment should be the first line of approach.  Many case reports where endometriosis is seen to occur outside the pelvis, such as the ureter, appendix, and bowel loops, and vagina. In one recent case report on the liver in which after surgical treatment, a SERM (conjugated equine oestrogens/ Bazidoxifene,) was used, as a modified HRT which preventing oestrogen acting on the endometrium (preventing the risk of endomtrial cancer), was used, and endometriosis completely resolved. I wonder if in future others will try to do this. Further research is needed to manage the postmenopausal Endometriosis and guidelines for surgical treatment and different newer HRT, will also be very welcome.

BOY OR GIRL? IT DEPENDS ON THE MALE PARTNER

This story starts in 1962. I was a very young doctor, just started a new job at a newly opened Medical school as a lecturer. It was my very first day, at my first job after completing my training. Those days there was no ultrasound, not even an x-ray machine nearby. My registrar called me to this new admission in the labour ward a woman was in established labour, who had never seen a doctor throughout her entire pregnancy. She had an enormous belly. It was difficult to feel anything. I expected it to be a twin pregnancy with too much fluid. We had no idea about her blood count. She told us she is trying for a male child and already has six daughters .Within minutes of her arrival the first child was born, the second child was already in a big hurry to arrive in the world , her belly was still somewhat biggish, however I gave her the injections to prevent bleeding which  is given after twin birth, then suddenly I realised that there was another baby, I had never witnessed  a triplet birth and never thought of it, we rushed a bit, to save getting  this baby trapped  after the injection, but luckily this baby arrived safely. Guess what, all the babies were girls well formed all normal with good weights between 4.5 lbs to 5 lbs. I suddenly felt very sad. I did not know how to tell the parents I told them of a family who had 8 daughters hoping for a son one day they all became very successful doctors. Here with this lower middle class family I was worried about their feeding and schooling.  60 years on, since I still think of what happened to them. In some countries there is such a fanaticism about having a son to carry the family name. Sadly the women are always blamed however it is the fathers Y chromosome which is responsible for the sex of the baby. In humans there are two sex chromosomes X and Y. The females have XX and male are XY. When a baby is being formed, an X chromosome comes from the mother and Y from the father, if there is a Y chromosome then the baby will be male. There is a 50 /50 chance in nature what will happen.  There are a few theories. The sperm can be male or female depending on what a particular man has inherited. The male are divided as mm, mf, and ff, men with mm sperm will mostly have boys and ff will mostly have girls. This varies in different generations.  The female sperm is longer stronger and also lives longer so a few theories were suggested that if you want to have a female child work out your ovulation and refrain from having sex two to three days before that, by the time you ovulate your male sperms may have demised, and if you want a male child have sex as close to ovulation as possible the fast running sperm will be able to fertilize the egg. In the 21^st century ovulation can be worked out by temperature charts, and ultrasounds, even an artificial inoculation of sperm can be done on the precise day. This in my very brief experience proved excellent. In more sophisticated medical situations where sexing is required for prevention of sex linked diseases, a micro sort system is recommended in preference to per implantation biopsy and intra villous sampling. Stories also go about what position you adopt during sex for a boy or girl. Inherited billionaires have more boys. People who have more brothers have more sons and vice versa. How do we guess in modern times when everybody has only one or two siblings? To my way of thinking the ovulation technique seems more scientific. Poor King Henry the VIII was not aware of any of this, and that it was he who was responsible for the sex of his child and not his queens.