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To boost your fertility, you have to be familiar with the symptoms of ovulation. The timing of ovulation can vary from ​person to person as well as from ​one menstrual cycle to the next. It is therefore important to learn and recognize​ the ​symptoms of ovulation. You will then be able to fine tune the timing of sexual intercourse with your partner in order to increase your chances of getting pregnant. The symptoms of ovulation are as follows: 1. Cervical Mucus The cervix (neck of the womb) secretes mucus all the time. Before ovulation the mucus is thick, sticky and tacky. This type of mucus is hostile to the sperm​ which are then trapped and prevented from swimming up the womb to meet the egg. At the time of ovulation, the mucus changes its characteristics and becomes thin, stretchy and looks like raw egg-white. This quality of mucus eases the passage of sperm through and is the best indicator of maximum fertility. Research studies have found that couples who had intercourse on the day when this type of mucus was detected were more likely to conceive. ​In addition, the amount of cervical secretion is also increased during ovulation. Youmay observe more vaginal secretions and discharge and increased lubrication of the vulva (private part). 2. Breast Tenderness Soon ​after ovulation, the ovary will produce a hormone called progesterone which may cause breast tenderness. Some women notice this sign around the time they ovulate. Others may not notice this until after ovulation. In any case, if you notice breast tenderness, it may mean that you are ovulating or have ovulated recently. 3. Increased Sex Drive During ovulation, there is a sudden surge of hormones in the body. These hormones stimulate the brain centre and may make you feel frisky and increase your sexual drive. ​ In this fertile phase, your body is primed to be more attracted to the male. 4. Spotting You may notice very light staining(spotting) in your underwear ​before, ​during ​and after ​ ovulation ​. This is due to the hormonal changes at this time of the menstrual cycle. 5. Ovulation pain About one in five women​ may​ notice dull ache or pain in the lower part of the ​tummy during ovulation. The discomfort, called mittelschmerz, occurs around the middle of menstrual cycle and usually lasts for a few hours. If you notice this type of pain, it may indicate that you are ovulating or near ovulation. 6. Bloatedness Around ovulation you may feel a little bloated in the tummy. The changes in hormones that takes place during ovulation is the likely cause. 7. Heightened sense of smell, taste and vision For some women, there m​a​y be a​ heightened sense of smell, taste and vision during ovulation. Not all the above-mentioned symptoms are present in every cycle and not all women will experience all the symptoms during ovulation. The most constant symptom is the presence of clear, stretchy and transparent mucus. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/. Other related articles are Female reproductive system Myths and misconceptions about fertility Tips for women trying to conceive

I am 41years old and my breasts are always painful before menses. Recently, my mammogram and ultrasound examination showed that I have some cysts in both breasts. My gynaecologist told me that I have fibrocystic disease and reassured me that those cysts are not cancerous. What is fibrocystic disease? Will it lead to cancer? Fibrocystic disease of the breast is a non-cancerous condition, characterized by lumpiness and occasional discomfort in one or both breasts. The condition is very common, occurring in 90% of women at some point in their lives. It is most common in women of childbearing age and tends to resolve after menopause. The exact cause is unknown and is generally believed to be due to hormonal imbalances, with dominance of the female hormone(oestrogen). Fibrocystic disease develops from two main tissues in the breast, the supporting connective tissues and the glands that secrete the milk during lactation. The connective tissue thickens and form firm, nodular and hard lumps (fibrosis) while the glands develop into fluid-filled sacs (cysts). Hormonal changes during the menstrual cycle may cause the fibrosis and cysts to get bigger and become painful before menstruation. Symptoms and signs of fibrocystic disease are tender and painful lumps which can mimic and/or mask breast cancer. Occasionally, there may be a clear or cloudy nipple discharge. The condition is not related to breast cancer. But, as it can co-exist with breast cancer development, any lump in the breast should be taken seriously and fully investigated. Other diagnostic tests in addition to screening mammography may be necessary in order to rule out an underlying breast cancer ​related articles​​Breast lumps  Breast self examination Breast cancer​ risks

CIN is a short form for “Cervical Intraepithelial Neoplasia”. It is a condition in which the healthy cells in the cervix (neck of the womb) undergo abnormal changes. The cervix is a cylindrical organ situated at the lowest part of the uterus. It has an outer surface which is covered by squamous cells and an inner surface lined by another type of cells called columnar cells. The area where these two types of cells meet is called the squamo-columnar junction. It is usually around this area that abnormal changes in the squamous cells take place. These cells do not invade into the deeper layers of the cervix or spread to other organs through blood or lymphatic vessels. But if left untreated, they have the potential to turn into cancer. CIN is caused by human papillomavirus (HPV). Of the over 100 types of HPV viruses, only about 20 are responsible for the abnormal changes in the cells. About 4 out of 5 adult women would have had cervical HPV infection at some time in their lives, and only a small number develop precancerous changes and a few finally progress to cervical cancer. Most patients with CIN have no symptoms. Occasionally, abnormal vaginal bleeding may occur. The cell changes are not visible to the naked eye and can only be suspected by an abnormal Pap smear or HPV DNA test. Diagnosis is made by biopsy of the cervix using a magnifying telescope (colposcope). CIN represents a spectrum of disease, ranging from CIN I (about one third of the cervical cells are abnormal ) to CIN2 (almost two third of the cells are abnormal) and CIN3 (almost all the cervical cells are abnormal) It is estimated that one out of six women will develop CIN 1, which usually resolves itself as the virus is cleared by the women’s own immune system. Further treatment is not required. But women with CIN 2 and CIN 3 may not spontaneously clear the lesion. They need further follow-up examinations and treatment to destroy the abnormal cells .The energy sources used include heat (electro cautery), laser and freezing techniques (cryotherapy). Although treatment of CIN 2 and CIN 3 using above modalities is generally effective, follow-up exams are essential. Consensus guidelines published in 2006 by the American Journal of Obstetrics & Gynecology (AJOG) report that the failure rate for the treatment processes is generally 5-15 percent. As a result, the incidence of invasive cervical cancer among women previously treated for CIN 2 and CIN 3 is substantially greater than in the general U.S. female population. For women who have completed the family or who do not wish to have any more children , removal of the womb (hysterectomy)may be another option. If treated early, CIN is 100% curable.

Q. I am 35 years old and single. I have been diagnosed with PCOS recently because of irregular and heavy periods. My gynae asked me to take oral contraceptive pills to regulate the menses. I am not very keen. Is there any alternative? What will be the consequences if I am not treated? A. PCOS or Polycystic ovarian syndrome is a common disorder caused by an imbalance of reproductive hormones. It affects about 10-15% of women of reproductive age. There are 3 components in this disorder: 1. Irregular ovulation resulting in absent, irregular, infrequent or prolonged periods that may be scanty or heavy. 2. Excess male hormones resulting in excess body and/or facial hair, severe acne, thinning of hair and weight gain. 3. Enlarged polycystic ovaries on ultrasound examination. The ovaries contain numerous small fluid-filled sacs(follicles) which surround the eggs. The exact cause of PCOS is unknown but the following factors may play a role: Excess Insulin: Insulin is the hormone produced by the pancreas that allows cells to use sugar (glucose). In PCOS, there is increased insulin production. This causes the ovaries to produce more male hormones which then interfere with the growth and release of eggs from the ovaries (ovulation). Low-grade inflammation. Research studies have shown that in PCOS, there is low-grade inflammation which causes the ovary to produce more male hormones. Heredity: Certain genes are found to be linked to PCOS. Women with PCOS require long-term care as there is no cure for this disorder. They have increased risk for the following conditions especially if obesity is also present. ·   Infertility ·   Abnormal uterine bleeding ·   Cancer of the uterine lining (endometrial cancer) ·   Gestational diabetes or pregnancy-induced high blood pressure ·   Type 2 diabetes ·   Metabolic syndrome with increased risk of cardiovascular diseases e.g. stroke and heart attack ·   High blood pressure ·   Cholesterol and lipid abnormalities ·   Severe liver inflammation caused by fat accumulation of fats in the liver Treatment of PCOS has to be individualised. Keeping your weight in check by dietary control and exercise will help restore ovulation. Since your main concern is menstrual irregularities and you are not comfortable taking oral contraceptive pills to regulate your menstrual cycle, an alternative approach is to take progesterone for 10 to 14 days every month. This type of progesterone therapy regulates your periods and offers protection against endometrial cancer, but it doesn't reduce the male hormone levels. You may also try taking metformin, an oral medication for diabetes that improves insulin resistance and lowers insulin levels. This drug may help with ovulation and lead to regular menstrual cycles. Metformin may also slow the progression to type 2 diabetes if you already have prediabetes and helps in weight management if your BMI is high.

Maternal nutrition during pregnancy will affect the growth of the foetus as well as its future health. A well-balanced diet should consist of an appropriate amount of carbohydrate, protein, fats, vitamins and minerals. In choosing what to eat during pregnancy, it is important to know the foods to avoid. These foods can be categorised as follows: 1. Foods contaminated with chemicals: · Studies have linked pesticides to premature births and possible birth defects. Foods contaminated with pesticides include fruits and vegetables with thin skins like peaches and strawberries. Washing these foods thoroughly with water before consumption may help. · Mercury can cause developmental delays and brain damage of the foetus. Some fish such as shark, tile fish and swordfish may contain dangerous levels of mercury. Choose smaller fish like pomfret, anchovies, salmon and trout instead. 2. Foods contaminated with harmful bacteria or parasites: · Unpasteurized milk and cheese may contain the bacteria, Listeria, that can cause miscarriage. Maternal infection can lead to blood poisoning, which may be life-threatening. · Raw eggs, or foods containing raw eggs, such as homemade Caesar dressings, ice cream and mayonnaise, may be contaminated with Salmonella. · Undercooked hot dogs and luncheon meats may be contaminated with Listeria. · Sushi, sashimi, raw oysters, scallops or clams may be contaminated with bacteria. Eating these foods may result in food poisoning. · Unwashed vegetables and fruits may be exposed Toxoplasmosis, a parasite that can cause miscarriage or foetal abnormalities. 3. Alcohol: Depending on the amount and timing, alcohol consumption during pregnancy can lead to Foetal Alcohol Syndrome and other developmental disorders. It should be avoided. 4.Caffeine The effect of caffeine on the foetus remains unclear although some studies suggest that drinking too much caffeine during pregnancy might be associated with an increased risk of miscarriage. It is recommended that limiting the amount of caffeine to 200 milligrams a day should be safe during pregnancy. This is equivalent to two 8-ounce (237-milliliter) cups of brewed coffee. 5. Herbs: As there is little data on the safety profiles of herbs on the developing foetus, it is advisable not to consume them. follow Dr.Peter Chew's articles on aLife's facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/. Other related articles are Prenatal vitamins Folic Acid

Recently, I was diagnosed with endometriosis which was confirmed by laparoscopy (fig 1). But I was perplexed why during my annual check-up two months ago, the ultrasound scan of my pelvis reported that there were ” no abnormalities seen in the uterus and ovaries”. Could the ultrasound examination miss the diagnosis? A. From the picture you sent (fig 1), it looks like you have endometriosis with implants on the lining of the pelvic wall (peritoneum) Endometriosis exists in 3 forms: 1. Patches or lesions on the peritoneum (the condition you have): These are implants on the surface of various pelvic organs. They are of various shapes, sizes and colours. These different colours usually reflect different stages of the disease.   The patches tend to be pink or red in early stages and turn brown or black when the disease is more chronic. Many women have a mixture of both types of patches. 2. Ovarian cyst or “chocolate” cyst (Also known colloquially as “blood” cyst) (fig2): A cyst is a sac filled with fluid. When endometriosis grows in the ovary, it fills the ovary with dark brown stale fluid, resembling that of chocolate and hence the name. The cyst can grow to several centimetres in size. They are usually formed in the later stages of endometriosis. 3. Deep Infiltrating Endometriosis: This is an uncommon form of the disease in which a solid hard  tumour is present. It usually penetrates into the bowel, bladder and/or vagina for 5 mm or more and cause very severe backache and pain. Of the modalities used in diagnosing endometriosis, ·         Laparoscopy continues to be the gold standard for the diagnosis of endometriotic implants and ovarian cysts. ·         Ultrasound is poor at diagnosing peritoneal implants but is useful in the detection and evaluation of ovarian cysts. ·         MRI is increasingly being used, especially in the evaluation of deep infiltrating disease.

The idea that tofu and other soy products affect male fertility is not new. These foods contain phyto-oestrogens, isoflavones, the plant chemical that mimics the female hormone (oestrogen) and may reduce male hormone (testosterone ) levels in the body. The impact of isoflavones on male fertility has been studied and remains unclear. In 2008, researchers from the Harvard School of Public Health in Boston found that regular consumption of these foods may lower the sperm count. They studied 99 men from infertile couples.These men were asked to complete a questionnaire that included items on how often, on average, they had eaten each of 15 soy foods listed during the past three months. They were also asked to describe their usual serving sizes compared to an illustration of a medium-size serving. They found that the men who ate soy foods had, on average, 41 million fewer sperm per ml than men who didn’t eat these foods. But there were no changes seen in the shape of sperm (morphology) or in their ability to swim (motility ) or in the volume of the ejaculate, all of which are important factors in fertility. The results of this relatively small study are not consistent with the large body of U.S. government and National Institute of Health-sponsored human and primate research, in which controlled amounts of isoflavones from soy were fed to subjects, with no effect on quantity, quality or motility of sperm. Besides, it is observed that east Asians have regularly consumed large amounts of soy foods without fertility issues, and they have produced very healthy children for centuries. Until further large controlled studies are done, there is no harm for you to consume tofu and other soy products.

For Macronutrients : Proteins (meat 2-3 servings/day) Carbohydrates(rice and alternatives 5-7 servings/day) Don’t add sugar in your food. Avoid sweet fizzy drinks, chocolates, ice-cream and desserts. Choose brown rice, wholegrain products over white refined sugar and flour Fats (sparingly) Use canola, sunflower, olive oil for cooking. Avoid palm oil , coconut oil and ghee For Micronutrients: Folic acid: green leafy vegetables, fish, fruits and nuts Iron: meats(beef , chiken, pork and lamb) , fish and green vegetables Calcium: milk and diary products, tofu, soya products Omega3-fatty acids: flaxseeds, fish oil Eat a diet rich in fibre(2 servings of fruits and vegetables each a day) ,so that you feel full and won’t get constipated Drink plenty of fluids to keep you well hydrated Continue to take prenatal vitamins and mineral supplements Avoid trans fats: found most often in frozen foods, pastries, crackers, potato chips, French fries and cookies

When C, a 33 year old mum and her husband came into my consultation room, they looked anxious and tense. “What is the matter?” I asked “Doc, you know I just delivered my baby 6 months ago by C- section. I am pregnant again. We don’t mind having a second baby but this is too soon. My friend tells me that I should wait for at least 2 years; otherwise the scar in my womb might burst. My husband and I are very worried. Should we terminate the pregnancy?” C said A vaginal ultrasound scan revealed that C was indeed 9 weeks pregnant and the baby was actively moving in her womb. I reassured her that the wound in her uterus had healed well and there was no medical reason to abort the baby. “Can I have a normal delivery this time?” she asked.” I was a bit upset that I could not deliver normally in the last pregnancy and that an emergency C-section had to be done because of fetal distress”. A Caesarean section (C-section) is the delivery of a baby by an incision in the uterus. During much of the last century, a woman who had a previous Caesarean section would almost have a planned repeat C-section and not a vaginal delivery for any subsequent births. Doctors were concerned that the scar from the previous incision in the uterus could rupture during labour, causing serious consequences to the mother and child. The blood vessels in the uterine wall might tear resulting in massive bleeding. An emergency operation would have to be done to save the mother’s life. In the process, the damaged uterus might have to be removed, ending hope for subsequent pregnancies. The effect of uterine rupture to the baby can be catastrophic. The baby would be expelled from the uterine wound resulting in instant death. Even if he or she is saved by an emergency operation, there is a risk of permanent brain damage. Because of all these concerns, the conventional wisdom is: “Once a caesar, always a caesar”. In recent times, however, medical studies have established the safety of vaginal delivery after a previous C-section. In Singapore, almost all the c-sections are done in the lower part of the uterus (lower segment caesarean section), the wound usually heals well and the risk of rupture during labour is very low (less than 1 per cent). Besides, there are advantages of a successful vaginal birth. Complications such as infection and blood loss are less common. Recovery is faster with a shorter hospital stay. Energy and stamina return more quickly. Many mums, like C, would like to participate in the birth process and experience a vaginal delivery. They can hold and breast-feed the baby sooner. A successful vaginal birth can also have a positive impact on future pregnancies. While repeat C-sections get more complicated each time, repeat vaginal deliveries tend to become progressively easier. However, not all women with a previous c-section are suitable for normal delivery. They include women with: • Big babies • Babies in an abnormal position such as breech or horizontal position • Serious maternal problems such as diabetes or high blood pressure • Multiple pregnancies • Abnormal placental positions such as placenta preavia (low lying placenta) • Previous uterine operations such as fibroid removal As C had none of the above conditions, I encouraged her to try for a vaginal birth, which she gladly accepted. She went into spontaneous labour at term and had a successful vaginal delivery. She had since delivered another baby naturally.

Starting a family was furthest from Celia’s mind when she got married at 30. She was a banker and her career was going at full steam then. She was happy with living a ‘double-income-no-kids’ life .Having a baby would mean the end of  cosy  tete-a tetes, candle-light dinners and twice-yearly holidays. She was not willing to give up this sort of life style. But things took a turn after she hit 35. “My husband and I had a serious talk about where our lives were heading,” she shared. “After much soul-searching, we decided that parenthood was something we really wanted and we did not want to regret missing out on it.” She tried to conceive for about six months without success. This was when she decided to see me. After the initial consultations and investigations, Celia was found to have multiple fibroids, a condition where there are benign growths in the muscle wall of the womb. These were removed successfully by key-hole surgery. Four months after the surgery, she was overjoyed when I showed her an ultrasound image of a foetus with its heart pulsating inside her womb after her period was overdue for 2 weeks. Her pregnancy progressed smoothly and she delivered a healthy girl by Caesarean section in December last year. Like Celia, more and more Singaporean women are starting a family late when they are in their mid-30s or older. Studies show that these mothers have more problems during pregnancy compared with their younger peers. There is an increased risk of miscarriage, most of which occur in the first trimester. About 10 percent of pregnancies for women in their 20s end in miscarriage. The risk rises to 20 percent after 35 and 35 per cent after 40. An older mum also has a higher chance of having an abnormal baby from chromosomal defects. The most common is Down’s syndrome, when affected children have varying degrees of mental retardation and physical birth defects.  The risk of a mother having a baby with Down’s syndrome increases from 1 in 1250 at the age of 25 to 1 in 400 at 35. There is also an increased incidence of coexisting medical conditions such as high blood pressure, diabetes and gynaecological problems such as ovarian cysts or uterine fibroids as in Celia’s case. These conditions have a negative impact on the the pregnancy outcome. For example, untreated diabetes can cause birth defects and miscarriage. Poorly controlled hypertension can result in stillbirth. Other complications that are more common in pregnant women over 35 include multiple pregnancy, placenta previa (low lying placenta), premature birth, intrauterine growth restriction and stillbirth. There is also an increased incidence of induced birth, assisted delivery using forceps or vacuum and Caesarean birth. Although Celia’s pregnancy was relatively smooth, she was monitored very closely during her prenatal period. To couples who have not embarked on the journey of parenthood, Celia has this to say:” Don’t wait too long to try. Fertility and pregnancy is not as easy as you would like to think. Allow ample time for the unexpected. Watch your biological clock!”

I have been having menstrual cramps for the past 3 years and confirmed with a diagnosis of endometriosis by key-hole surgery recently. I am 30 years old and getting married next year. What can I do to ease this condition besides taking medications? A. Endometriosis is a protracted condition (refer the article “endometriosis “in “gynaecological conditions” in our website) with a very high chance of the disease recurring. There are quite a few ways that may help reducing the symptoms. 1. Maintain a healthy body weight. Endometriosis is a hormone dependent condition. It remains active in the reproductive age when the levels of female hormone – oestrogen - are high and regresses after menopause when the hormone levels are low. Maintaining a healthy weight will reduce the production of oestrogen by the fat cells. This can ease some of the symptoms of endometriosis such as pain and bleeding. 2. Reduce stress: Women with endometriosis are often found to have elevated levels of stress hormones. Reducing stress with exercise like walking, swimming, and yoga and focusing on emotional health such as meditation often lead to improved quality of life. 3. Take more Omega-3: Research has suggested that a diet high in omega-3 fatty acids will reduce the risk of having endometriosis. Food like salmon and flax seeds are rich sources of omega-3. 4. Eat Turmeric: Studies in experimental animals suggested that this spice has anti-inflammatory properties and slows down the growth of the endometrial implants in endometriosis. But more research is needed in human beings. 5. Avoid exposure to environmental toxins such as PCBs (Polychlorinated biphenyls) and BPA (Bisphenol A) found in plastic and packaging materials. 6. Alternative medicine: Acupuncture has been shown to relieve painful periods and pelvic pain.

Recently, I was diagnosed with endometriosis which was confirmed by laparoscopy (fig 1). But I was perplexed why during my annual check-up two months ago, the ultrasound scan of my pelvis reported that there were ” no abnormalities seen in the uterus and ovaries”. Could the ultrasound examination miss the diagnosis? A. From the picture you sent (fig 1), it looks like you have endometriosis with implants on the lining of the pelvic wall (peritoneum) Endometriosis exists in 3 forms: 1. Patches or lesions on the peritoneum (the condition you have): These are implants on the surface of various pelvic organs. They are of various shapes, sizes and colours. These different colours usually reflect different stages of the disease. The patches tend to be pink or red in early stages and turn brown or black when the disease is more chronic. Many women have a mixture of both types of patches. 2. Ovarian cyst or “chocolate” cyst (Also known colloquially as “blood” cyst) (fig2): A cyst is a sac filled with fluid. When endometriosis grows in the ovary, it fills the ovary with dark brown stale fluid, resembling that of chocolate and hence the name. The cyst can grow to several centimetres in size. They are usually formed in the later stages of endometriosis. 3. Deep Infiltrating Endometriosis: This is an uncommon form of the disease in which a solid hard tumour is present. It usually penetrates into the bowel, bladder and/or vagina for 5 mm or more and cause very severe backache and pain. Of the modalities used in diagnosing endometriosis, · Laparoscopy continues to be the gold standard for the diagnosis of endometriotic implants and ovarian cysts. · Ultrasound is poor at diagnosing peritoneal implants but is useful in the detection and evaluation of ovarian cysts. · MRI is increasingly being used, especially in the evaluation of deep infiltrating disease.