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With the news coverage over the last weeks, many people are aware of the rapid spread of Zika virus in the Americas and the concerns over the risk of microcephaly--a congenital condition associated with incomplete brain development and mental retardation--in babies whose mothers are exposed to the virus. The Obstetrical & Gynecological (O & G) Society of Singapore has produced a short write up for its members. This is reproduced below for our readers The Zika virus is a mosquito-borne single-stranded RNA virus related to Dengue virus. Significantly increasing transmission has been noted in South and Central America over the past few months. The virus is transmitted to humans primarily through the bite of an infected Aedes species mosquito. Once infected, the incubation period for the virus is approximately 3-12 days. Symptoms of the Zika virus disease are non-specific but may include fever, rash, arthralgia, and conjunctivitis. It is not currently known if pregnant woman are at greater risk of infection than non-pregnant individuals. However, it is possible that when contracted in pregnancy, the virus may lead to foetal microcephaly, although it is not yet clear whether this association is causal (although emerging evidence suggests that they may be) or whether additional factors are involved. In November 2015, the Brazilian Ministry of Health declared a public health emergency following reports of a 20-fold increase in the number of babies born with microcephaly, suggesting a potential link with the ongoing outbreak of the Zika virus infection in the region. The Centres for Disease Control and Prevention (CDC) now recommend that all pregnant women should consider postponing travel to areas where the Zika virus transmission is ongoing, and this recommendation has been issued by a number of other countries including Singapore's Ministry of Health. If travel to affected areas cannot be avoided, one should undertake strict precautions against mosquito bites, and monitor their health on return to Singapore for the next 14 days and consult a doctor if symptoms of Zika are present. While no cases of Zika virus infection have been detected in Singapore thus far, the possibility that there may be undetected cases cannot be ruled out as most infected persons may display mild or no symptoms. It is therefore important to stay vigilant against possible suspect cases, and consider the diagnosis of Zika virus infection among individuals returning from South or Central America, the Caribbean, or the Pacific region who developed a fever and/or other symptoms suggested of Zika virus infection while abroad or within 2 weeks of returning to Singapore.

1. What is the normal amount of semen produced during sexual intercourse? The amount ranges from 2- 5 ml 2. What type of body check should couple do before conception? Any clinic to recommend and cost? Preconception examination or pre-pregnancy care is important in helping couples to have a healthy pregnancy and a healthy baby. It involves assessments of the couple’s overall health and identifications of risks factors that may complicate pregnancy. Pl refer to the article “preconception examination” under pre-pregnancy category in our website 3. During menstruation if there are a bit of jelly lumpy discharge is it cyst? Cyst is a collection of liquid in a sac. It usually refers to growth inside the ovary i.e. “ovarian cyst”. The jelly like discharge in your menses is normally due to blood that clots 4. Symptoms of endometriosis? What are the different treatments for endometriosis? What are the chances of fertility with endometriosis? Pl refer to our article “endometriosis” under the category ”gynae conditions” 5. Can Chinese herbal medicine help fertility? Some Chinese herbs may help in the treatment of infertility. 6. Is there a good time in a day to copulate or have sex? There is no scientific study to suggest that copulation during certain time of the day will improve chances of conception. As long as you have sexual intimacy around the time of ovulation, chances of conception will increase. 7. What is the best time in a day for both to have sex to ensure conception? See answer to Q. 6 8. If one fallopian tube is blocked with rooted fibroid, can one still conceive with one good fallopian tube? The chances of conception are reduced if one fallopian tube is blocked but conception is still possible 9. Does excessive caffeine intake affect sperm quality? The jury is still out with regards to the effect of caffeine on the quality of sperm. Some studies even suggested that it may help the motility of the sperm 10. Hi doctor, I have heard that doggy style is also good to get pregnant faster. Is it true? Conception can occur with doggy position. I am not aware that this position will make the woman to get pregnant faster 11. If found had endometriosis, after laparoscopy and during the treatment of GNRH can use acupuncture? Thank you. Acupuncture has been found to aid in fertility treatment.

I am a first-time mum at 26 weeks of pregnancy. Recently, my obstetrician told me that I have gestational diabetes and asked me to eat a diet low in glycaemic index (GI). What is glycaemic index? A. Carbohydrate is one of the main nutrients in our food. When eaten, it is broken down into glucose which is the main source of energy for the cells in our body. The glycaemic index is a system of assigning a number to carbohydrate-containing foods according to how much each type of food increases the levels of the blood sugar. It rates the effect of a specific amount of a food on blood sugar compared with the same amount of pure glucose. For example, a food with a glycaemic index of 28 boosts blood sugar only 28% as much as pure glucose. One with a GI of 95 acts like pure glucose. Foods with carbohydrates that break down quickly during digestion and release glucose rapidly into the bloodstream tend to have a high glycaemic index (GI); foods with carbohydrates that break down more slowly, releasing glucose more gradually into the bloodstream, tend to have a low GI. Patients with gestational diabetes should eat a diet with low GI. This is because there will be a slower rate of digestion and absorption of the carbohydrate. Blood glucose levels and insulin levels will not spike rapidly. With a better control of the sugar levels , there will be a reduction in obstetric complications such as premature birth, stillbirth and delivery of a large baby. Foods low in GI include: Green vegetables, beans, lentils and fruits such as apples, pears, berries, bananas, and papayas Grains in the least-processed state such as brown rice, whole barley and whole wheat

HPV (human papillomavirus) is a common sexually transmitted disease. Generally, the infection is not associated with infertility but can cause precancerous and cancerous cells to grow in the cervix (neck of the womb). This may reduce a woman's chances of conception or maintain a pregnancy. Precancerous cells can be treated relatively easily if they are detected early. But the treatment may, in some cases, lead to fertility problems later on. When precancerous tissue is found in the cervix it needs to be removed. There are several ways of doing this. The tissue may be removed by laser biopsy as in your case, freezing or burning. These treatments may leave some scarring of the cervix, which could, in future, prevent the access of sperm to swim up the genital tract. The production of cervical mucus may also be reduced. Sperm need a certain amount of cervical mucus during ovulation to help them on their way to meet the egg. If too much cervical tissue is taken away, the cervix may be weaken and becomes “incompetent”. This will increase the risk of miscarriage at second trimester or premature labour. Since there are no trace of HPV since 2015, you should not delay trying to conceive.

Q. If IVF fail? What can be the other options we can do? A. IVF is only one of the ways of treating infertility. There are many other ways depending on the cause . Q. Hi Dr Chew, my husband is on Tegreto. Can he still take multivitamin such as comples B with folic acids etc together or he need to have a 2 hrs break in between? A. Tegretol is a common brand name for Carbamazepine. It is an anticonvulsant and a mood stabilizer. It can be taken with multivitamin without any break in between Q. How long after should we try again for a baby after D & C? A. For D&C, I presume you mean evacuation of the womb after miscarriage. You can try to conceive after 3 months. This is to allow your wife to recuperate from the physical and emotional stress of miscarriage Q.I am a male type 1 diabetic since 3 years old and currently I am 33 years old. Will it affect my fertility? Should I consider a fertility check after 3 months of unprotected sex? A. Diabetes can affect fertility. You should have the fertility check after 3 months of unprotected sex. Q. Can man having slimming pills affect fertility? A. there are many types of slimming pills. Some may affect fertility. Q. I used to take diane for my acne condition. I had it for about 6 months and stop after my skin condition gets better. Ever since I stop diane my menstrual cycle is irregular. My menses doesn’t come every month. Shortest is 2 months one time longest can get up to 4 months one time. May I know is there any problem to my health? Does it affect fertility? A. When you are on Diane, which is an oral contraceptive pills, you would have so called “normal periods” . This is not the “natural menstrual periods” resulting from normal ovulation. After you stop the medication and your menstrual cycle becomes irregular. You should go and have a health check . This may indicate hormonal upset and definitely will affect your chances of conception. Q. Are there foods for women to eat to encourage more eggs (chances of twins)? A. Not that I know of. Q. What are your views of TCM? A. TCM such as acupuncture has been proven to be useful in infertility treatment. Q. What about freezing eggs? What’s the procedure like? A. Egg freezing is a complex procedure. It involves stimulation of the ovary with medications , surgical retrieval of eggs under ultrasound guidance, selection of good quality eggs under microscope and finally storage at very low temperature under very stringent conditions. Q. What food helps to increase level of progesterone? A. Not that I know of .There are some herbs that purportedly can raise the levels of progesterone. Q. I am 23 years old female and have been trying for a baby with my husband for 1 year but there is no result. We are healthy, what could be the issue? A. You should have a fertility health check to find out the cause and get appropriate advice. Q. If my husband does not have much strength and low sex drive except in the morning. How do improve? A. Try to have intimacy in the morning or after a good rest especially during your ovulation period. Q. If we have been having sex for 5 months and often during fertile and ovulation period, is there any problem with our fertility? A. You should have a fertility health check to find out the exact cause and get appropriate treatment. Q. Can we have coffee and tea during pregnancy? A. Yes. You can have them in moderation. Q. How would ovarian cyst affect pregnancy? A. Pl refer to our article “ovarian cyst pregnancy” under “pregnancy “ in our website. Q. How to increase chance of pregnancy? A. Pl refer to the article ”Tips for Women Trying to Conceive” under “pre-pregnancy” Q. What is the purpose of pre conception checkup? What is covered generally? A. Pl refer to the article “preconception examination “ under “pre-pregnancy”

Folic acid is a B vitamin. It helps the body produce and maintain healthy new cells and is essential for the development of a baby’s spine, brain and skull in the early weeks of pregnancy. Studies have shown that folic acid greatly reduces the incidence of spina bifida, in which the baby’s spine does not close properly during development and anencephaly, a serious birth defect in which a baby is born without parts of the brain and skull. Folic acid is also found in preventing miscarriage and reducing the risk of high blood pressure and anaemia ("lack of blood") during pregnancy. Our body does not store folic acid, so it has to be taken through diet or supplements. Foods high in folic acid include dried beans, peas, nuts, leafy green vegetables , fruits, and enriched cereals, breads, pasta , crackers and other grain products. Folic acid supplements are usually prescribed to women who are trying to conceive or are pregnant. A daily dose of 400 micrograms is recommended.

I am now in my 4th month of pregnancy. My friends advise me to take a lot of fish so that my child can have a better I.Q. I do not like to eat fish. Besides, I am afraid that fish may contain toxic substances, like mercury, which are toxic for my baby. Can I take other types of food? Should I take supplements? I presume you are referring to the omega-3 fatty acids found in fish. They belong to a class of fatty acids called essential fatty acids which the body cannot produce and must be obtained from food. Omega-3 fatty acids are the "good" fat that come in more than one form. The types found in fish, called DHA and EPA have the best health benefits. Another form known as ALA is found in vegetable oils, flaxseed, walnuts, and dark leafy vegetables. Omega 3 fatty acids are important for building healthy cells and maintaining brain and nerve function. They are important for the intellectual and visual development of the fetus. They have been found to reduce the risks of pregnant mother getting high blood pressure and premature birth. Studies have also suggested that they reduce the chances of babies having intrauterine growth restriction (IUGR)-a condition where the baby stops growing in the womb and remains small for the period of pregnancy. They also lower the incidence of maternal depression after birth. Rich sources of omega-3 fatty acids are found in fish, such as salmon, Pollock, tilapia, catfish, cod, anchovies, mackerel, sardines, sea bass and trout. World Health Organization recommends 1-2 servings of fish per week. As you rightly pointed out, there are increasing levels of mercury in fish from pollution in the environment. Large “predator” type of fish such as swordfish and shark are unsafe for pregnant women. Since you do not like fish, there are other sources of omega-3 such as egg yolks and meats, flaxseed, walnuts, canola and soybean. Vitamin supplements containing omega-3 fatty acids may be another option. The supplements are absorbed more efficiently with meals. But you may have the side effects of a fishy breath, a fishy taste in your mouth, occasional nausea and stomach upset. If these side effects are too much to bear, you may try algae supplements. Algae that is commercially grown is generally safe, though blue-green algae in the wild may contain toxins.

I had sex with my husband the other day. The condom was torn. I was worried as I did not intend to get pregnant. My family doctor gave me a pill to take the next day. He told me it was for emergency contraception. How does it work? How effective is it? Any side effects? Emergency contraception refers to the birth control method that prevents unintended pregnancy after an unprotected sex or if there is contraceptive failure such as a torn condom during sexual intimacy. Occasionally it is used in women after sexual assault or rape. The following are methods of emergency contraception: 1. Taking emergency contraceptive pill (also known as the morning after pill) 2. Inserting an IUCD (intrauterine contraceptive device) Emergency contraceptive pills are more commonly used. They work by preventing or delaying the release of an egg (ovulation). They can be taken within up to 5 days after sex but are most effective within 12 hours after intercourse. When consumed within 72 hours after unprotected sex, they reduce the risk of pregnancy by about 75% to 90 %. They are used as a back-up and not as a regular contraceptive method. They do not have serious or long-term side effects Common side effects are abdominal pain, irregular menstrual bleeding, nausea, fatigue and headache. Less common side effects include breast tenderness, dizziness and vomiting. The second method of emergency contraception is by inserting an IUD which can be done within five days after unprotected intercourse. It is about 99% effective. Side effects include heavy menses, menstrual pain and vaginal discharge.

I am a first time mum in my last trimester. Recently, I read in the newspaper that the number of babies suffering from whooping cough is on the rise and the Government is reviewing the policy of vaccinating pregnant mothers as a way of prevention. Do I need the vaccination? Is it safe? Any side effects? Whooping cough or Pertussis is a serious and very contagious disease caused by the bacteria, Bordetella pertussis. The disease causes damage to the lungs which may result in death especially in young infants. It spreads easily through the coughs and sneezes of an infected person. Many infants get it through the older siblings, parents, or caregivers who may not even know they have the disease. In the initial stage, symptoms of whooping cough are similar to those of a common cold such as coughing, sneezing, running nose and low grade fever. After about 1-2 weeks, the patient may gasp for air with a typical high-pitched "whoop" following many rapid and prolonged coughing fits. Vomiting may occur during or after the coughing bout. Infants may not cough with the whooping sound, but they may try to catch their breath during the coughing spells. Serious complications such as pneumonia (lung infection), apnoea (a pause when breathing stops) and death may occur especially in those who are not fully vaccinated. Vaccination during pregnancy is the most effective way to protect the new born. According to the 2016 edition of the “CLINICAL PRACTICE GUIDELINES ON ADULT VACCINATION IN SINGAPORE” published by Society of Infectious Diseases Singapore, Institute of Infectious Diseases and epidemiology, College of Family Physicians Singapore and Chapter of Infectious Disease Physicians, Academy of Medicine, Pertussis vaccination is recommended for routine administration in pregnancy. The ideal time for vaccination is at the last trimester of pregnancy as the immune response to the vaccine peaks two weeks after administration After vaccination, the mother will produce the protective antibodies which then pass to the infant to provide early protection. The vaccine is safe with no adverse effects to the mother and child. It is also safe to breastfeed. Side effects are usually mild and include mild fever, fatigue or soreness at the site of the injection.

1. Is there any side effects for taking hormones pills? Like pills to increase progesterone level. Does taking hormones pills increase breast cancer rate? There are various types of hormone pills. Some are given during the treatment of infertility to support the pregnancy, while others are used in contraception. Like all medications, they have various side effects. You can also refer to the article “contraceptive pills” in our website. 2. How do you calculate ovulation from your menstruation date? It depends on whether the menstrual cycle is regular or not. If it is a regular cycle, ovulation date can be calculated as 14 days +/- 2 to 3 days prior to the expected date of the next menses. 3. Does history of STD (Gonorrhoea) affects female reproduction? Gonorrhoea is a common sexually transmitted disease (STD). It can cause inflammation of the fallopian tubes resulting in blockage and infertility. 4. How much does it cost to do the checks at the clinic or hospital? You can find out the cost from restructured hospitals (KKMH, NUH and SGH) as well as private hospitals and gynaecologist's clinics. 5. Is it important to store the cord blood? Please refer to the article “cord blood stem cells” in our website. 6. What is the recommended daily intake for folic acid and zinc for men to increase sperm mortality and count? Folic acid and zinc are important nutrients for sperm production, maturation and functions. There is no recommended daily dose for folic acid and zinc to improve sperm functions. But some experts have suggested that daily intake of 700mcg of folic acid and 15 mg of zinc could improve sperm quantity and quality. 7. I work near radars. Does it affect fertility? Studies have shown that exposure to radiofrequency fields during work with radiofrequency equipment and radar can cause a reduction of sperm motility and increase of abnormal sperm. 8 .Does taking long term gastric medication impact fertility? Most gastric medications do not affect fertility. But cimetidine, which reduces gastric acid may cause a decrease in sperm production. 9. Does cycling every day for an hour affect my sperm quality? Does padded shorts help? Researches have suggested that cyclists are more likely to have lower sperm count and abnormal sperm compared to those who lead a sedentary life. This is especially so for cyclists who regularly ride longer distances. Many contributory causes such as raised temperature from tight clothing, seat friction and riding pressure have been suggested for the low sperm count.Padded shorts may not help if you already have low sperm count. 10. Does low potassium level affects pregnancy rate? There are many causes of low potassium levels in the blood. If it is due to temporary causes such as diarrhoea and vomiting, fertility would not be affected. If it is due to chronic health issues such as kidney problems or diabetes, fertility may be affected. It is important for you to consult your health care provider to find out the cause of low potassium and get it treated accordingly . 10a. Does endometrial scratch improves chance of implantation? I presume you mean endometrial biopsy, which is a procedure using a fine instrument to sample the lining of the womb (endometrium) in the second half of the menstrual cycle. The result may indicate whether the hormone, progesterone is adequate enough to support implantation of the fertilised egg. As it is an invasive procedure, it is usually replaced by measuring the blood levels of the progesterone nowadays 11. Does coffee or tea affect fertility? Pl refer to our article (KEEP THIS QUESTION AFTER OUR ARTICLE IS RELEASED)….. 11a. Besides Viagra how can one overcome erectile dysfunction? Is there a negative effect to taking too much Viagra? There are many causes of ED. You should find out the cause and treat it appropriately. Taking too much drug without medical guidance is not a good practice. 12. Will birth control methods like IUD/IUS affect fertility? After removal of IUD/IUS, how soon can you start trying for a baby? IUD and IUS are used for contraception. You can start trying for baby straight away after removal. 13. I am diagnosed with pcos but managed to have my first child after consuming clomid. What are my chances of having the second child? PCOS may recur as there are some genetic basis of this condition. You may require treatment with clomid again if you want to conceive again. 14. Where can we get our sperm check? You can have a sperm check in gynaecologist’s clinic in restructured hospitals and in private hospitals. 15. Does good health means good sperm? Generally, a healthy body will produce good sperm. 16. How do you improve sex drive? Sex drive or libido refers to a person's desire for sexual activity. It differs in male and female and is influenced by biological, psychological and social factors. To improve the sex drive, it is important to identify reasons that cause its decline and try to rectify with appropriate method. 17. Is 26 days cycle considered short and the flow is not a lot signs of concerns? Menstrual cycle that occurs every 26 days is considered as normal. As long as the menses are regular and the amount of flow does not change abruptly, there is no sign of concern. In doubt, please consult your gynaecologist. 18. Does bulky uterus affect fertility and how does it affect? It depends on the cause of “bulky uterus”. If it is due to big uterine fibroids or adenomyosis (refer article in our website), fertility may be affected. 19. What checks should a newly married couple go for when trying for a baby? Pl refer to the article “preconception examination” in our website. 20. Why does more red meat intake lower sperm count whereas more intake of vegetables increase sperm count? Is there any substance in the red meat that reduce sperm count? Some studies have found that taking too much red meat may lower the sperm count and suggested that the chemicals, possibly pesticides found in red meat may interfere with male hormone production and affect fertility. Vegetables and fruits have lots of vitamins and trace minerals which are important nutrients for sperm production. 21. How do we differentiate whether the fertility problem is at the ovulation or implantation stage? What are the treatment approaches for each stage? Ovulation can be determined by various methods (refer to the article “fertility awareness “in our website). Fertility problem due to ovulation malfunction can be treated by various medications including clomiphene and gonadotrophin injection. Implantation problem can be discerned during IVF cycle where fertilised eggs fail to develop after embryo transfer. Various drugs such as progestogens have been used to improve the lining of the womb to improve implantation. 22. I have a poor sperm morphology and good sperm movement rate, how to improve sperm morphology? Sperm morphology refers to the appearance and shape of the sperm. Abnormal shaped sperm is an indication of poor sperm development and can be due to genetic cause, exposure to toxic chemicals, increased testicular temperature and infection. It is important to find out the cause so that appropriate treatment can be given. 23. What is sperm agglutination? Sperm agglutination refers to sperm sticking together or “clumping” due to infection or the presence of sperm antibodies. This will reduce or inhibit sperm’s movement and its ability to fertilize the egg. 24. If husband has diabetes and is taking medication, does it affect the health of new born? If the sperm is healthy, it should not affect the health of the new born. 25. What sexual position is the best to conceive? Missionary position will help the sperm to gravitate towards the neck of the womb and may improve chances of conception. 26. To clarify, the best time to check ovarian cysts is during or right after menses? To find out whether the ovarian cyst is functional or not, vaginal ultrasound examination is done during or soon after menses. 27. For having large fibroid over 5cm, must I operate to remove them? Understand it will be difficult to deliver naturally after that? For large fibroid of over 5cm, surgical removal would depend on whether it is symptomatic or not. Pl refer to the article “fibroid”. Mode of delivery of the baby after surgical removal of fibroid depends on many factors including whether the fibroid has entered the uterine cavity. The attending obstetrician should be the one to advice. 28. Will ovarian cyst surgery affect conception chances? Removal of ovarian cyst may cause damage to adjacent tissues in the ovary and may thus affect fertility. 29. If wife go toilet to wash immediately after sex, will it wash away the sperm and affect chances of pregnancy? To increase chances of conception, it is advisable for the female to lie on her back for about 30 minutes for the sperm to swim up the genital tract.

There are studies linking fried fast food and processed meat like bacon and sausages to lower sperm count and poorer sperm quality. Researchers from Harvard Medical School have found that eating too much junk food which contains large amounts of saturated fat is associated with a lower sperm count and quality. Men consuming the most omega-3 fatty acids found in fish had a better sperm quality. This study showed an association but could not establish a cause -effect relationship. Further studies have to be done to confirm the findings as a large proportion of the participants were overweight or obese, which could have had a negative impact on sperm quality as well. In another study carried out by Harvard Medical School, the scientists found a link between processed meat intake and lower sperm quality. They suggested that chemicals found in processed meat might interfere with male hormone production and thus, affect fertility. Again, a causal relationship could not be established. All the above studies suggest that to improve your fertility, a good and healthy diet is important.