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My first pregnancy ended up as a miscarriage and an evacuation of uterus was done a month ago. Can I try again to conceive after my first menses? The emotional impact of miscarriage to the woman is always a mixed one. It is natural for you to want to conceive right away after going through the heartache of losing a baby. On the other hand, you may also experience apprehension, anxiety, sadness, guilt and even anger after the miscarriage. Whatever feelings you may have, it is important that a rational decision be made when you are physically and emotionally ready. From the medical standpoint, patient is encouraged to wait for 2-3 menstrual cycles for the womb to recover and for its lining to become healthy before trying to conceive. The World Health Organization (WHO) advises a waiting period of at least six months. But a recent study in Scotland suggests otherwise. The researchers found that there was no medical advantage of such a delay. Their data showed that the sooner a woman conceived again, the better her chances of having a healthy pregnancy. The women were less likely to miscarry again or had other pregnancy-related complications compared with those who waited for a longer period of time. A consensus among the gynaecologists as to how long a patient should wait before trying to conceive is yet to be reached. Many women are concerned whether a repeat miscarriage will happen. Statistics have shown that at least 85% of women will go through a successful pregnancy subsequently. Although there is nothing you can do to prevent a miscarriage, preparing yourself for the next pregnancy by making healthy lifestyle choices is important. Eating a balanced diet, maintaining a healthy weight by regular exercise and taking prenatal vitamins and folic acid supplement will help improve the chances of a healthy pregnancy.

Q. Is chicken pox dangerous during pregnancy? Should I get the vaccination before getting pregnant? How long do I have to wait before conceiving after vaccination? A. Chickenpox is a very infectious illness caused by a virus called herpes zoster. It usually causes an itchy red rash with blisters but can occasionally affect the lungs (pneumonia), the liver (hepatitis) and the brain (encephalitis). Very rarely, pregnant women may die from these complications. For the unborn baby, the risk of getting chickenpox depends on the stage of the pregnancy when the mother gets infected. The highest risk is during the last 4 weeks of pregnancy. If the mother has chickenpox: · before 28 weeks of pregnancy, the baby is unlikely to be affected. However, there is a small chance (less than 1 in 100) that damage could occur to the eyes, legs, arms, brain, bladder or bowel. There is no increased risk of miscarriage. · between 28 and 36 weeks of pregnancy, the virus will stay in the baby’s body but will remain asymptomatic. The virus may become active again, causing shingles in the first few years of life. · after 36 weeks of pregnancy, the baby is at greatest risk of getting chickenpox. Chickenpox rash may appear after birth and the baby may have severe complications involving lungs, liver or brain. It is advisable that you get your blood checked first to find out whether you have the immunity against chickenpox. If you do not have the immunity, you should get vaccinated before getting pregnant. The vaccine contains a weakened form of the chickenpox virus and works by causing the body to produce antibodies (resistance) to protect against the disease. The vaccine should not be given during pregnancy and you should avoid getting pregnant for 3 months after the injection, based on guidelines by the Royal College of Obstetricians and Gynaecologists, U.K. It is given in two doses, one to two months apart. The vaccine can have side effects but they are usually mild. They include: - Redness, swelling, or soreness at the injection site. - Mild fever - Mild chickenpox-like rash, usually within a month of vaccination - Allergic reaction, usually mild.

1. This few months cycle shorten to 25 days only. Just turned 36 too. Does it matter? Before its 30 days. Longest 35 days. Normal menstrual period occurs every 21 to 35 days and lasts about 5 days. There is no cause for concern if it remains regular even it is shorten. 2. Hi doc, can you recommend where to go for fertility test in Singapore? What’s the cost of it? Fertility tests can be done in all restructured hospitals and many private clinics run by gynaecologist with special interest in fertility. 3. Hi, how does Hep B affect fertility? Hepatitis B or HBV is the most common hepatitis virus. It can be transmitted from mother to infant, through sexual contact, or through contact with infected blood. It does not affect fertility. But if you are planning to conceive, it is good to immunised yourself prior to conception. 4. Cycling will affect sperm quality and quantity. How about running? Running may also warm up the testes. If your semen analysis is good, running may not affect the quality and quantity of the sperm much. 5. Is it recommended to do ivf if ever had abnormal cyst? I presume the cyst you mentioned refers to the ovarian cyst. It is advisable to remove the cyst prior to performing the ivf 6. How is surgery to unblock a blocked fallopian tube done? Is there any risk? Blocked tube can be surgically opened up using microsurgical techniques. But the chances of successful pregnancy are usually low. The risk of ectopic pregnancy may be high. 7. Is there any medical treatment for Varicose veins without surgery? I do not know of any medical treatment of varicose veins around the testis. 8. Does Adenomyosis affects fertility? Pl refer to the article adenomyosis in aLife’s website 9. Hi, both fertility test result passed. Both age 31. Tried for 1 year still no baby. Whats the next step? There are many fertility tests. I do not know the details of the tests you have done. Perhaps you may want to seek a second opinion to review all these fertility tests 10. My wife just suffer from a miscarriage…what are the things to do prior to retrying to have a baby again? Are there any things to avoid doing during the recuperating period? What are the chances of getting pregnant for people suffered from miscarriage? Please refer to the Q&A section on miscarriage in aLife’s website 11. How long is the recovery time to trying for conception after laparoscopic myomectomy? The recovery time depends on how many and how big the fibroids you have removed. Pl follow the advice of your gynaecologist before trying to conceive. 12. Does coffee affect fertility for women? Please refer to the article on Q&A on 16 Nov: “My friend tells me that drinking tea or coffee may affect my chances of conception. I am drinking 2 cups of coffee a day. How much caffeine do they contain? Will I get infertile as a result?” 13. Can antidepressant affect the fetus in the first trimester? The risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is very low. Some medications have been proved safe while other may have been associated with health problems in babies. Please consult your health service provider for advice. 14. Can medicine which helps to stimulate ovulation and help implantation be taken on a monthly basis so as to increase the chances of conception? It is not necessary to take the medications unless there are problems with ovulation 15. I have to fly for work very often. Weill exposure to radiation in aircraft affect my sperm quality? The amount of radiation exposure received during commercial flights is too low to affect sperm quality. 16. Does an alkaline diet help increase pH of the vagina so more sperm can survive? Eating alkaline diet such as vegetables and fruits is good for fertility in general. What impact it has on the vaginal pH and perm survival is unclear. 17. I don’t have vagina discharge during ovulation possible? If you have regular menstrual flow, you should have clear transparent cervical mucus at ovulation. It is possible that you may not discern it because of many factors such as vaginal or cervical infection and previous surgery to the cervix 18. Are there optimal time of the day for sex for conception? You should have sex at the ovulation day .There is no optimal time to have sex on that day . 19. What is the best frequency of making love? Will high frequency affect male’s sperm health? An average of sexual intimacy of 2-3 times a week would be good for conception. 20. Have been having irregular mensus for months. It will come bit by bit for one month and the following month it will be very heavy. Went for ultra scan but it was normal. Is there any problem? Ultrasound scan only indicates that there are no masses such as uterine fibroid or ovarian cyst in the pelvis. It does not give you the diagnosis of irregular menses. You should consult your gynae to find out the cause and treat appropriately. 21. Is 30+ days menstrual cycle considered normal? If not, what can be done? Please refer to the article Q&A on intermenstrual bleeding 22. How does a woman perform self-examination to treat viscosity of her cervical mucus to assess her fertility? You need to be guided for self examination of the cervical mucus. 23. Are there any treatment for delayed ejaculation? Yes . There are medications for treatment for delayed ejaculation. But you need to see a gynaecologist interested in male fertility for medical assessments 24. There is a test done during menses. For cyst, can elaborate more? How much is it? I presume you mean ovarian cyst which can be functional or pathological. To differentiate both, you could have your scan done during or soon after menses. The functional cyst would disappear but not the pathological one. 25. Does tinea cruris affect spermicide quality and count? Tinea cruris is a fungal infection that affects the skin of your genitals, inner thighs and buttocks. It does not affect the quality and count of your sperm 26. Is there a way to increase sperm volume? Have some changes in your life styles. Reduce stress, eat a balanced diet, exercise regularly and have adequate rest. 27. What options are available for older couples (say male>40, female>35)? If you are still keen to try to conceive, you should have a medical check to sort out the problem early and treat appropriately. . Assisted reproductive procedures may help. 28. At what age would you not recommend to try any more since there are higher chances of child abnormalities? There is no hard and fast rule regarding what age the person should stop trying to conceive. It depends on the individual’s desire. Foetal abnormalities do increase in children born to older couples but the percentage is not 100%. 29. Does spotting in between period of concern for infertility? Yes. It can be an indication of impaired fertility. Please refer to the article Q&A on intermenstrual bleeding 30. May I know if there is a difference between clomid and letrozole? Is it better to take letrozole for ovulation? Clomid (clomiphene) and Letrozole are medications used to treat women with ovulation problems. They work by helping the pituitary gland (a small pea-size gland located at the base of the brain) stimulate the developing eggs in the ovaries through different physiological mechanisms. Both drugs works equally well. 31. Can you share more about vaginismus and what to do please? Pl refer to the article “Experiencing Painful Sex? Vaginismus?” in our website. 32. What does slight bleeding between periods mean? Please refer to the article Q&A on intermenstrual bleeding 33. I have bleeding between periods sometimes. Does doing vigorous exercise after menses cause such bleeding symptoms? Please refer to the article Q&A on intermenstrual bleeding.

Normal menstrual period occurs every 21 to 35 days and lasts about 5 days. Vaginal bleeding in between periods or intermenstrual bleedingis abnormal. Vigorous exercise, unless resulting in undue stress, is perhaps not the reason for the bleeding. Most cases of intermenstrual bleeding are due to non-cancerous and treatable causes. Occasionally, it may be due to cancer or pre-cancer. Thus it has to be assessed and treated promptly. Common causes of intermenstrual bleeding include: · Pregnancy complications: Miscarriage and ectopic pregnancy · Hormonal imbalance from emotional or work-related stress. · Cervical or endometrial polyps : These are benign or non-cancerous growths in the cervix (neck of womb) or lining of the womb · Hormonal contraception: Irregular bleeding can happen during the first three months of taking hormonal contraception in the form of pills, vaginal rings, skin patches, implants or injections · Infection of the cervix from sexually transmitted diseases · Uterine fibroid: This is a muscle growth of the womb. It it protrudes into the uterine cavity, it can cause heavy and irregular bleeding Polycystic ovary syndrome (PCOS): The irregular or absent ovulation in this condition may result in irregular bleeding. · Cervical cancer or pre-cancer may cause irregular bleeding, especially bleeding after sex · Uterine cancer: this is more common in older women, who may present with abnormal bleeding during menopause.

Clomid (clomiphene) and Letrozole are medications used to treat women with ovulation problems. They work by helping the pituitary gland (a small pea-sized gland located at the base of the brain) stimulate the developing eggs in the ovaries through different physiological mechanisms. Clomid has been used for decades whereas letrozole, which is an anti-breast cancer drug has been used only recently to treat ovulation disorders. Both medications are prescribed for five days during each cycle, usually beginning on day three and continuing through day seven. About 80% of women will respond to either medication. However, only half who ovulate will become pregnant. Why this is so remains unclear. 10% to 20% of women taking clomiphene or letrozole will experience side effects. Most of these are minor and short-lived. They include hot flushes, blurred vision, nausea, bloatedness and headache. Serious side effects are rare. The frequency of twins occurring in women who conceive while taking clomiphene or letrozole has been reported to be as high as 10%. Unlike clomiphene which inhibits oestrogen receptors in the brain, letrazole works by stopping the production of oestrogen in our body. Thus, it has the advantage over clomiphene in having better hormonal stimulation of the endometrium (lining of the womb) and the cervical mucus, a lesser chance of having twin pregnancy, a better side-effect profile with fewer hot flushes and mood symptoms and a more rapid clearance by the body. Both drugs are equally effective in fertility treatment. But a recent study in 2014 found that letrozole was more effective in treating women with the polycystic ovary syndrome. Chances of ovulation, conception, pregnancy, and live birth were found to be significantly higher with letrozole. Further studies are required to confirm these findings.

Losing a baby at any point during your pregnancy is probably the most devastating experience an expectant parent would have to deal with. And if you miscarry more than once, your confidence takes a beating.When Diana Chan, 37, suffered a second miscarriage, she felt sorry for her husband and useless as a mother. Chan notes that she and husband got to a point where they were so sick of feeling happy and optimistic, only to have to deal with the grief of losing their baby.It’s hard to prevent a miscarriage ― also known as a spontaneous abortion ― as most are the result of medical emergencies. SmartParents ob-gyn expert Dr Christopher Chong has this down-to-earth advice for grieving parents, “It may well be nature’s way of not letting what is not good enough to progress, rather than letting it [turn into] an abnormal chid and suffering.” “It may well be nature’s way of not letting what is not good enough to progress, rather than letting it [turn into] an abnormal chid and suffering.” Both Dr Chong and Dr Peter Chew, senior consultant ob-gyn at the Peter Chew Clinic for Women, offer facts about miscarriage… 1) Genetic abnormality is the most common cause About 70 to 80 per cent of miscarriages are the result of faulty genes. Dr Chew explains, “It is nature’s way of cutting down the number of malformed babies.” Your gynae will obtain a cell culture of the foetus to determine if genetics is to blame for your miscarriage. If it is indeed due to genetic factors, there is no effective way — including bedrest or drugs — to save your pregnancy. The good news is genetic malfunctions seldom manifest themselves again. 2) Health issues should be addressed, stat! Getting regular health checks and prenatal tests before you try to conceive can address any issues that may affect your pregnancy. Womb health issues are another common cause of miscarriages among Singaporean women. Dr Chew points out, “When the womb is malformed or has multiple fibroids — muscle growths in the womb — and when the womb’s neck [becomes loose] from repeated abortions, a miscarriage can occur.” If you experience infrequent periods, your lack of hormones could also cause you to miscarry. 3) Healthy mother = Healthy baby It’s important to prepare yourself for a healthy pregnancy by making healthful lifestyle choices like eating well and exercising regularly. Dr Chew says your diet should also include adequate vitamins like folic acid and minerals like iron. Dr Chong advises that taking folic acid two months before you try for a child can help reduce your foetus’s risk of getting spinal defects during pregnancy. Leading an active life can help avoid chronic health conditions like hypertension and diabetes, which can cause foetal death. And if you are a heavy smoker or drinker, you should put an end to these harmful habits. 4) It may be difficult or even impossible to uncover the reason for your miscarriage This is because any number of factors can result in the loss of your baby, so getting to the root cause can be a complex process. Sometimes, your foetus’ organs or genes may be developing abnormally, explains Dr Chong. Other times, it can result from placental infections and issues. Most worrying of all, autoimmune diseases — where the body creates antibodies that reject the foetus — can cost a baby its life.Did you know that your miscarriage risk increases with age? 5) Get your jabs! Be sure to get vaccinated against infections like chickenpox, rubella (German measles) and hepatitis B. Although you might have received these jabs as a kid, the vaccine’s protective properties will wane over time. 6) You’ll heal faster if you miscarry at an earlier stage of pregnancy Most miscarriages occur during the first trimester of pregnancy ― if yours was an uncomplicated miscarriage, your body should heal within a week, notes Dr Chong. After a miscarriage, your gynae will carry out dilation and curettage — often referred to as D&C ― on you. In this common surgical procedure, he will scrape the uterus lining to remove any remaining tissue, for instance, bits of the placenta, since these can increase your risk of a womb infection. Dr Chong stresses that women should then refrain from trying to conceive in the three months following surgery to give the womb’s lining time to heal. If the lining is thin, this can increase a woman’s chances of enduring another miscarriage. Also, he adds that you should only start thinking about planning another pregnancy when both your body and emotions are ready. Take all the time you need to grieve over your loss… Turning to a support group you can count on can also make a world of difference. 7) You have a high chance of a successful pregnancy after your first miscarriage Most women will go on to enjoy a normal pregnancy — the success rate is well above 95 per cent ― if the miscarriage they suffered was the result of a non-recurring pregnancy complication, notes Dr Chong. If the reason is a genetic malfunction, Dr Chew stresses that at least 85 per cent of women will experience a successful pregnancy after one miscarriage. Even after three miscarriages, with no known causes, your chances of giving birth to a healthy full-term baby is about 70 per cent, Dr Chong adds. 8) Your risk of suffering a miscarriage increases with age Women aged to 20 to 29 face a 15 per cent chance of suffering from a miscarriage. The rate doubles to 30 per cent for those between 30 and 39 years, and if you’re aged 40 or older, your risk jumps to 40 per cent. This is why Dr Chew advises, “Don’t delay parenthood.” A late-in-life mother is also likely to experience more pregnancy complications than her younger counterparts. The baby also has a higher risk of experiencing developmental issues increase in tandem with the mother’s age. 9) Spot the warning signs Vaginal bleeding in pregnancy is the most common sign of trouble. Dr Chew says that you could be producing a bloody discharge that can range in colour from red and brown, to even black. Dr Chong points out that you should also be alert to abdominal cramps and the water-bag breaking. Other times, your miscarriage can manifest as a sudden relief from all your pregnancy-related symptoms like engorged breasts or swelling and fluid retention. If you experience or notice any of these signs, it is vital to make an emergency visit to the hospital and get examined by a doctor. 10) A good support group can do wonders for your recovery Needless to say, dealing with the loss of a pregnancy isn’t easy at all, especially if you and your hubby have been trying to conceive for a while. Take all the time you need to grieve over your loss. In the meantime, engage with your family and friends and get involved in meaningful activities! Turning to a support group you can count on can also make a world of difference ― Dr Chong stresses, “Ventilate!” Dr Peter Chew is a senior consultant obstetrician-gynaecologist at Peter Chew Clinic for Women, he is also a board member of I Love Children. Dr Christopher Chong is a consultant obstetrician-gynaecologist at Gleneagles Hospital. In case you missed these reads Never say this to a woman who’s miscarriedLabour plans: C-section risks6 facts to know about birthing big babies

Depression during pregnancy is difficult to manage as hormonal changes in the body can trigger a wide range of emotions. If left untreated, it can have harmful effects on both the mum and the baby. The mum may be listless. She may not have enough energy to look after herself and attend the antenatal visits regularly. She may not bother about her own nutritional needs and may even indulge in smoking or drinking. The baby may be born prematurely with low birth weight and may have difficulty bonding with the mum who may have postpartum depression. Taking antidepressants is the definitive treatment. But like many other medications, there are concerns on the safety profiles. Many antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs) are generally safe. The risks of birth defects and other health problems are very low. Reported risks for the baby include: • Persistent pulmonary hypertension in the new born which is a serious condition of the blood vessels of the lungs. • Heart defects • Deformities of the nervous system, the abdominal organs and limbs • Low birth weight For the use of antidepressants, your psychiatrist and obstetrician will help you make a decision based on the balance between risks and benefits. If they feel that you can stop taking antidepressants during pregnancy, they will wean you off gradually as sudden stoppage of the drug would put you at risk of a relapse. Stopping an SSRI abruptly might cause various signs and symptoms, including: nausea, vomiting, chills, fatigue, anxiety and irritability. If you do have to take antidepressant throughout the pregnancy, you should be aware that your baby might have temporary withdrawal symptoms like jitters or irritability at birth.

I had a fibroid removed recently. I was told it was adenomyoma. How is it different from the fibroid? A. “Fibroid” is a common term referring to a solid, benign growth in the muscle wall of the womb. Under the microscope, two types of “fibroid” can be recognized: “leiomyoma” and “adenomyoma”. The former arises from the multiplication of the muscle cells and usually presents as multiple lumps that may distort the anatomy of the womb. It can be cored out easily from the womb during operation. Adenomyoma, on the other hand, results from the lining cells of the womb that have grown into the muscle wall. During menstruation, these lining cells bleed. This causes the surrounding muscle cells to react and form scar tissue around it. With time, a swollen area in the womb called adenomyoma is formed. It mimics “leiomyoma” on ultrasound examination and has similar signs and symptoms. Unlike “leiomyoma” ,it cannot be dissected out easily .

Q) I am an 18-year-old girl. I suffer from minor acne every now and then, which worsens when my period is here. By then, I will have a large pimple either around my chin or mouth. I experience irregular periods as well. I read that this might be due to an imbalance of hormones and birth control pills can help. I was thinking if there are any natural ways to balance out my hormones. Does drinking green tea help? I believe that my body is "cooling", so I try not to drink too much tea. A. Hormones are chemical “messengers” that affect the way cells and organs in our body function. It is normal for their levels to fluctuate at different times of the menstrual period. Hormones play an important role in the development of acne, although the exact mechanism is not clear. Male hormones (androgens) cause the oil glands under the skin to produce more oil. This will clog up the skin pores, resulting in bacterial infection and inflamed acne. Androgens are present in small amount in women and they are produced by the ovaries and the adrenal glands (small triangular shaped organs above the kidneys). Women with hormonal imbalances due to diseases such as polycystic ovary syndrome (PCOS) may experience problems with acne. They have raised levels of androgens. By lowering the levels of these hormones using oral contraceptive pills acne will improve. Healthy diet is a natural treatment for acne. Food high in saturated fats, processed grains, meat fats, and refined sugar has been shown in many studies to increase androgens whereas fresh vegetables, fruit, fish, fibre, antioxidants will lower the androgen levels. Green tea, being a powerful antioxidant, may help in relieving acne. A study in Finland in 1984 showed that by switching a diet high in saturated fat to one with less fat and more polyunsaturated fats (nuts, seeds, fish, leafy greens) for six weeks, there was a significant reduction in the blood levels of androgens and consequently an improvement in acne. Yogurt containing “good” bacteria may create a healthier environment in the intestines, improve immune system and help prevent inflammation and acne. Increase fibre consumption by eating more fresh fruits, vegetables and whole grains will help in relieving the acne too. Fatty fish like salmon and nuts such as walnuts and almonds are high in the omega fatty acids which can help acne by reducing inflammation in the skin. Cortisol, the stress hormone, has been found to increase the severity of acne. By exercising regularly and reducing stress, acne will improve.

Teresa, 26, was overjoyed when the home pregnancy test kit showed a positive result. She then made an appointment to see me 3 weeks later. Before her appointment, I received an urgent call from the husband informing me that Teresa was having severe tummy aches while they were out for dinner. I rushed to the A&E department to find Teresa in pain on the examination couch. “There was a sudden pain in my stomach and I felt sick. I vomited and almost fainted,” she recalled. She was sweating. Her blood pressure was slightly low, her pulse rapid, and her abdomen was bloated and tender to the touch. Ultrasound examination showed that she was 10 weeks pregnant with a healthy fetus. There was a 5 cm ovarian cyst in the right ovary and the womb was surrounded by some fluid Teresa had a ruptured ovarian cyst. She was rushed to the operating theatre for an emergency operation .The cyst was successfully removed by the laparoscopic key-hole surgery. She recovered well and had a normal delivery 7 months later. This case illustrates the importance of preconception check. It involves assessment of a woman's overall health and identifications of risks factors that may otherwise complicate pregnancy. It is essential in ensuring a healthy pregnancy and a healthy baby. If Teresa had the gynaecological assessment before conception, the ovarian cyst would have been detected, removed and a traumatic, emergency operation avoided. In Singapore, many women do not visit a doctor for preconception check. Ideally, preconception care should begin a year before conception. During the check up, you will be asked: · Your age and the age of your spouse · Years of marriage · Gynaecological history, including menstrual regularity, menstrual pain, vaginal discharge, sexual pain, previous contraceptive methods and history of sexually transmitted diseases. · Lifestyle: smoking and drinking habits · Dietary plan · Exercise regime. · Bodyweight: underweight or overweight is not conducive for conception · Medical history including family history of high blood pressure, diabetes and other medical problems · Past surgical history involving reproductive organs, hernia repair and appendicectomy · Past pregnancy losses (miscarriages and stillbirths) · Status of previous vaccinations especially German measles, hepatitis B and chickenpox. · Genetic disorders that may run in your family. From these medical evaluations, many risk factors leading to maternal complications and serious birth defects can be identified and appropriate treatment given. For examples, diabetes can pose serious problems during pregnancy. If managed properly before pregnancy, the risk of birth defects can be greatly reduced; Obesity can lead to gestational diabetes and birth defects. It's better to have weight under control before becoming pregnant. You will be advised on how to prepare your body optimally for a healthy pregnancy such as taking folic acid and other important nutrients .You should stop smoking and drinking alcohol before you are pregnant. If you have ovarian cysts or fibroids , they should be evaluated and removed prior to conception. Your exercise regime can be carefully planned so that you have a healthy bodyweight. You will be taught on how to detect ovulation so that you can determine the optimal time for conception. Preconception check is so important with many advantages. You should make it a priority

I have been married for 3months. I cannot consummate my marriage as the semen ejaculates before I could have penetration. My wife and I are upset and depressed. We are too embarrassed to talk to our doctor. What should we do? A. Premature ejaculation is common among couples who just get married. It is most often caused by anxiety and rarely due to physical problems. For man, sexual responses vary. Sometimes he reaches orgasm quickly while at other times, he takes longer. On the average it takes about two to four minutes from vaginal penetration to ejaculation. Premature ejaculation becomes an issue when couple cannot have proper sexual intercourse and feel frustrated and unsatisfied. The couple may slowly lose the desire for sexual intercourse leading to problems in marital relationship. Fortunately, the condition improves with medical guidance. Practice makes perfect and relaxation will help you deal with the problem. You can try to distract yourself by having non-sexual thoughts to avoid becoming excited too fast. Do not be too preoccupied with sex to the exclusion of all other sexual activities and do not end a sexual encounter as soon as you have an orgasm. In marital relationship, your wife may consider affection, romance and passion more important than the physical aspects of sexual responses. Some helpful tips: ¨ The "stop and start" technique To delay the ejaculation, the man should first learn how to identify and control the sensations leading to orgasm. Sexual stimulation is done by the spouse with lubricant until he is close to climax. The stimulation is then stopped for about thirty seconds. This allows him to relax before starting again. Repeat the procedure few times until final ejaculation occurs. ¨ The squeeze technique This is a variation of the above. This technique involves sexual stimulation until the man recognizes that he is about to ejaculate. At that point, the wife gently place the thumb and index finger around the tip or mid shaft of the penis and squeeze firmly for 15 second withholding further sexual stimulation for about 30 seconds, and then resuming stimulation. The sequence may be repeated by the spouse until ejaculation is desired, the final time allowing the stimulation to continue until ejaculation occurs. ¨ Sexual position can also affect a man’s ability to control ejaculation. Allowing the wife to be on top will make the man to be more relaxed and have a better control. ¨ Avoid drugs and alcohol. ¨ Antidepressants and other selective serotonin reuptake inhibitors (SSRIs) may be helpful because they may prolong the time to achieve ejaculation. ¨ Local anesthetic creams may be applied to the penis to decrease stimulation. Decreased feeling in the penis may prolong the time before ejaculation. Condom use may also have this effect for some men. Learning ejaculatory control is like learning any skill. It requires patience and perseverance of a committed partnership.

Q. I have been married for 2 years. I tried to get pregnant for the past 8 months but was not successful. Recently when I went for a check up, the gynae told me my womb is tilted backwards. Is this something I am born with? Could this be the reason for infertility? Can sexual intercourse change the position of the womb? Do I have to operate to help me conceived? A. The womb (uterus) is a pear-shaped organ situated in the lower part of the abdomen between the bladder (urinary passage) and the rectum (bowel). Every woman is born with her uterus in a certain position. It is either tilted forward towards the bladder (anteverted uterus), or backward towards the rectum (retroverted uterus). About 20%of women are born with retroverted uterus. This is normal. Medical studies have shown that this does not cause infertility as well as miscarriage. To “correct” and bring the womb forwards by surgery is therefore not necessary for conception. Sexual intercourse does not shift the position of the uterus. However, uterus can be pulled backwards by scar tissues from conditions such as endometriosis (backflow of menstrual blood) and sexually transmitted diseases. These conditions can cause infertility and the tilted uterus can cause pain during sexual intercourse. To increase chances of conception, you may try the following ¨ Missionary (man on top) position: Gravity will help the semen to deposit in the vagina ¨ Putting a pillow under the buttock after sex. This will allow semen to stay longer in the vagina. ¨ Rest in bed for at least half an hour after sex. The semen will liquefy and some watery discharge will flow out of the vagina. This is normal. If you still do not get pregnant after trying for a year, you and your spouse should have a proper infertility evaluation.