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.

She sacrificed her life for her unborn child Mrs. S, a 35-year-old woman in her second pregnancy, was diagnosed with breast cancer. She was then four months pregnant and was offered a termination of pregnancy by a gynaecologist. But she delayed her decision to abort the baby. She told her husband: “I am going to take my chance and let my baby live.” She came to see me in her sixth month of pregnancy and said that she had felt a painless lump in her right breast while bathing. She was then in her third month of pregnancy. The lump was firm to the touch and grew rapidly from the size of a small fishball to a golf ball within a month. Soon, there were lumps appearing in the right armpit. She consulted a surgeon who told her that she had advanced breast cancer and she was referred to a gynaecologist for an abortion prior to surgical removal of the cancer. Breast cancer is the most common cancer among women in Singapore. One in five cancers occurring in Singaporean women is breast cancer. Every year, about 1,100 new cases of breast cancer are diagnosed. That means three women are diagnosed with breast cancer each day. And about 270 die from the disease each year. Breast cancer occurs in about one in every 3,000 pregnancies and most often when the mother is between the ages of 32 and 38, as in the case of Mrs. S. It usually appears as an innocuous lump and may cause retraction of the nipple as it grows. Breast cancer is usually difficult to detect early in pregnant women, whose breasts are often tender and swollen. By the time the patient presents herself to the doctor, the cancer is usually at the advanced stage. This is what happened in Mrs. S, whose cancer had spread to the lymph nodes in the armpit. When I examined her, she appeared anxious, but was firm about her decision to continue with her pregnancy even though this was contrary to the surgeon’s advice. She knew very well that the cancer would grow more rapidly during pregnancy due to the increase in female hormones. This would make the management of her condition difficult. After many sessions of prolonged discussion with her and her husband, I was moved by her willingness to risk her life for the sake of her baby. A holistic approach was required in this unique case as I worked closely with my surgical colleagues. Mrs. S underwent removal of her breast with clearance of the lymph nodes in the armpit during the seventh month of her pregnancy. The cancer was found to be aggressive in nature. A baby boy was delivered in the eighth month of her pregnancy by Caesarean section. He was discharged after a week in the neo-natal intensive care unit. Soon after the delivery, Mrs. S had radiotherapy and adjuvant chemotherapy. This was more palliative than curative as the cancer was found to have spread to the brain. This information was passed on to patient’s husband. It was to prepare him for the inevitable. A difficult time Three months later, I received a phone call from her husband and was informed that she had passed away in her sleep. At that juncture, I could only be reminded of the brave decision she had made and her love for her unborn son. It was difficult time for me as I thought of the days when we journeyed together during her pregnancy. I constantly encouraged her and affirmed her determination to proceed with her pregnancy even though the odds were against her. When I attended the funeral, I met the patient’s admirable husband who was looking after the two children. I was surprised when he approached me and put a note in my hands. He said that Mrs. S wrote this note about a week before her death. It took me a while before I decided to read it. I was on verge of tears after reading the touching note which said: “Dear Doctor Chew, I appreciate your concern and care. You have certainly provided me with the opportunity of motherhood even though it may be a short one.” As an obstetrician, I have encountered numerous cases but it is these instances that render the fruits of my labour worthwhile and continue to inspire me as a health-care professional. I have kept the note till this day and it has been a source of motivation when the going gets tough.

I am a first time mum in my first trimester. I have been suffering from depression before pregnancy and am taking antidepressant. 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.

Obesity is an “epidemic” in developed countries. It increases the risks of chronic diseases such as hypertension and diabetes and has a negative impact on reproductive health like erectile dysfunction and infertility. Dietary control is essential in the management of obesity. Many diet plans have been proposed for the reduction of body weight, sometimes in an unhealthy way. Fad crash dieting, for example, is potentially dangerous. Eat smart with a healthy balance diet is thus the most important thing in weight management. Below are some of the foods that may be helpful in weight management. Almond Almond is rich in nutrients, including magnesium, iron, calcium, vitamin E and fibre. It may help maintain healthy cholesterol levels. Almond is also a superior snack when compared to junky options such as pastries. Chewing the nut will make you feel as if you are eating something substantial. Beans Beans are a great source of protein. They are also high in fibre and slow to digest. You would feel full longer, which may stop you from eating more. Oatmeal Oatmeal is made from rolled or ground oats which are rich in B vitamins, omega-3 fatty acids, and potassium. They also contain complex carbohydrates, as well as water-soluble fibre, which slow digestion down and stabilize levels of blood-glucose. Broccoli Broccoli is rich in calcium, potassium, Vitamin C, folate, fibre and phytonutrients. Phytonutrients are compounds that reduce the risk of developing heart disease, diabetes, and some cancers..It contains antioxidants , beta-carotene and sulforaphane, a chemical that is said to have anti-cancer and anti-inflammatory qualities.However, overcooking broccoli can destroy many of its nutrients. So, eat it raw or lightly steamed. Apple Besides vitamins, apple is an excellent source of antioxidants, which combat free radicals. A research in the Florida State University has found that older women who started a regime of eating apples daily experienced a 23 percent drop in levels of bad cholesterol (LDL) and a 4 percent increase in good cholesterol (HDL) after 6 months. Egg Egg is another source of protein that can easily be incorporated into a balanced diet. It contains vitamin B-2 and vitamin B-12, both of which are important for energy and red blood cells. It is also a good source of the essential amino acid leucine, which is important for stimulating the production of muscle protein. The yolk of the egg contains the majority of the vitamins and minerals. It also contains the fat and cholesterol. Research has shown that taking eggs in moderation do not increase the risk for heart disease.

I am 30 years old. Recently I noticed some bloody discharge after intercourse? This has happened about 3 to 4 times. What are the causes? Should I see a gynaecologist? What examination or tests would he/she do? A. There are many reasons why a woman bleeds or has bloody discharge after sex. The medical term for this condition is called "post-coital bleeding"(PCB).While the bleeding may be alarming, it is not that uncommon affecting up to 10 percent of women of reproductive age. Although it is called "vaginal" bleeding, most of the time it comes from the neck of the womb(cervix). Other parts of the genital and urinary systems may also be involved.The most common cause for PCB is inflammation of the cervix, or cervicitis. It can result from a sexually transmitted infection, such as chlamydia or gonorrhoea or from a non-infectious cause such as allergic reactions to feminine douches. An overgrowth of some of the bacteria that are normally present in the vagina, a condition known as bacterial vaginosis, can also cause cervicitis. The second common reason for bleeding after sex is the presence of a cervical polyp. These are usually non-cancerous growths. (see cervical polyp in the website) Other causes of PCB include: Vaginal dryness caused by reduced vaginal secretions, Vaginal infection, Vagina tears from childbirth, Genital sores caused by herpes or other infections, Cancer of the cervix, vagina, or uterus. While many of the causes are harmless, occasionally, PCB can be a sign of a more serious problem such as cancer or precancer of the genital tract. If the PCB is repeating itself as in your case, you should consult the gynaecologist to find out the cause so that appropriate treatment can be given. The gynaecologist will probably ask you some questions to see if there is an obvious reason for the bleeding. He or she may also want to know if you are having pain during sex, which can be a sign of inadequate lubrication or infection. A vaginal speculum will be used to open the vaginal walls to look for the source of the bleeding in the cervix or vagina. A swab of the vaginal discharge will be taken to test for sexually transmitted infections like chlamydia and gonorrhoea. A Pap smear test will also be done to detect any sign of abnormal, precancerous growths or cancer cells of the cervix. If the Pap smear test reveals any abnormalities, your gynaecologist may advise further test using a special magnifying device called colposcope to get a closer look at the cervix. (see colposcopy in the website)

She looked tense and agitated. “I have been married for three years and have a good relationship with my husband,” my patient told me. “It took me a long time to realize that I was not achieving climax during sex. I get aroused easily but I do not get the pleasurable orgasmic sensations that my close friends have experienced. The frustration is indescribable. “My husband is feeling the stress too. We discussed different approaches such as more foreplay and going away on short holidays, which might help us feel more relaxed. It was all to no avail. I am afraid that this may affect our relationship in the long run.” F, a 32-year-old, is suffering from a common female sexual disorder called anorgasmia in which she is unable to reach orgasm when sexually excited and is distressed by the problem. Orgasm is a phase of sexual response where there is a feeling of intense physical pleasure and release of tension, accompanied by involuntary, rhythmic contractions of pelvic muscles. Sexual response is a complex coordination of the mind and the body and both need to be functioning well for orgasm to occur. Anorgasmia affects between 15 and 40 per cent of women. It can be divided into a primary disorder, in which a woman has never experienced orgasm, as in F’s case, and a secondary one, when the ability to reach climax is lost. Inability to reach orgasm is usually a result of sexual inexperience, performance anxiety, past sexual trauma or a strict upbringing that led to an inhibition of sexual response. In F’s case, she was brought up in a very strict and traditional family where the subject of sex was never brought up. Other causes include diabetes, neurological diseases, blood pressure medications and antidepressants – particularly selective serotonin reuptake inhibitors (SSRIs). Women who have relationship issues such as a lack of emotional connection with their partner, unresolved conflicts, poor communication of sexual needs and preferences and infidelity or breach of trust may also suffer from anorgasmia. An evaluation of this condition usually consists of reviewing a patient’s thorough medical history and physical examination to rule out underlying medical conditions. Like many sexual dysfunctions, diagnosis is somewhat subjective and depends a great deal upon the thoughts, emotions and desires of the patient. A treatment plan includes sex education, communication training and behavioural exercises. For many Asian women, socio-cultural influences and family upbringing (as in F’s case) often lead to inhibitions and difficulty in receiving pleasurable sexual stimuli. It is important to educate the couple on the anatomy and physiology of sexual intimacy. The couple should also be counselled on the emotional or situational factors that might contribute to the lack of orgasm. Women who are suffering from the side effects of SSRIs may benefit from a change to alternative medication (like Bupropion). Older women can be helped by the use of vaginal lubricants or female hormonal cream. This may improve blood flow to the vagina and make intimacy more pleasurable. Clitoral vacuum pump devices that improve clitoral blood flow and sexual sensations are helpful. Herbal supplements and testosterone (male hormone) have been used with varying degrees of success. If there are other sexual dysfunctions (such as lack of interest and pain during intercourse) present at the same time, these need to be addressed as well. F and her husband were taught the mechanisms of sexual arousal and the differences in the male and female sexual response. To help her achieve orgasm, sensate focus (specific sexual exercises) and Kegel exercises (contracting and relaxing of the pelvic floor muscles) were recommended to improve the tone of her pelvic muscles. Through the body-awareness programme and comfort with orgasm, F slowly took charge in directing her husband during intimacy. Last Christmas, I received a card from F. She wrote: “Dear Doc, thanks for your help, my marital life is more fulfilling and I feel more complete as a woman now.”

I am 34 years old and trying to conceive. I am diagnosed as having type 2 diabetes. My doctor has been monitoring my blood levels of HbA1c which is 9.6 % at present. He told me I should wait a while till the levels drop to 6.5% or lower before I try to get pregnant. Why should it be so? What is HbA1c? What does the percentage represent? Keeping the blood sugar levels under control is very important for diabetic patients who are trying to conceive. This is because uncontrolled diabetes during pregnancy may have serious consequences affecting the baby such as miscarriage, premature birth, stillbirth and having a big baby requiring Caesarean section. When sugar is absorbed into the body from the food, it is circulated in the bloodstream as glucose .A certain amount of glucose gets attached to the haemoglobin, a protein in the red blood cell that carries oxygen. The compound formed is called “glycated” haemoglobin or HbA1c. The amount attached is directly proportional to the total amount of blood glucose present in the body and is expressed as a percentage of the total haemoglobin. As the life span of the red blood cells is 8-12 weeks, measurement of HbA1c is used to assess the average blood glucose levels over that duration. This provides a useful gauge of blood sugar control in diabetic patient. In healthy people, the HbA1c level is less than 6% of total haemoglobin. Your level of 9.5% is high and indicates that your diabetes is not well controlled. Studies have demonstrated that the complications of diabetes can be reduced or prevented if the HbA1c level can be kept below 6.5%. Since you are planning to become pregnant, you should be monitored with HbA1c monthly to help monitor your diabetes control. Meeting the target of 6.5% or below will help minimise the risk of the baby developing congenital malformations or ​other complications during pregnancy. As your level of HbA1c still high, you are advised to avoid becoming pregnant until good diabetes control is achieved and sustained.

My previous boyfriend infected me with gonorrhoea for which I have been treated. I am now married and have been trying to have a baby without success. Could the cause of infertility be due to gonorrhoea? A. Gonorrhoea is a sexually transmitted infection (STD) caused by the bacterium Neisseria gonorrhoeae. It can cause infections in the genitals, anus, and throat through unprotected vaginal, anal, or oral sex. It is a very common infection and can affect both men and women. While some men may not have any symptoms, many may complain of: · Burning sensation while urinating; · White, yellow, or green discharge from the penis; · Painful or swollen testicles occasionally Most women have no symptoms but some may have: · Painful or burning sensation while urinating; · Copious yellowish vaginal discharge; · Lower abdominal discomfort or pain; · Bleeding between menstrual periods · Fever Anal infections may cause symptoms in both men and women . They include: · Discharge; · Anal itching; · Soreness; · Bleeding; · Painful bowel movements. Whether or not you can get pregnant after contracting gonorrhea depends on how well you have been treated. Usually, antibiotics can eradicate the disease quite successfully. But if the bacteria is resistant to the antibiotics or if left untreated, the infection can travel up the genital tract and cause inflammation in and around the fallopian tubes forming scars. This leads to blockage of the tubes preventing the sperm from fertilizing the egg. It is this condition called pelvic inflammatory disease (PID) that may cause infertility. Another complication that may arise from PID is that the scarred fallopian tube can also prevent the fertilised egg from entering the womb. This may result in an ectopic pregnancy which is non-viable and can cause massive internal bleeding when the tube ruptures. Though you have been treated, your husband should also be assessed and treated if necessary to prevent reinfection.

I attended a workshop on “vaginal rejuvenation” procedure in Seoul recently. It is simple and is done by passing the laser beam via a narrow rod-shaped device inserted in the vagina. It takes 15 to 20 minutes to complete and the patient is discharged on the same day. Vagina or “birth canal” is the passage through which the baby is born .It is a hollow stretchy organ with a firm thick wall. With repeated childbirths, growing age and declining levels of hormones, it loses its elasticity and becomes lax. This leads to a “loose vagina” or vaginal relaxation syndrome (VRS) VRS may have physical and psychological problems such as a decline in sexual satisfaction and desire for both the female and her partner. She has less contact with the penis and may not have orgasm. Occasionally, she passes gas during sex. This dampens her mood and causes further embarrassment. As the laxity worsens, her womb and the urinary bladder move downwards and bulge to the outside. She may have a heavy sensation or feel a “lump” at the private area. Urinary incontinence and incomplete emptying of bowel may appear. The treatment of VRS includes Kegel exercise, hormone cream or spray to tighten the pelvic muscles and vagina. These are simple methods but may not be effective. Surgery is usually done in severe cases. It is permanent but recovery is longer. It may also have complications such as vaginal scarring and pain during sexual intercourse. Vaginal rejuvenation is the latest mode of treatment for early VRS. The passage of laser would stimulate and toughen vaginal tissue and renews the cells of its wall. The procedure is simple, easy to learn and is done as an outpatient without anaesthesia. It is painless except for an occasional warm feeling. It does not damage the vagina and has no complications such as bleeding or infection. Results from centres in Europe, USA and Korea are good. With an aging population in Singapore, this procedure offers an option for the prevention of severe VRS.

Q. I am 30 years old and have been married for 3 years. Recently, I am trying to conceive. My menses are rather irregular occurring once every 6 weeks to 2 months.  My gynecologist thinks my menstrual irregularity is due to my being overweight as my BMI is 27. He advises me to lose weight if I want to become pregnant. How does obesity affect fertility? I have difficulty losing weight. I have tried taking appetite suppressant drugs. I lose weight temporarily but I become fat again as soon as I stop taking medicine. I am rather depressed. Can you help? Will surgery to reduce stomach help? A. Normal menstruation essentially depends on the balance of two hormones (estrogen and progesterone) produced by the ovary. These hormones, in turn are influenced by pituitary gland (a small gland at the base of the brain) as well as other centers in the brain. There are two sources of estrogen in the body. The main source is the ovary while an indirect and small source is from the adrenal gland (a small gland on top of kidney). The ovary produces estrogen directly and cyclically while the adrenal gland produces estrogen indirectly through the fat cells. In obese patient, the erratic inflow of estrogen from the fat cells interferes with the cyclical estrogen production of the ovary. This ultimately results in disturbance in ovulation and infertility. Another reason for obese patients to be infertile is its association with a disorder called PCOS (polycystic ovarian syndrome) where there is excess of male hormone (testosterone) and a diabetic-like state in the body. This deranged biochemistry makes the ovary unlikely to ovulate or produces poor quality eggs. There is no easy and quick-fix way to weight loss. An approach involving lifestyle changes through proper diet, exercise, behavior modification, stress reduction together with medications is found to be most effective. The key to successful weight loss lies in your brains, not in your stomach. You may consider the following: • Joining a slimming group. Group work, with regular weigh-ins and sharing of experiences, can help motivation. • Learn your own weaknesses and food triggers: look for ways to beat them • Tell people you are dieting - you might bore them, but it helps you to commit to the idea • Do not be overambitious - a gradual loss of 1kg max a week is the most you should expect. Medical research has shown that a reduction of 10% of body weight in obese patients may correct the hormone and metabolic derangements. This will increase the chances of conception. Stomach stapling is not advisable in your case as you are not extremely obese. It is an invasive procedure and carries surgical risks. It should be used as a last resort.

I am a first-time mom. My baby is now 2 months old and still on full breast feeding. My husband wants to have sex with me, but I am frightened of pain. Besides, I have no desire. Can I resume sex now? Will it be painful? My friend told me that as long as I breast feed my baby, I cannot get pregnant. Is it true? Sexual intercourse may be resumed after the red or brown vaginal discharge called lochia has stopped and stitches at your vagina healed. Usually, most women would have recovered by 6 to 8 weeks after delivery. Several factors can affect your sexuality besides the fear of pain. · You may be suffering from lack of sleep and exhaustion attending to your baby’s endless needs. · You may be so tired by the demands of being a new mother, that you have little time for your husband. · Sex seems like another physical demand on your body that you may not want to connect with your husband emotionally. · Fear of another pregnancy may also be an inhibiting factor. · Breastfeeding suppresses ovulation. This would reduce the amount of female hormone (oestrogen) circulating in your body to below normal levels, causing vaginal dryness and a general dampening of sexual desire. However, every woman is different, and some nursing mothers report that breastfeeding does not affect their libido. Physically, you may notice a change in the size and shape of your vagina after birth. For the first few times, sex may be painful due to vaginal dryness. Use a water soluble lubricant such as K-Y jelly or Femglide, and try positions that allow you to be in control of penetration. You may experience "let down"(leaking of milk) during sex. This is normal and there is no way to prevent it. While it is true that on average, most women who breastfeed fully would not be fertile for about six months after childbirth. It is not a foolproof way of contraception. You can become pregnant again even before you have your first period.

When Mrs M stepped into my consulting room, she was tense, anxious and almost in tears. “Doc, please try to save my baby,” she pleaded. Married for five years, Mrs M, a 32-year-old housewife, had had difficulty conceiving. She was eight weeks pregnant when she came to see me that day. The bad news was fresh vaginal bleeding that morning. Eight months earlier, a blood cyst in her left ovary had been removed by key-hole surgery. She subsequently conceived after receiving injections (GnRH agonist) to suppress her hormones. When I examined her that day, there was bleeding from the vagina. The neck of the womb (cervix) was closed and the baby’s heart beats were present on the ultrasound scan. She was immediately admitted to hospital for observation. Then, that night, I received an urgent call: Mrs M was having intense abdominal cramps and had passed a large amount of blood with clots. I rushed to the hospital. Mrs M was in a state of shock, crying incessantly and calling out the name she had chosen for her child as soon as she knew she was pregnant. By then, the cervix was open and foetal tissues ware passing through – it was a miscarriage. What was needed now was an emergency operation to empty the uterus to stop the bleeding. Traumatic as the miscarriage (the loss of a foetus in the first 20 weeks of pregnancy) was for Mrs M, it is a fairly common occurrence. Let me explain. The American College of Obstetricians and Gynaecologists( ACOG) says that about 15 per cent of known pregnancies end in miscarriage. The actual number is probably much higher because many miscarriages occur so early in pregnancy that a woman does not even know she is pregnant. More than 80 per cent of the time, it happens in the first three months of pregnancy (first trimester). In most cases, a miscarriage cannot be prevented because it is caused by random genetic or chromosomal change that occurs during conception and / or early foetal development. In few cases, a mother’s health condition – such as uncontrolled diabetes, thyroid diseases, infections, or problems with the uterus or cervix – may lead to miscarriage. Certain factors like being an older mother (above 35), smoking, drinking, and previous history of miscarriage put a woman at higher risk of having a miscarriage. A number of terms are used to explain miscarriage. An inevitable miscarriage is bleeding and cramping with sighs that the cervix may be opening. An incomplete miscarriage, as in the case of Mrs M, is when the uterus expels the foetal tissues partially. This can lead to heavy blood loss. A blighted ovum is one that has occurred so early that no clearly defined foetal tissues have formed. A missed miscarriage is when there is foetal demise and the uterus does not expel the tissues for a while. Spotting and staining are common. Finally, a recurrent abortion is when a woman miscarries two or more consecutives times. Mrs M came back for a check-up one week after her miscarriage. She was grieving and kept blaming herself for not resting adequately. She blamed her husband for shifting and changing furniture in her bedroom. “Doc,” she asked, “could the miscarriage be due to renovation in my baby’s room?” I reassured her, saying there is no medical evidence that all these activities caused her miscarriage. Losing a pregnancy is always heart- breaking. It is like the loss of a loved one. A patient should be treated with the respect and dignity she deserves. Telling her “You can always have another” or “It was just miscarriage” usually does not help. Consoling would be better: “I’m so sorry for the loss of your baby”. I suggested to Mrs M that she should take her time to grieve so that she could heal emotionally and physically before trying for another pregnancy. Mrs M is now 23 weeks pregnant and both the mother and baby inside her womb are well.