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J, a 28-year-old engineer, would never forget the afternoon when she was rushed to the hospital for an emergency surgery. J had a slight abdominal pain and nausea which started suddenly, shortly after taking her breakfast at a hawker center. “I thought I might have been sensitive to the food I just ate,” she recalled. She was not immediately alarmed. But the pain got progressively worse. She started to vomit and eventually fainted in her office. Her colleagues decided to rush her to the hospital. J was conscious but  in severe pain. Her body temperature was normal. Her pulse rate was 100/min. and her blood pressure 110/70mm Hg. The abdomen felt hard and stiff (rigidity)and was guarded with gentle pressure. She was given intravenous fluids, anti-nausea treatment and pain medication. An ultrasound examination of the pelvis and a CT (computerized tomography) scan of the abdomen were done immediately. The investigations revealed that she had a 5 cm right ovarian cyst, which had twisted and was cutting off the blood supply to the ovary. What is ovarian cyst torsion? The ovaries are held in place in the pelvis by some suspending ligaments. In one of the ligaments, the ovary receives its blood supply. Torsion occurs when the extra weight of the cyst causes the ovary to twist and rotate around its supporting ligaments. If the twist is minor there may be little or no consequences. However, if the twist is severe enough to ‘kink’ the blood vessels, the blood supply to the ovary may be compromised and may lead to tissue death  eventually. Figure 1 How common is torsion? Ovarian cyst torsion is generally thought to be uncommon. Studies have shown that around 2%–15% of gynecological surgeries for ovarian masses were done for torsion. Most ovarian torsions occur in the reproductive age group. It is less common before puberty and after menopause. What are the symptoms and signs? The symptoms of ovarian cyst torsion are somewhat non-specific. They include: severe abdominal/pelvic pain nausea and/or vomiting fever occasionally These symptoms usually present suddenly and without warning. If the cyst twists and then untwists, the symptoms may 'come and go', sometimes over hours, days or even weeks. If this occurs, the diagnosis may be challenging since these symptoms may mimic many other conditions. How is it diagnosed? A pelvic exam is done to locate areas of pain and tenderness. A pelvic ultrasound is done to view the ovary and its blood flow. A CT scan is usually done to rule out other potential diagnoses, such as: Appendicitis Acute pelvic infection Ectopic pregnancy Kidney stone A definitive diagnosis is usually made by direct visualization of the ovary during surgery. What is the treatment? Laparoscopic surgery is the method of choice. It is done to ‘untwist’ the ovary and remove the cyst. If the ovarian damage is minimal, the ovary can be salvaged and its functions restored. If tissue death has occurred, removal of the ovary along with the cyst should be done. J had a laparoscopic surgery immediately. The ovary and the cyst appeared dark purple, indicating that the ovarian blood supply was compromised. After untwisting the cyst, which wound round the ovarian ligament twice, the ovary returned to its normal colour after a while. The cyst was then removed with conservation of the ovary. J recovered well after the surgery. Her abdominal pain had disappeared the next day and she was discharged 2 days later.

I was called to the emergency room in the hospital to see M as she was screaming in pain. She had intermittent mild abdominal cramps and bloating for the past one week. She did not pay much attention as she thought it was due to some spicy food she ate over the weekend. M, 50, was rolling in pain when I saw her. Her abdomen was hard and bloated. When she was more settled, I could feel a huge mass in her lower abdomen. An urgent MRI (Magnetic Resonance Imaging) of the abdomen revealed a large left ovarian mass measuring 20 cm x 14cm x 11cm. It was a multiloculated cyst with many partitions and fluid-filled sacs. Some of the sacs had solid frond-like growth and one of these showed signs of bleeding. The abdomen was also filled with ascitic fluid and there were solid tumors on the omentum (a large flat fatty tissue covering the ovary) and the peritoneum (lining of the abdomen cavity). M was suffering from an advanced stage of ovarian cancer. How common is Ovarian Cancer? According to the Singapore Cancer Registry, ovarian cancer is the second most common female genital cancer and the fifth commonest cancer among women in Singapore. Its incidence is rising in recent years. Ovaries contain 2 types of cells: epithelial cells and germ cells. Epithelial cell cancer is more common than germ cell cancer. The former occurs more often among older women while the latter affects younger women. Why is ovarian cancer deadly? Ovaries are located deep in the pelvic cavity and hidden away. As a result, early cancerous changes are more difficult to detect. By the time these changes occur, the tumor is usually in the later stages of development and spread. Besides, in early stages, ovarian cancer seldom has symptoms and signs and they are usually non-specific such as bloating and indigestion. Screening tests like blood tumor markers and ultrasound examination may also not be as effective. What are the symptoms and signs of ovarian cancer? Please refer to the article “Ovarian Cancer” in this website Risk Factors of ovarian cancer Risk factors associated with ovarian cancer include: Early onset of menstruation and late menopause Family history of ovarian cancer Late pregnancy or women who have never had children History of breast cancer, womb cancer and colon cancer Endometriosis Menopausal hormone therapy How is ovarian cancer diagnosed? Ovarian cancer can be detected by using various imaging techniques-- vaginal ultrasound, CT scan and MRI. The size, solid areas, multiple partitions(septa), blood flow of the ovarian mass as well as ascitic fluid in the abdomen and tumors in adjacent organs may suggest the cancerous nature of the ovarian growth. Blood tumor marker, CA125 may not be that accurate in diagnosing ovarian cancer even though it is raised in about 80% of patients with epithelial ovarian cancers. This is because it is also raised in non-cancerous conditions, such as endometriosis and appendicitis. The result of elevated CA-125 must therefore be interpreted with care. Surgical removal of the tumor is the ultimate proof that the tumor is cancerous and originates from the ovaries. What is the treatment of ovarian cancer? Ovarian cancer is usually treated by surgery and chemotherapy. M had an extensive surgery (debulking operation) done after her condition was stabilized. At the operation, the cancer was staged by checking the actual extent of the spread. Fluid in the abdomen was sent for analysis under a microscope. Her uterus, ovaries and fallopian tubes were removed together with the omentum. Tumor tissue of the peritoneum was removed. She recovered well after the operation. Histology (microscopic examination) of the tumor confirmed Stage 3 ovarian cancer. She was referred to the oncologist and has been tolerating the first course of chemotherapy well.

Bacteria have a reputation for causing disease. But not all bacteria are harmful. Ironically, some illnesses can be treated with bacteria. These beneficial microorganisms which play an important role in our health are known as probiotics. They have been used since the mid-1990s to treat several digestive disorders, delay the development of allergies in children and prevent vaginal and urinary infections in women. It is estimated that there are trillions of probiotics residing in our normal, healthy intestines and different strains have different effects on our body. The most common probiotics are strains of two main species. These species are also the most studied of probiotics: 1. Bifidobacteria: This species of bacteria is commonly used in foods and supplements. They are thought to: · Help digest fibre, reduce weight gain and lower the risk of diabetes, heart disease and other chronic disorders, · Support the immune system, · Prevent infection by limiting the growth of harmful bacteria in the intestine, · Produce nutrients like vitamins and essential fatty acids. 2. Lactobacillus: These bacteria produce lactic acid. They can: · Help control the population of unfriendly bacteria, · Serve as muscle fuel, · Increase the body’s absorption of minerals. Probiotics have been used widely in maintaining vaginal health. The vagina has an intricate balanced ecosystem of microflora. Normally, the dominant Lactobacilli produces acid which suppresses the growth of the harmful microorganisms. But the balance can be disrupted by antibiotics, spermicides, and birth control pills. As a result, the unfriendly pathogens cause common vaginal disorders such as bacterial vaginosis, yeast infections, and urinary tract infections. Probiotic therapy helps in these situations by restoring the balance of the microflora. Probiotics may play an important role during pregnancy. Lack of certain strains may increase the risks of miscarriage, premature rupture of membranes (water-bag) and preterm birth. Taking probiotics during pregnancy has been shown to reduce the risks of developing gestational diabetes, lower postnatal depression and anxiety and decrease the incidence of breast inflammation in the puerperium . Until recently, organs of the upper genital tract-ovary, fallopian tubes and uterus-previously thought to be sterile are found to have live probiotics with lactobacillus being the most prevalent. Similarly, seminal fluid has probiotics that are protective to the sperm. Studies have suggested that probiotics therapy may improve vaginal health and may have a positive impact in fertilisation and conception.

For T, a 32-year-old peripatetic service engineer, a visit to a gynecologist with his wife was somewhat “uncomfortable and embarrassing”. His wife was having difficulty getting pregnant as he had problems releasing the semen during sexual intercourse. They had been married for 2 years. “When I first got married, I was able to attain orgasm and ejaculate normally,” he recounted anxiously. “I have been travelling regularly for work and the frequency of intimacy with my wife has been low. During the periods when I was away, I masturbated often. I gradually noticed that I took a longer time to reach sexual climax and ejaculation during sexual intercourse with my wife. The more anxious I was during the sexual act, the longer I took to release my sperm. For the last 6 months, I simply couldn’t ejaculate even though I have the erection. This has also caused conflicts in our relationship.” Delayed ejaculation (DE) or retarded ejaculation is a condition in which an extended period of sexual stimulation is required for men to reach sexual climax and ejaculation. In severe cases, the patients are unable to ejaculate at all as in T’s case. It is a problem if it's ongoing or causes distress for the couple. DE can be a lifelong problem or it may develop later in life. In some men, DE occurs in all sexual situations, while in others, it only occurs with certain partners or in certain circumstances. This is known as “situational delayed ejaculation.” Prevalence of DE Because of the lack of a precise definition of DE and as the condition is typically self-reported, the actual prevalence of DE is not known. Studies have estimated that it affects between 1% to 4 % of men. Causes of DE DE is a poorly understood ejaculation problem. There are many possible causes. They include; Psychological causes such as relationship problems, depression, performance anxiety, cultural and religious taboos. Frequent masturbation: This may increase the threshold of arousal necessary for orgasm. Excessive alcohol consumption. Medications such as antidepressants, anti-hypertensive medicines, anti-seizure medications. Age: The incidence of DE increases after the age of 50 years. Compared with men younger than 59 years, men in their 80s report twice as much difficulty in ejaculating. Race: In general, DE is more commonly reported by men in Asian populations than by men living in the United States, Australia, or Europe. Such variation may be due to cultural or genetic differences. Chronic health conditions such as stroke or diabetes and prostate surgery. How is DE diagnosed? There is no consensus on what constitutes a reasonable time frame for ejaculation to occur. In general, DE is assumed to be present if orgasm and ejaculation do not occur after 30 minutes or more of sexual stimulation. Complications of DE While DE does not pose any serious medical risks, it reduces sexual pleasure and desire. This may cause stress and anxiety during sexual performance. Fertility issues will further aggravate relationship problems resulting in marital discord. T’s physical examination, blood tests and urine investigations were normal. His semen analysis and the blood levels of testosterone were normal. He was given anti-anxiety medication and was referred to a psychiatrist for counseling. He was advised to curtail his habit of masturbation and reduce the frequency of his travels. He gradually regained his confidence. His symptoms of DE slowly resolved he was very happy when his wife eventually became pregnant after 8 months of therapy.

For the past six months, H, 40, was puzzled as to why her menstrual cycles were getting very irregular, lasted for a shorter duration and the flow was less. “My menses used to be very regular every month and lasted 6 days,” she recounted. “But now, I menstruate between 40 to 60 days and it lasts two days at the most. Am I having an early menopause?” she asked. H had been married for 7 years. She had only tried to actively conceive the past 3 years as she thought that she could get pregnant anytime she wanted with the help of advanced reproductive technologies. However, with three failed attempts of IVF and two unsuccessful transfers of frozen embryos, she had become disillusioned, angry and depressed. With time, she eventually came to terms with her infertility. She had a right dermoid cyst which was operated on when she was a teenager. At the age of 28, she was diagnosed with endometriosis and had a chocolate cyst removed from her left ovary. Her blood level of the pituitary follicular stimulating hormone (FSH) was slightly elevated and the Anti-Mullerian hormone (AMH) was low for her age. Ultrasound pelvic examination revealed that her ovaries had a reduced number of follicles. H was suffering from reproductive aging. What is reproductive aging (RA)? Reproductive aging refers to the functional decline of the female reproductive system due to tissue and cell deterioration. It is a natural process that occurs in all women, eventually leading to reproductive agedness and menopause. With the increasing trend of late marriage and delayed motherhood, many women like H, often misjudge the age at which a significant decline in fertility occurs and overestimate the success of assisted reproductive technologies to circumvent infertility. What are the causes of RA? Age: Women are born with a finite number of eggs during foetal development. Eggs peak in number when the foetus is about 20-week-old with approximately 6-7 million eggs. They then undergo degeneration, and do not regenerate. At birth, the number of eggs falls to 1-2 million, and at puberty, only 300,000-500,000 eggs are left. From puberty through menopause, women release one egg per month. It is estimated women will ovulate about 400-500 eggs in their reproductive life. After menopause, the ovary no longer releases eggs. Besides quantity, the quality of the eggs also deteriorates with age. It is optimal when the woman is in her mid-20s, representing the most fertile period in her life. After 35, there is a significant decline of fertility potential, with further deterioration after 40s. Smoking: Cigarette smoke contains a mix of over 7,000 chemicals. Many of these chemicals such as carbon monoxide and nicotine can damage the ovarian cells. Studies have shown that smokers will have a menopause two years earlier than the non-smokers. Surgery: Surgical removal of ovarian cysts will invariably damage the surrounding healthy tissue. Should complications arise occasionally, the gynaecologist may have no choice but to remove the entire ovary. In both situations, ovarian reserve will be reduced. Ovarian diseases: Endometriosis, pelvic inflammatory disease and ovarian cancer can cause damage to the ovary. Radiation, chemotherapy and drugs: Low ovarian reserve can result from these agents. Genetic diseases : Some rare genetic conditions can cause premature aging of the ovary. What are the consequences of RA? RA can result in increased incidence of Infertility Miscarriages, stillbirth, prematurity and Cesarean section Failure rate of IVF and other assisted reproductive technologies Early menopause How is RA diagnosed? RA is usually diagnosed by the assessment on day 2 or 3 of the menstrual cycle of serum FSH (follicle-stimulating hormone) and oestrogen level, AMH (anti-Müllerian hormone), and the ultrasound examination of the ovary (Antral follicle count). However, the results should be interpreted with caution as they are not strictly accurate in predicting the pregnancy potential and the age of menopause. When H was first told of her diagnosis, she was in a state of disbelief. But when symptoms of early menopause started to appear one year later, she gradually accepted her condition. With the support of her husband, H now gracefully awaits the arrival of menopause.

She was upset when I told her that she had to avoid eating her favourite desserts including chocolate and ice-cream as she had been diagnosed with gestational diabetes (GDM). D, 30, a first-time mum was at her 20 weeks of gestation. She was slightly overweight with a BMI of 27 before pregnancy. Her father had diabetes at an old age. As she did not have symptoms of morning sickness, she developed a hearty appetite after she became pregnant. As such, she gained a lot of weight since her first trimester, of between half to one kilogram every week. D understood the serious medical problems associated with GDM (refer to “A Mother’s Not-So-Sweet Story: Pregnancy diabetes” in the website). She also knew that by changing her dietary habits, GDM could be better managed. What should be the dietary changes for GDM? Have a well-balanced diet. It should include lean sources of protein, plenty of non-starchy vegetables and correct portions of complex carbohydrates. In order to keep the blood sugar levels stable, a pregnant mother should eat the meal or snack at regular intervals. In this way, she can keep herself satiated and stabilize the blood sugar levels. Eat three regular sized meals with one or more snacks in between each day. Eating too much at one time can cause the blood sugar to spike. Do not skip meals and snacks. Keep the amount and types of food (carbohydrates, fats, and proteins) about the same from day to day. Whenever feasible, choose the right type of food by reading the food label. Avoid foods which are processed and high in refined sugar. What are the foods to eat? Take protein with every meal : These foods help one to feel full and are the essential building blocks for the baby’s growth. They include chicken, eggs, fish and low-fat dairy. Eat 2 to 3 servings a day. One serving equals: 2 to 3 oz (55 to 84 grams) cooked meat, poultry, or fish 1/2 cup (170 grams) cooked beans 1 egg Non-starchy vegetables . These provide important vitamins, minerals and fiber. They include broccoli, cucumbers, green beans, onions, peppers and salad greens. Eat 3 to 5 servings a day. One serving equals:1 cup (340 grams) cooked or chopped raw leafy vegetables. Fruits: Eat whole fruits rather than drink juices. Eat 2 to 4 servings a day. One serving equals: 1 medium whole fruit such as a banana, apple, or orange. Complex carbohydrates : High-fiber, whole-grain carbohydrates are healthy choices. They include brown rice, Greek yogurt, sweet potatoes and whole-wheat bread. Eat 6 or more servings a day. One serving equals: 1 slice bread 1 ounce (28 grams) ready-to-eat cereal 1/2 cup (105 grams) cooked rice or pasta Healthy fats : These are beneficial for heart health. They include avocado, nuts, olive oil, seeds and nut butters like almond and peanut. Milk and dairy are important sources of calcium. Eat 4 servings of low-fat or nonfat dairy products a day. One serving equals 1 cup (240 millilitres) of milk or yogurt Snacks: Healthier choices include: Raw veggies with cheese. Hard-boiled eggs Fresh fruit with a small amount of nuts Unsweetened Greek yogurt topped with sunflower seeds What are the foods to avoid? Fast food Sugary drinks including fruit juice, soda and sweetened beverages Baked foods, such as muffins, donuts, or cakes Fried food Sweets and chocolate Starchy foods, such as white pasta and white rice D was given a meal plan by the dietician. She followed the plan diligently albeit with slight initial reluctance. Her blood sugar levels remained normal after that and she delivered a healthy baby at term weighing 3.2 kg.

Recently, I attended a seminar on the use of weight loss medication, specifically GLP-1 agonists (Saxenda), i n the treatment of patients who had polycystic ovarian syndrome (PCOS) and were obese and were struggling with infertility. Patients suffering from PCOS experience symptoms resulting from the disruption of ovulation as well as the overproduction of the male hormone, testosterone. This leads to the formation of multiple small cysts in the ovary, irregular menstrual cycles, and infertility. Patients with PCOS often develop insulin resistance and are at an increased risk of developing Type 2 diabetes and other metabolic issues later in life. What is a GLP-1 Agonist? GLP-1 agonists, or Glucagon-Like Peptide-1 Agonists, are a class of medications that mimic the action of the hormone GLP-1, which is produced in the gut. GLP-1 plays an important role in regulating blood sugar levels, stimulating insulin secretion, and slowing gastric emptying. These drugs are primarily used to treat Type 2 diabetes, and Saxenda is one of them. They  are generally given by injection under the skin either daily or weekly. How Does  GLP-1 Agonist    Work? Improving Insulin Resistance:  Insulin resistance is the cause of the disruption of ovulation in PCOS. GLP-1 agonists improve insulin sensitivity, which helps restore ovulation. Weight Loss:  By slowing gastric emptying and suppressing the appetite center in the brain, GLP-1 agonists induce significant weight loss, improve metabolic health, and increase the chances of spontaneous ovulation and pregnancy. Hormonal Regulation:  GLP-1 agonists reduce elevated levels of testosterone in PCOS patients. Impact on Fertility Although GLP-1 agonists are  not a form of fertility treatment, their effects on improving insulin resistance, reducing body weight, and regulating the levels of reproductive hormones may enhance fertility in women with PCOS. Studies have shown that using GLP-1 agonists, often in combination with other forms of fertili ty treatment, can improve ovulation and pregnancy rates. The impact is more pronounced in obese patients. What Are the Side Effects of Saxenda? Common side effects include: Gastrointestinal Issues: Nausea:  The most common side effect, especially during the initial stages of treatment. Vomiting and diarrhea:  These can occur as the body adjusts to the medication. Constipation:  Some individuals may experience this as the digestive system slows down. These symptoms usually subside after a few weeks but may persist in some cases. Loss of Appetite Hypoglycemia:  Low blood sugar is generally rare but can occur if combined with other diabetes medications. Injection Site Reactions: Redness, itching, or swelling can occur at the injection site, though this is usually mild and resolves on its own. What Are the Complications of Saxenda? Pancreatitis and Gallbladder Issues:  While rare, inflammation of the pancreas and gallbladder have been linked to the drug. Gallstones:  Some studies suggest an increased risk of gallstones, particularly with significant weight loss. This may occur due to changes in bile composition during rapid weight loss. Kidney Function:  In rare cases, GLP-1 agonists have been associated with worsening kidney function, especially in individuals with pre-existing kidney issues. Thyroid Tumors:  Animal studies have shown a slight increase in the risk of thyroid tumors, but this has not been found in humans. Conclusion While GLP-1 agonists are generally safe and effective, particularly for weight loss and glucose control, they come with some side effects and potential complications. In the treatment of PCOS with fertility issues, the medication  has been recommended i n obese patients and should be monitored closely for side effects and complications.

H, 33, was married for 5 years and had been actively trying to conceive for the past 3 years without success. Her husband’s semen analysis showed that the sperm count was on the low side of normal (reference to the WHO standard) while the sperm quality was normal. “Doc, my friend told me that according to a recent study in Europe, frequent use of a cell phone could affect the sperm count. Is it true?” She asked. The impact of cellphones on male fertility has been a topic of interest and study in recent years. The widespread use of cellphones has raised concerns about the potential adverse effects of electromagnetic radiation emitted by these devices on reproductive health. An electronic field Cell phones are becoming indispensable in our lives. They emit low-level radio-frequency electromagnetic fields, or RF-EMF. They are constantly sending and receiving signals when in use. According to the California Department of Public Health, RF-EMF are found to be reduced when texting messages and are at their highest when downloading large files and streaming audio or video. When they emit at maximum power, they can heat up the surrounding tissue by 0.5 degrees Celsius. Animal Studies Studies in mice have found RF-EMF at levels similar to cell phones do lower male fertility by causing sperm death and changes in the tissue of the testes. However, other animal studies have not confirmed these effects. Human studies Studies in humans have focused on the ability of RF-EMF to penetrate body tissues including the testes. Some researchers suggest that carrying cell phones in pockets close to the groin area or prolonged usage could lead to an increase in the temperature of the scrotum. This may adversely affect sperm production and its quality. Electromagnetic radiation may also induce oxidative stress within the body. This can cause an imbalance in the production of free radicals in our body. Sperm DNA could be damaged. Studies have suggested a correlation between cellphone radiation exposure and increased levels of oxidative stress markers in the semen. Another possibility is that the RF-EMF could interfere with the connection between the pituitary gland in the brain and the testes, thus affecting sperm production. Conclusion A recent study by Swiss researchers (2023), using more than a decade's worth of data, found that young men who are heavy users of mobile phones have lower sperm concentrations and sperm counts than men who rarely do. But scientists could not draw a direct cause-and-effect link between cellphones and male infertility. Other studies have also indicated a potential link between cellphone use and sperm quality but the findings are not conclusive. The general consensus is that more research is needed to establish a definitive causal relationship. As evidence linking cell phone use and declining male fertility is not definitive, I advised H’s husband to take some practical steps to minimize potential risks. These include: · Using a hands-free device or speakerphone to reduce direct exposure to the groin area · Avoiding carrying cell phones in pockets close to the genitals · Taking regular breaks from prolonged cell phone use. Additionally, adopting healthy habits, such as limiting prolonged exposure and maintaining proper cell phone placement, can be prudent measures.

For the past 18 years, Mrs M, a 30 year-old teacher has been suffering from menstrual cramps. “ I had my first period at 12. The pain wasn’t too bad, and it was relieved after a hot shower. But by my late teens, it was getting more severe and I had to take Panadol regularly,” she recalled. “Later, Panadol was not effective anymore and I have to take other stronger pain killers. My mum took me to her gynaecologist, who prescribed oral pills to me and told me that it would disappear after I had given birth. I took the pills and the pain was relieved somewhat though not completely.” “ I got married at the age of 26. My husband is 5 years my senior. Procreation was never in my priority list as I assumed that fertility can be turned on and off like a tap, and that we can have children when we want it to happen. It took me 3 years to decide it’s time for me to start a family. I have been trying for the past year with no result. This is the reason of my visit here” “What about your menstrual cramps” I interrupted “Menstrual pain returned as soon as I stopped the pills and I noticed discomfort at the back whenever my husband was too harsh during deep penetration.” “Any investigation done?” I asked. “Yes. An ultrasound scan. I was shock to know that I had an ovarian cyst in my right ovary.” The gynae then suggested an operation where a telescope was inserted through my belly button to check my womb (laparoscopy). I reluctantly agreed as the pain was getting unbearable.” “What were the findings?” I asked. “My gynae found small chocolate-coloured spots of menstrual blood at the back of the uterus and ovaries which she removed during the operation. My pain went away and I was symptom-free for the next few years until recently when I experienced pain during sexual intercourse. The backache and menstrual pain returned and I had pain when I passed motion during menses.” When I examined AG, her uterus was tender to the touch and relatively immobile. An ultrasound scan showed an ovarian cyst about the size of a tennis ball on her left side. It was subsequently removed through key-hole surgery and was confirmed to be an endometriotic cyst or “blood cyst”. Endometriosis is a common and troublesome disease affecting about one in 10 women of reproductive age. In women with fertility problems, the number may be as high as 50 per cent. It is also a progressive disease, as is the case for AG. The lining of the womb (endometrial tissues) is spilled into other parts of the reproductive organs including the fallopian tubes, ovaries and the back of the womb. These abnormal and wayward tissues bleed every month during menstruation. The surrounding areas become inflamed and form scars which pull on the nerve endings and cause pain. But some women will have little or no pain despite having extensive disease while others may have severe pain with only a few small affected areas. The endometrial tissues trapped in the ovary will bleed and lead to the formation of the dark, thick and chocolate- coloured cyst known as “chocolate cyst” or “blood cyst”. It may leak and form adhesions (abnormal tissues that bind organs together). The adhesions can block the fallopian tube and interfere with ovulation, causing infertility. The exact cause of endometriosis is not well understood. A familiar association exists as it can affect many siblings in a family. Past pelvic infection can also be a cause. Common symptoms of endometriosis include menstrual cramps, backache and pain during sexual intercourse. Menstruation may be irregular, with staining before or after menstruations. There may also be clots in the menses. An ultrasound scan may be misleading in the diagnosis of endometriosis. It is usually normal if there is no cyst formation as in the case of AG when she consulted the first gynaecologist. The diagnosis is based on clinical suspicion and confirmed by laparoscopy. A blood tumour marker test (CA125) is also not very helpful as the level may be normal or raised. When a cyst is present, surgical removal and microscopic examination is the only way to confirm the diagnosis as in AG’s case. The recurrence of endometriosis is very common. It will only dry up after menopause when the lesion is no more stimulated by ovarian hormones. Pregnancy has a beneficial effect on endometriosis. Hormonal changes cause the diseased areas to become inactive. As infertility may be a consequence of endometriosis, I discussed with AG and her husband the possibility of their conceiving a baby. They heeded my advice and AG is now pregnant. Give ample time and allow for unexpected delays, and do not wait till it’s too late. Watch that clock!

It is a popular belief that men can go on fathering children into their 60s and 70s. They could impregnate their wives as easily at 70 as when they are at 20. But a mounting body of evidence shows otherwise. In a study of 2112 pregnant women in U.K .,it was found that when the man’s age was more than 45, it took him  5 times longer  to achieve a pregnancy compared with a man aged 25 and below. Another study examined patient’s records of more than 12,000 couples treated at a fertility clinic and separated out the influence of male and female ages on the couple’s chances of having a baby. The pregnancy rates were lower if the husband was 40 and above. There were more   miscarriages if he was 35 or older. This is due to deterioration of the quality of sperm with age. In 2004, German researchers reported the decline in the volume, motility (ability to move toward the egg), and genetic structures of sperm in ageing sperm. There is also a significant impact of ageing sperm on the birth outcomes. In a study of more than 3400 cases of Down’s syndrome, it was found that advanced paternal age contributed to the risk when both parents were over 35 at the time of conception. Children born to older men also run a higher risk of developing schizophrenia, a devastating mental disorder. In one study, researchers discovered that men between the ages of 45 to 49 were twice as likely to have children with schizophrenia as were men 25 and younger. The risk tripled for men over the age of 50. More and more Singaporeans are getting married late .The decision of many men postponing their fatherhood may not be wise. These men should not take fertility for granted. Their biological clock is ticking away just the same as in their spouses.

Mrs. B, my patient of 14 years, came to see me with her husband. She was anxious while the husband was quiet and appeared depressed. “Doc,” she said, “You know we have been happily married for the past 15 years, and you have delivered our two children. All along, we have always enjoyed a good sexual relationship and we have been intimate at least twice to three times a week. I am only 40 years old and he is 45. “However, for the past few months, he has suddenly lost interest in sex. Whenever we are in the mood, he simply cannot get an erection. The more we try, the worse it is. His friend advised him to take Viagra but I felt he should you first.” Mr. B, a sales executive, had been a smoker for the past 25 years, smoking up to 10-20 cigarettes a day. He drank socially and was slightly overweight, having a BMI of 28. He told me some of the reasons he was losing his sexual desire were the increasing level of stress at work and tiredness. His impotence began insidiously and this was gradually making him lose confidence in having sex. His self-esteem went down and he would reject his wife’s sexual advances. This resulted in occasional conflicts. Fortunately, they were resolved quickly and amicably. However, with time, his wife became suspicious that he might be involved in some hanky-panky. To refute this, he agreed to come for treatment. Nowadays, couples like Mr. and Mrs. B are becoming more aware of the importance of sexual health. A commonly encountered problem appears to be erectile dysfunction. Many Asian men still find it embarrassing to discuss this problem with their doctors or to seek treatment. Referrals usually come from their wives. Erectile dysfunction (ED or impotence) is the inability to attain and/ or maintain an erection sufficient for intercourse. In Singapore, about 50 per cent of the male population aged 30 years and above reportedly experience some form of ED. ED is usually due to psychological factors such as stress, tiredness, depression and performance anxiety (nervousness over the ability to perform sexually). Occasional loss of erection is relatively common. However, if ED persists, it may lead the man to question his masculinity, causing performance anxiety. Trying to force an erection may increase the chance of failure. Anxiety will make it difficult for the man to be sexually aroused, preventing any lovemaking. The vicious circle will make ED worse with time. Other causes of ED include diseases affecting blood flow, such as atherosclerosis (hardening of the arteries), diabetes, nerve disorders including injuries to the spine, and diseases of the urinary system or prostate gland surgery. Chronic illness, medications like antidepressants, tranquillisers, some cholesterol-lowering drugs and a condition called Peyronie’s disease (scar tissue in the penis) can also cause erectile dysfunction. Studies have shown that ED can precede hypertension, diabetes and high cholesterol. It is thus important to seek early treatment. The spouse has an important role in the treatment of ED. She should avoid being critical of her husband’s sexual performance. The couple should try to resolve the problem in cooperative and non-demanding manner. It is important that ED be discussed openly between the partners so it can be recognized and addressed – as in Mr. B’s case. Treatment for ED should be a decision by the couple so that mutual support can be given. This can keep the relationship strong and even increase the success of the treatment. An informed wife is also important in the use of oral ED agents. The pills do not automatically cause an erection. The patient must be stimulated after taking the medication in order to achieve an erection. If the partner is aware of this, she can help him to achieve a good erection at the right time. Also, if she knows that it will take some time for the medication to work, she will be patient and wait before getting physical, or prolong foreplay until the medication becomes effective. Mr. B examined clinically. There was nothing wrong with his nervous or urinary systems. He was tested for diabetes, cholesterol and hormones and was quite healthy. He was put on a weight reduction regime. He was also advised to quit smoking. An oral ED agent was given to help him regain his confidence. Many people think that any heart condition makes oral ED drugs harmful or risky. Mrs. B was reassured of the safety of the medication. This made her feel more comfortable. A worried wife does not make a good lover. A few weeks later, I received a card in which Mrs. B wrote, “Dear Doc, thanks for your encouragement and reassurance. My husband has shed 5kg. He is as fit as a fiddle. He has quit smoking as well, and he doesn’t need the drug any more. Our love life is once again rekindled.”

1. Is it possible that ovulation prediction kit test shows negative but we may still be ovulating? Ans: The OPK can give false positive (i.e. patient not ovulating but the test is positive as well as false negative result. 2. Does oral sex kills sperm? Ans: Saliva, if used as lubricant for vaginal sex can affect the motility and viability of the sperm. Chances of conception may be reduced. 3. What is basal temperature and how do you measure it? Ans: Pl refer to the article on “fertility tips” It should be taken when you wake up in the morning before getting out of bed. 4. How long does it take for the birth control pills to "wear off" in the body? Ans: There is no “wearing off” period. You can try for baby as soon as you are “off” the pills. 5. a) Should caffeine be avoided to conceive? b) Any advice on products like maca powder and goat weed? Ans: a) Moderation is key. One to two cups a day is fine.        b) Maca and goat weed are herbal supplements that may help improve female fertility  6. a) Is there medical evidence to prove the effectiveness of acupuncture and TCM for fertility? b) If acupuncture is good for fertility, what is the recommended frequency? Ans: a) There are instances where acupuncture and TCM may boost the chances of fertility.     b) See your doctor for further advice. 7. Is there a max age to try conceiving?  Ans: There is no maximum age when trying to conceive, but do bear in mind that fertility declines with age for both male and female. Try for baby earlier in life to avoid complications that come with age. 8. Will the chance of conceiving be reduced if you have inverted/ re-troverted uterus? Ans: No. Retroverted womb is present in 20 % of normal females. It has no relationship to infertility. 9. With age, quality of sperm decreases. How does the quality of the sperm affect the chances of pregnancy or the health of the foetus or the baby eventually? Ans: Sperm quality and quantity decline after 35. Depending on the age of the spouse, the chances of natural conception will decline after she passes 26 years, as the optimal age for women to conceive naturally is between 22 to 26. Miscarriages happen even in younger women. It’s the body’s natural way of discharging an unhealthy foetus. 10. What diet will help increase quality of sperm for a 40 year old? Ans: According to the American Society for Reproductive Medicine,  a healthy diet including plenty of fish, vegetables, and whole grains will help increase quality of sperm A diet high in trans fats may lower the number of sperm . 11. I would like to know what and when is ovulating period? How about the case for irregular menstruation? Ans: the ovulation period can be assessed even if the periods are irregular by        o   Basal Body temperature        o   Ovulation prediction kits        o   Vaginal ultrasound examination 12. Does IPL hair removal affects fertility. Does it apply to male and/or female? Ans: IPL hair removal does not affect male or female fertility. 13. Is pre-conception check good for trying couples? Ans: Pre-conception checks are recommended for couples who are trying for baby. Any re-structured hospitals and private medical centres in Singapore would be able to provide this service. 14. a) What are the possible causes of failure in IVFs? b) What is the recommended resting period between IVFs? Ans: a) There are many causes of failed IVF, the ovary may fail to respond to the drugs, the egg may not be retrieved during the procedure, the quality of the egg retrieved may be of lower grade, failure of the egg to be fertilized, the fertililsed egg may fail to get implanted in the womb.        b) There is no hard and fast rule as to the rest period between IVFa three to six months of rest period is advised for patient to grieve over the failure but there are women who would try again without any break. 15. Does chronic disease affect fertility? Ans: There are many chronic diseases e.g Diabetes, heart diseases that affect fertility. Seek medical advice and go for pre-conception checks when trying for baby. 16. My menstrual cycle is irregular and I'm having a hard time conceiving. My doctor told me that I may not be releasing eggs during ovulation because I'm still breastfeeding my 19m daughter. I have never heard about this. Is this true? Ans: Breastfeeding is a “natural contraception”. However, this does not mean that you cannot get pregnant when you are nursing your child. During breastfeeding, there could be months that you may not be releasing eggs therefore, you will not be able to get pregnant.