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On a recent reflection of her infertility journey, B told me that her emotions were like going on a rollercoaster ride. There were times when she felt high with anticipation and excitement. At other times, her emotions were down with pain, helplessness and hopelessness. “Doc, I am married for the past 4 years and have been trying to conceive since marriage.” B recounted “I have gone through all the fertility tests and have tried IVF 3 times without success. I do not mind enduring the physical pain of going through the process of daily injections, eggs retrieval and embryo transfer. But the emotional stress is too overwhelming. Every time after the embryo is transferred, I am on an emotional high. I feel excited and would imagine that I am pregnant. I even work out the estimated date when my baby would arrive. Then comes disappointment. I cry when menses come. The low levels of the hormones during my period could only aggravate the pain of yet another failure. I feel angry, frustrated and impatient. Helplessness and grief consume me. When pregnancy evades me again and again, I sink into hopelessness and depression.” B felt lonely. The emotional aspects of women grappled with infertility are often ignored. Research studies have shown that the anxiety and depression in women who suffer from infertility is just as severe as those suffering from cancer and heart disease. In dealing with infertility, it is important to understand how the women feel and what go through their minds so that her negative emotions can be better managed. I explained to B the various emotional stages that she had gone through and that it was alright to expect the ups and downs. The feelings might appear out of control but they were usually temporary. She should acknowledge her losses so that she could grieve them accordingly. Accepting the loss every month will not take the pain away, but it would discharge her pent-up feelings of anger, frustration and sadness. She should also “ventilate” her emotion with her husband or close friends. By “talking them out”, the negative emotions would become more manageable. “Letting go “can be liberating. She could also write her feeling in a journal if she would like to keep her feelings private. Her relationship with her husband was also important. They should support each other with good communication. I referred B to a professional counsellor who helped her cope with grief and stress. B began to re-examine her life with a different perspective. She reframed her perception of infertility and decided to adopt a child moving forward.

She looked worried and upset when she stepped into my consultation room. “Doc, my menses has a fishy smell for the past 2 months.” She said. “Am I having a growth in my vagina?” T, a 32-year-old housewife had been married for 5 years. Her husband worked in a neighboring country and returned home for a week every 2 to 3 months. She last had sexual intercourse with him 2 months ago. On further questioning, T also noticed yellowish, sometimes greenish vaginal discharge on and off for the past 6 months. The discharge was accompanied by occasional itchiness and burning sensation around her vulva. On examination, her vulva was inflamed and red. The vaginal discharge was creamy yellow and foul-smelling. The cervix was angry looking with red hemorrhagic spots. A microscopic examination of the vaginal discharge demonstrated the presence of the parasite, trichomoniasis vaginalis as shown in Figure 1 below. Figure 1 T was suffering from trichomoniasis, a disease caused by the micro-organism, Trichomonas vaginalis. The parasite is approximately the size of a human white blood cell. The fishy smell in the vaginal discharge and the menses is due to the presence of a chemical compound known as trimethylamine. How common is trichomoniasis? Trichomoniasis is one of the common sexually transmitted disease (STD). It occurs more often in women than in men. Risks factors of the infection include: Multiple sexual partners Sex workers Drug abuse Older women Poverty How is it transmitted? The parasite lives in the semen and vaginal fluids. It is transmitted between couple during unprotected vaginal sex. In women, the most commonly infected area is the lower genital tract (vulva, vagina and cervix). Other body parts, like the hands, mouth, or anus are usually spared. Occasionally, the infection can be spread by sharing sex toys. Very rarely, it can be transmitted through objects like wet towels and toilet seats. What are the  symptoms of trichomoniasis? Only about 30% of infected patients have symptoms. It is unclear why the rest remain asymptomatic. Probably this is related to the person’s age and overall health. The symptoms vary and can occur sporadically. They can present as a mild irritation or severe infection. The incubation period ranges from 5 to 28 days or longer. If untreated, the infection can last for months or  years. For women, the common symptoms are: White, yellowish, or greenish with an unusual fishy smell. Itching, burning, redness or soreness of the genitals; Discomfort with urination Pain during  sexual intercourse. Urinary frequency Lower abdominal pain What are the complications of trichomoniasis? Trichomoniasis increases the risks of getting or spreading other sexually transmitted infections such as chlamydia and gonorrhea. Pelvic inflammatory disease and infertility may result. If it occurs during pregnancy, there is an increased incidence of premature birth ,intrauterine growth restriction (IUGR) and baby with  low birth weight. What is the treatment for trichomoniasis? Trichomoniasis can be easily treated with medication. To avoid getting reinfection, both sexual partners should be treated  at the same time. It is advisable to have a review 3 months later to make sure the infection is completely cleared.  T was treated with medication for 5 days. She noticed drastic improvement in her symptoms the next day and her menses was not smelly on her next cycle. However, reinfection occurred as her husband refused to be treated as he was asymptomatic. After much counseling and persuasion, he finally agreed to take the medication together with T who had remained symptom free since.

Endometriosis is a complex disease where tissue similar to the uterine lining grows outside the uterus, causing pain and/or infertility. It affects about one in ten women of reproductive age. Treatment includes medications which may have unpleasant side effects and/or surgery which is invasive and costly. Thus, it is understandable that many women seek help on alternative treatment such as herbal supplements, acupuncture and dietary interventions. During a consult for a second opinion, G, a 35-year-old lady with 3 previous surgeries for endometriosis and was currently on hormonal medication, asked whether dietary modifications were effective in treating the disease. She was told by her friend that giving up dairy products and eating gluten-free food can cure the condition. “I would like to eat the food I love if there is no medical evidence of such dietary changes,” she said.. In the social media and internet, there are many articles or blogs which claim that the symptoms of endometriosis are cured or subside after dietary modifications. Such information can undoubtedly offer hope to those facing devastating pain and infertility. So, is there any scientific evidence to substantiate such claims? What are the foods that have been suggested to affect endometriosis negatively? Observational studies have found that the following foods are associated with increased risk of endometriosis development. They include: Trans fat Red meat Gluten Alcohol and caffeine High FODMAP diet (fermentable oligosaccharides, disaccharides, monosaccharides and polyols, which are short-chain carbohydrates (sugars) that the small intestine absorbs poorly). These foods include milk, ice-cream, cereal, beans, lentil, asparagus, garlic, apple and pears What are the foods that purportedly may impact endometriosis positively? Animal and observational studies have indicated that foods promoting anti-inflammatory response in the body may benefit patients with endometriosis. They include: Colorful fruits and vegetables, such as oranges, berries, spinach, and beets Legumes, and whole grain Oily fish like salmon Walnuts, chia, and flax seeds Dark chocolate Vitamin A, C, E, D, calcium and magnesium Curcumin What is the latest scientific evidence as of 2021? Studying the cause-effect relationship between foods and disease is very complicated and difficult as it is not easy to restrict or control patients on the intake of certain foods. Most studies of the effects of nutrition on endometriosis are based mainly on observational and animal studies with very few well controlled randomized trials. The numbers of subjects are usually small and the results are often difficult to replicate. Although there appears to be a link between diet and endometriosis, the evidence is still inconclusive at present. Further well-designed trials are needed to accurately determine the influence of diet on endometriosis. Some studies have advocated diets excluding certain food products e.g. grains and dairy. This may result in nutritional deficiencies if the nutrients are not adequately replenished. Furthermore, adherence to a certain diet can be costly and failure to adhere to it can cause patients feeling stressed and guilty. It should be noted that foods that purportedly impact endometriosis positively are healthy foods. They may relieve the symptoms but not the progression of the disease. Besides, they may not work for every patient. At present, no universal dietary intervention has been proposed and patients are advised to eat a well-balanced healthy diet. G appeared to be happy with my explanation and was referred to the dietitian to check her nutritional needs.

C was bathing when she suddenly felt a gush of clear watery fluid flowing out of her vagina. Taken aback, she quickly finished her bath and alerted her husband who rushed her to the hospital. C, a 28-year-old financial executive was a first-time mum at her 33 weeks of gestation. She was seen early in the first trimester and her antenatal checkups had been normal. She was a non-smoker and there was no history of vaginal bleeding. She did not engage in vigorous exercise or sexual activity recently. C looked anxious on examination. Her body temperature, blood pressure and pulse rate were normal. Ultrasound scan of the abdomen revealed that her foetus appeared normal and weighed about 1.7 kg. The fetal heart was beating at 156 beats per minute. The amount of amniotic fluid surrounding the foetus was normal. There were occasional painless Braxton-Hicks uterine contractions. Speculum examination of the vagina found a pool of clear fluid in the posterior recess of the vagina. This was confirmed to be the amniotic fluid by the swab test (Amnicator) which showed a pH value of 7.1. C had ruptured her water bag before the onset of labour, a condition known as prelabour rupture of membranes or PROM. As this occurred before 37 weeks of gestation, it is called “preterm PROM”. How often is Preterm PROM? Preterm PROM occurs in about three in a hundred pregnancies and is associated with 30 to 40 % of preterm births What are the causes and risk factors of preterm PROM? The cause in most cases is not known. Risk factors include: Having a short cervix (neck of the womb). Infection of the reproductive organs. History of preterm birth in a previous pregnancy. Vaginal bleeding during pregnancy especially in the second and third trimesters. Smoking or taking illicit drugs during pregnancy. L ow socioeconomic status. Why is preterm PROM a concern? Preterm PROM complicates as many as one third or more of premature births. About 50% of babies will deliver within one week after the membranes rupture. A preterm baby has many serious life-threatening problems (see the article “premature birth” on our website). Other complications of PPROM include: Serious infection to the mother and the baby as a result of Infected amniotic fluid and placental tissues (chorioamnionitis). Premature separation of the placenta from the uterus (abruptio placentae). Compression of the umbilical cord. Increased incidence of Cesarean section. Infection after delivery. What are the symptoms of Preterm PROM? How is it diagnosed? The typical symptom is a sudden gush of fluid from the vagina. Other symptoms include: Uncontrollable leaking of fluid per vagina Feeling of wetness in the vagina or underwear Most cases can be diagnosed on the basis of the patient's history and speculum examination of the vagina. Vaginal fluid is then tested for the pH value with the nitrazine-based swab test. Amniotic fluid can also be dried on a glass slide and a fern-like pattern may appear under microscope. How is Preterm PROM treated? Treatment depends on the severity of the condition and the stage of pregnancy. It includes: Bed rest in hospital to monitor the mother for signs of labour and infection. The baby should also be monitored by ultrasound for its well-being and heart rate. Antibiotics are given to prevent and treat the infection. Steroids may be given to help the baby’s lungs grow and mature. Tocolytic medicines may be given to stop labour contractions. Timing and mode of delivery will depend on the severity of infection, the presence of obstetrical complications, the viability of the baby and the pediatric medical support. C was admitted for rest with an expectant management. Steroid and antibiotics were administered. She was monitored for signs of infection by regular blood tests. Foetal wellbeing was assessed with foetal heartbeat monitoring (CTG) and ultrasound scan. One week after admission, she began to show signs of an intrauterine infection. A Caesarean section was done and a healthy baby boy weighing 2 kg was delivered. He was monitored in the NICU (neonatal intensive care) for 3 days and was discharged well.

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.