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Dr Chew: Chances of pregnancy decline with age, while risks of miscarriages and foetal abnormalities increase with age. At 24 yrs old, a woman’s chances of natural conception are about 25% per month. At 35, it’s down to only 5%. As for men, his age is also critical in conception as sperm quality and quantity decline after 35 years. Risks of miscarriage and foetal abnormalities are higher too. So do plan early as baby-making is not a matter of hitting the jackpot on the very first try! 周志勇医生： -         一个女人在24岁时，自然生育能力是每个月百分之25，但到了35岁，就下降到只有百分之5。 -         男性的年龄也至关重要。精子的素质和数量在35岁过后开始下降。胎儿的风险将随之提高。 -         提早规划是关键。您应该在身体处于最佳状态时生育。

You can also take note of the following to boost your fertility 1. Your BMI: An optimal BMI is good for conception. Overweight or underweight in the woman may lead to problems in ovulation and irregular periods. If the man is obese, he may have problem in erection during sexual intimacy. 2. Reduce stress:  Stress is linked to fertility .It is a common knowledge that stress causes women to be childless. Easing stress and getting hold of better coping techniques may improve the total health of the individual, which may result in pregnancy. 3. Sexual intimacy at the right time: The life span of the egg is short. Detection of the ovulation and having sex at the right time is vital in increasing the chances of conception. 4. Medical check for the couple: A gynaecological check-up may detect conditions that cause impairment of the fertility such as endometriosis, pelvic inflammatory disease, fibroids. Early treatment of these conditions will enhance fertility. A medical examination of the man may lead to early detection and treatment of varicocoeles, sexual dysfunctions and past STDs.

In Singapore, one in 5 to 6 married couples have problems getting pregnant. Half of these difficulties is due to low sperm counts and/or abnormal sperm function. Thus, in the assessment of male fertility, it is important to test the semen, which contains the sperm and the fluid secreted by the male genital tract (the seminal vesicles, the prostate gland and the bulbourethral glands). Collection of sample: Semen can be collected by: · Masturbation and collection into a wide mouthed cup · Using a non-spermicidal condom during sexual intercourse · Withdrawal before ejaculation during sexual intercourse · Electrical stimulation or prostatic message Masturbation is usually the preferred method. Preparation for Semen analysis · Abstinence of 3-4 days is recommended. According to World Health Organization in 1999, the optimal abstinence period is 2-7 days. · Avoid alcohol, caffeine, herbal medications and lubricant use. · Keep the semen at body temperature. · Send the sample to the laboratory within an hour. · Do not take the test if you are sick or stressed. . What are normal results? Semen analysis includes the evaluation of various sperm parameters such as the volume of semen, concentration of sperm, the vitality, motility and morphology) of sperm. The results should be compared with the World Health Organization reference values published in 2010. • semen volume: 1.5 ml or more • pH: 7.2 or more • sperm concentration: 15 million spermatozoa per ml or more total sperm number: 39 million spermatozoa per ejaculate or more • total motility (percentage of progressive motility and non-progressive motility): 40% or more motile or 32% or more with progressive motility • vitality: 58% or more live spermatozoa • sperm morphology (percentage of normal forms): 4% or more. Semen Volume A low or excessive semen volume could indicate infection of the prostate and seminal vesicles. Appearance The normal appearance of semen is whitish to gray and opaque. Semen that has a red or brown tint could indicate the presence of blood, while a yellow tint could indicate infection. pH A pH level higher than 8.0 may suggest an infection. A pH of less than 7.0 could indicate the specimen is contaminated or that the ejaculatory ducts are blocked. Liquefaction Semen is initially thick and takes 15 to 30 minutes to liquify to facilitate the sperm to move up the genital tract. If semen is slow to or does not liquefy, it may indicate an infection. Sperm concentration Sperm concentration refers to the number of sperm found in one milliliter of semen. Low sperm count or oligospermia will make conception difficult. If no sperm are found, the condition is called azoospermia. Sperm Morphology Sperm morphology refers to the shape of the head, neck and the tail. A normal shaped sperm that fertilizes a normal egg will result in a healthy baby. Motility (Movement) Motility is the percentage of sperm which moves. The movement may be forward either in line or in a large circle This is important for the sperm to travel up the female genital tract to fertilize the egg. Vitality Sperm vitality refers to the percentage of live sperm in the semen sample. If Your Results Are Abnormal As semen test in the individual can vary from day to day and from laboratory to laboratory, one abnormal result is not necessarily a sign of impaired male fertility. It is common for doctors to repeat the tests in order to have a better assessment of the sperm health. According to the American Association for Clinical Chemistry (AACC), the tests should be conducted at least seven days apart and over the course of two to three months

Canned foods come in tins that are lined with Bisphenol–A or BPA, an industrial chemical used to prevent metal corrosion and breakages and to preserve the food inside. For years, scientist have been debating about just how much BPA lurks in the canned foods and whether this could pose a health risk. A recent study published in the journal Environmental Research in 2016 has revealed that consuming canned foods is the surest route to exposing our body to BPA. The study included data collected on 7,669 people, ages 6 and older, in the United States between 2003 and 2008 as part of the National Health and Nutrition Examination Survey. The researchers found that BPA in canned food is excreted mainly in the urine. People who consumed one canned food item the previous day had about 24% higher concentrations of BPA in their urine compared with those who had not consumed canned food. The consumption of two or more canned food items resulted in about 54% higher concentrations of BPA. The study also found that canned soups and pasta can expose consumers to higher levels of BPA than canned vegetables and fruit as BPA leached more into the soup when the food is heated up. BPA is known to disrupt the normal responses of hormones in the body by mimicking the effects of oestrogen. In doing so, it can reprogram cells, causing a plethora of health problems including diabetes, obesity, cardiovascular disease and infertility. Studies have shown that BPA can lower sperm count and motility and can damage the DNA of the sperm. It is also linked to low testosterone levels in men. For women, the chemical has been shown to impact cell division in the ovaries and alter menstrual cycles. A recent study, published in 2016 in the Journal of Clinical Endocrinology and Metabolism, examined 239 women who underwent IVF in Massachusetts from 2007 to 2012. Of the women with the highest exposure to BPA, 17 percent had a baby, compared to 54 percent of women with the lowest exposure. Although it is not clear how much BPA in the food would be safe, the U.S. Environmental Protection Agency suggests that exposure to BPA should not exceed 50 micrograms per kilograms of body weight each day. The U.S. Food and Drug Administration (FDA), after reviewing hundreds of studies about BPA's safety has maintained that current authorized uses of BPA in food packaging are safe and will not have any negative impact on health. Nevertheless, for couples who are embarking on the journey of parenthood, cooking and preparing food fresh should be the best option.

Uterine polyps are overgrowth of the inner lining of the womb. They are common in women in their reproductive age and are generally non-cancerous. There are 2 types of uterine polyps: those located in the neck of the womb (cervical polyps) and those found in the body of the womb (endometrial polyps). Both types are linked to infertility. How they adversely impact fertility is not well understood. For cervical polyps, researchers have suggested that it may interfere with the production of cervical mucus. During ovulation, cervical mucus is thin and slippery to help the sperm on its journey to fertilize the egg. Polyps with the associated inflammation will make the mucus thick and sticky, thus preventing the transportation of the sperm up the genital tract. In the case of endometrial polyps, the mechanisms are thought to be as follows: 1. Mechanical interference with sperm movement 2. Prevention of embryo implantation because of associated inflammation 3. Hindrance of embryo development Studies have shown that resection of polyps can improve natural conception rates in infertile women with pregnancy rates ranging from 43% to 80%. For intrauterine insemination and in vitro fertilization (IVF), the pregnancy rates also improved after patients had undergone polyp removal. It is recommended by the American Association of Gynaecologic Laparoscopists(AAGL) in their practice report that infertile women with uterine polyps should have them removed surgically.

I had an abortion when I was a teenager. I am now 27 years and am planning to get married next year. I am worried about whether the abortion would have affected my fertility. What should I do? A: Abortion, also known as termination of pregnancy, is a surgical procedure usually performed in the first trimester of pregnancy under general anesthesia . In this procedure, the neck of the womb(cervix) is gradually forced open by the gynaecologist using metal dilators of various sizes. After the cervix is dilated to about 6-10 mm, a plastic tube with holes at the tip is inserted into the cavity of the womb and connected to a suction machine. The foetus is then extracted out in pieces.  In experienced hands, complications following the procedure are few. Occasionally, they may be life threatening or may cause emotional upset  in the patient for a long time. They can be categorized into early and late complications. · Early complications include · Pelvic Infection with fever · Excessive vaginal bleeding · Perforation (puncturing) of the womb · Injuries to the lower genital tract (vagina and cervix) · Injuries to the surrounding organs (urinary bladder and intestines) · Shock from blood poisoning (septicemic shock) due to severe infection · Complications from general anesthesia Late complications include · Loss of blood, leading to anaemia (low red cell count) · Lower abdominal discomfort from chronic pelvic infection · Laxity of the cervix, resulting in repeated miscarriages or premature births · Ectopic pregnancy ( pregnancy outside the womb ) · Infertility · Psychological trauma, · Increased risk of breast cancer  Fertility can be affected: · if there is excessive damage to the lining of the uterus from overzealous scraping (curettage). This will result in scanty or absence of menstruation (Asherman's syndrome) · if there is pelvic infection, which lead to blockages of the fallopian tubes · if there is laxity of cervix, which may result in repeated miscarriages or premature births. You should consult a gynaecologist and have a preconception check to assess your fertility potential. You can also do a self-test using the fertility index at our website.

Sleep plays an important role in our physical and mental health. When we sleep, our body is busy restoring and regulating fertility hormones such as those produced by the pituitary gland (a pea-sized gland at the base of our brain), the thyroid gland and the adrenal glands. Any disturbance or lack of sleep will invariably cause imbalance in these hormones. With the advent of artificial light, curtailing the hours of sleep is becoming a norm in our society, Sleep has been reduced to the minimum tolerable so that more time is available for work or leisure. This reduction in the quantity and quality of sleep are increasingly recognised as important factors affecting female fertility. Recent studies have shown a link between lack of sleep and a decrease in the production of reproductive hormones. When these hormones decline, conception becomes difficult. Sleep disorders can also affect the male. Sleep apnoea, a condition when breathing repeatedly stops and starts during sleep, can negatively impact the hormonal system. Men who suffer from sleep apnoea produce very low levels of male hormone, testosterone. Sleep-deprived men also produce fewer sperm, the quality of which is also compromised. Fatigue due to lack of sleep may lead to chronic stress and performance anxiety. This may cause erectile dysfunction and diminished sexual drive resulting in further reduction in the chances of conception. Below are some of the suggestions to help sleep-deprived couples improve fertility: · Establish a healthy sleep pattern: Be strict in the sleep routine. Go to bed and wake up at the same time each day. Don’t oversleep in the weekends · Do not sleep for prolonged periods in the day so as not to upset your sleep cycle · Exercise regularly but not before bedtime · Avoid drinking coffee, tea and alcohol at night · Stop smoking · Avoid medications that may interfere with sleep · Start a relaxing bedtime routine: Take a warm bath. Dim the lights and keep the temperature of your bedroom cool.

I am trying to conceive and understand that eating plenty of leafy green vegetables and fruits will help improve my chances of conception. But I am worried about the food safety especially with so many scandals in the media recently. Can pesticides affect my fertility and that of my husband? How can I reduce exposure to these chemicals? A. Your concern regarding the food safety of pesticide residues on the vegetables and fruits is important. Indeed, pesticides do affect human fertility. In our present world, pesticides are ubiquitous. They are used to protect crops against insects, weeds, fungi and other pests. They are present on the vegetables and fruits we eat. Animal studies have shown adverse effects of pesticides on fertility. Researches in human have also linked pesticide exposure to the deleterious effects on reproductive health. In males, total sperm count, volume of semen ejaculated and percentage of morphologically normal sperm are all reduced. In females, pregnancy outcomes have also been shown to be adversely affected. The numbers of stillbirth, spontaneous abortion, foetal abnormalities and mothers suffering from hypertension during pregnancy(preeclampsia) are increased. In Singapore, thanks to the strict standards imposed by our food safety authorities, the Agri-Food and Veterinary Authority of Singapore (AVA), the amount of contaminants that actually reaches our grocery baskets is extremely small. Vegetables and fruits on sales have to comply with the maximum pesticide residue limits allowed to protect consumers from the toxic effects of the chemicals Despite the strict enforcement by the government, people like you who are trying to conceive are still anxious to know whether taking these foods is safe to the mother and the foetus. Until now, there has been no safety data to indicate whether long term consumption of the small amount of pesticide contaminants will affect the reproductive system. Be that as it may, it is prudent for people to take steps to minimise exposure to these chemicals, however small the amount. Below are some of the suggestions: · Thoroughly wash all produce with running water, even when it is labelled “organic”. Generally, a 30-second rinse followed by a 15-minute soak, and a final rinse will help to remove a significant portion of the pesticide residue. · Dry the fruits with a clean cloth or paper towel when possible. Gently rubbing the surface of your fruits and vegetables while rinsing can also help in removing residue. · Scrub firm fruits and vegetables, like melons and root vegetables. · Discard the outer layer of leafy vegetables, such as lettuce or cabbage. · Peel fruits and vegetables when possible. For fruits, peeling is effective for eliminating pesticide residue. · Eat a variety of fruits and vegetables. Different pests attack different crops which, in turn, require the use of different pesticides. By eating a variety of food, the exposure to one specific pesticide is reduced. · Blanching, cooking and frying the food will also lower the amount of the pesticide residue. Follow Dr.Peter Chew’s articles on aLife’s facebook page https://www.facebook.com/alife.org.sg as well as http://alife.org.sg/articles/ .

M looked depressed when he came into my consultation room with his wife. They have been married for 3 years and were grappling with fertility issues. “Doc, my wife has been checked. She is alright.”  He said, “The problem lies with me. My sperm count is low. The other doctor suggested IVF but I am not very keen for my wife to undergo the procedure as I know it is quite uncomfortable, stressful and doesn’t guarantee success. Are there any ways that you can help me improve my sperm count?” M was overweight with a BMI of 29. He did not smoke or drink. There was no history of sexually transmitted diseases or past surgery on his reproductive system. Examination of his genitals and ultrasound scan of his testis were normal. His blood hormone levels were within normal limits. A repeat semen analysis showed a sperm count of 12 million per ml. which is below the normal value of 15 million per ml.The motility of the sperm and shape of the sperm were slightly below par. Low sperm count or oligospermia is a common cause of male infertility It is a complex problem and in about 50 % of patients, no cause can be found. Other causes of low sperm count include: · Frequent use of saunas or hot tubs, sitting for long periods, wearing tight clothing and working on a laptop computer for long stretches of time · Taking drugs, drinking alcohol and smoking cigarettes · Infection of testis and prostate gland caused by tuberculosis, mumps and sexually transmitted diseases like Chlamydia and gonorrhea · Presence of varicoceles or testicular tumours · Previous hernia or testicular operations · Genetic causes resulting in children born with small and undeveloped testis · Abnormal hormone production from the brain causing small testis and low sperm count. · Long standing liver or kidney diseases I advised M to wear loose undergarments and trousers and to lose weight by regular exercise such as swimming. I also told him not to go for sauna and to try to bathe with cold water as far as possible. As for a balanced diet, M was instructed to take food rich in vitamins and trace elements such as brightly colored fruits and vegetables like carrots, tomatoes, spinach, broccoli, green beans, oranges berries and nuts like almond and walnuts. I also prescribed supplements rich in Vitamins A, B complex, C and E and trace elements Zinc and Selenium. M took my advice seriously. He felt better after losing about 7 Kg in 5 months. His sperm quantity and quality improved gradually. His wife conceived recently after the second attempt with IUI (intra-uterine insemination of the sperm). Recently, I received a greeting card from him. “Doc, thank you for helping us bring a new life to this world. It is the best gift for this new year,” he wrote.

Some months ago, I had a call from the emergency department of the hospital. My patient L, 30, was admitted with a high fever of 40 degree Celcius  and with severe lower abdominal pain for a day. She was rolling in pain on her bed when I saw her. Her face was red and flushed and her pulse rate was rapid at 100 per minute. Her lower abdomen was tense and tender. When I examined her, there was a small amount of foul smelling discharge from her cervix (neck of the womb). Vaginal examination was extremely tender. Blood tests and pelvic ultrasound examination suggested that she had a severe pelvic infection. She was given a strong antibiotic intravenously (through a vein) immediately. Her fever subsided and her condition improved dramatically the next day. She was discharged after 3 days in the hospital. As pelvic infection is usually transmitted sexually, I called L’s husband discretely. He admitted sheepishly that he had a “one-night stand" in a foreign country during a business trip a few weeks ago. "Doc, how can it be since I had used a condom and my blood tests done after that were OK?” he asked. I explained to him patiently that using a condom and having normal blood test results did not mean he did not have sexually transmitted infections (STDs). He finally agreed albeit reluctantly to have the antibiotic treatment. Pelvic infection, also known as pelvic inflammatory disease (PID), is one of the most common infections in women of reproductive age. It infects female reproductive organs including the cervix, uterus, fallopian tubes and ovaries. It is more common among younger women (less than 25 years) and those with more than one sexual partner. Women with a previous history of STDs or whose husbands are promiscuous have increased risks of contracting PID.  More than 85% of infections are sexually transmitted and caused by organisms like chlamydia or gonorrhoea. It can also occur after an abortion or insertion of an intrauterine contraceptive device (IUCD). In the early stage, the symptoms and signs may be minimal. When the infection gets worse, the following symptoms may be present: · Pain in lower abdomen  and pelvis · Smelly vaginal  discharge · Bleeding between periods · Pain during sex · Fever and chills · Pain when passing urine The infection if left untreated can cause the fallopian tubes to become scarred and narrowed, leading to partial or complete obstruction. The surrounding pelvic organs may also develop adhesions. This may lead to long term complications such as chronic pelvic pain, infertility and ectopic pregnancy. Diagnosis of PID is usually made based on clinical symptoms and signs. However, it may not always be easy as the site of infection cannot be assessed easily and the symptoms sometimes mimic those of other conditions, such as appendicitis, or a twisted or ruptured ovarian cyst. Blood tests, ultrasound examinations and other imaging procedures and laparoscopy may be helpful in making the diagnosis. The mainstay for the treatment of PID is antibiotics. Very often it is caused by more than one type of microorganisms. Multiple antibiotics may be necessary. Antibiotics can be taken by mouth or intravenously in severe case. Surgery may be required if pus accumulates in the swollen tube. L had been married for 7 months. She was keen to start a family. I advised her to wait for 2 months after treatment to make sure that she had recovered fully and there was no relapse. On her follow-up visit 6 months later, she walked into my clinic smiling. She had missed her period. She was very happy when I showed her the baby’s heart beating on the ultrasound examination. She was full of gratitude that her fertility was unaffected by the severe bout of pelvic infection as her condition was treated promptly.

T, a 46-year-old housewife looked apprehensive and was fidgety while waiting for the result of her mammogram. She felt a lump, the size of a fish ball, in her right breast 3 weeks ago. “I felt the lump while bathing. It was firm but not painful. I did not have any nipple discharge. My husband and daughter encouraged me to go for a mammogram. I was resistant to the idea initially and was reluctant to do so as I did not have a family history of breast cancer and was told the procedure was very uncomfortable and painful,” she said. Her mammogram was indeed abnormal and was reported as BI-RADS 5 which was highly suggestive of cancer. She was referred to a breast surgeon who did a biopsy on the lump and confirmed that it was cancerous. What is a mammogram? A mammogram is a specialized low-dose X rays to image the breasts. It is used to detect early breast cancer before the growth can be felt by a physical examination. Early detection and treatment greatly enhances the chances of survival. In Singapore, as many as 2000 women are diagnosed with breast cancer every year. This makes it the most common female cancer. How is a mammogram done? Using a specialized X-ray machine, the technician places each breast on a flat X-ray plate. A compressor is gradually applied on the breast for a few seconds to spread out the breast tissue evenly for the X-rays to penetrate. The images are then captured and read by the radiologist. The mammogram is usually uncomfortable because of the compression. But this step is necessary as the pressure keeps the breast from moving which may cause blurring of the images and it also minimizes the dose of radiation required. The discomfort or pain, however, is usually short-lived. When should mammography be done? There is no ideal age to start screening for breast cancer. Women with an average risk may begin mammograms at age 40 and have them every one to two years. Professional organizations also differ on their recommendations. The American Cancer Society advises women with an average risk to begin screening mammograms yearly at age 45 until age 54, and then continue every two years. The U.S. Preventive Services Task Force recommends women start screening every two years starting at age 50 until age 74. However, these groups agree that women can choose to be screened starting at age 40. In Singapore, BreastScreen Singapore (BSS) , the national breast cancer screening programme recommends annual screening from age 40 to age 49 and once in two years from age 50 onwards. Women with a high risk of breast cancer such as a family history of breast cancer or a history of precancerous breast lesions may benefit by beginning screening mammograms before age 40. Magnetic resonance imaging (MRI) in combination with mammograms may also be done to achieve optimal result. What are the risks and limitations of mammograms? Risks Many women are concerned about the radiation exposure from mammograms. The risk is low and is equivalent to about 6 months of background radiation exposure from daily living. For most women, the benefits of regular mammograms outweigh the risks posed by this amount of radiation. Limitations While mammography is an excellent screening tool for breast cancer, mammograms do not detect all breast cancers. The accuracy of the procedure depends on the technique used, age of the patient and breast density. It may give false-negative or false-positive results. Mammograms in younger women can be difficult to interpret. The breasts of younger women contain more glands and fibrous tissue than do those of older women, resulting in dense breast tissue that can obscure signs of cancer. With age, the breast tissue has more fatty tissue and fewer glands, making it easier to interpret and detect changes on mammograms. How is the mammogram reported? The mammogram is usually reported according to the diagnostic system developed by American College of Radiology called BI-RADS, or the Breast Imaging Reporting and Database System. In this system, there are seven categories, ranging from zero to six. Each category describes whether additional images are necessary, and whether an area is more likely to have a benign (noncancerous) or cancerous lump. T had her right breast removed by surgery followed by chemotherapy. She remained well for the past 5 years. On her recent visit for her gynecological check-up, she was in good spirits. “ Doc,” she said, “luckily the mammogram picked up my cancer early. My surgeon told me that I should have excellent prognosis.”

She looked nervous and anxious when she stepped into my consultation room. “Doc, I have a fleshy lump in my genital area for the past 3 days. It is not painful but itches occasionally. It has been getting bigger and has started to bleed today. Could it be cancer?” she asked worriedly. E, a 19-year-old student was sexually active since the age of 16. She had 3 previous sexual partners. “I was not using condoms as I was on the pills. I did not worry about sexually transmitted diseases as my current boyfriend is “clean”. He just had his blood tests done few weeks ago,” she said. Clinical examination revealed that E had a cauliflower-like growth about 1 cm. protruding from the opening of the vagina. She had genital warts. What are genital warts? Genital warts are one of the most common sexually transmitted infections. They affect the moist tissues of the genital area like the vulva, the walls of the vagina, the cervix, the area between the external genitals and the anus and the anal canal. The vast majority of genital warts are the direct result of skin-to-skin contact during vaginal or anal sex, with the rare instance of transmission via oral sex. They can be passed on to others even when there are no visible warts or symptoms. What are the causes? Genital warts are caused by the human papilloma virus (HPV) and are almost spread through sexual contact. There are over 100 different strains of HPV. The strains of HPV that cause genital warts are different from those that cause genital cancers such as cervical cancer. However, they can coexist together. What are the symptoms? In the females, the symptoms of genital warts include One or more small, flesh-colored, brown, grey or pink swellings in the sites described above A cauliflower-like growth due to several warts growing together Itching or bleeding from the vagina or anus Vaginal discharge In some cases, genital warts can be so small that they may not be visible. Very rarely, they can multiply and develop into big clusters that may block the vaginal opening. It is important to note that symptoms of genital warts can appear weeks, months or years after the patient has had contact with HPV virus. What are the risk factors? Risk factors include: Having sex with multiple partners Having unprotected sex Having had other sexually transmitted infections Becoming sexually active at a young age Having a weakened immune system, such as from HIV or drugs from an organ transplant Smoking How are genital warts treated? Small warts may be removed by applying topical cream or solution. Larger lesions may need minor surgery. The modalities of surgery include: Electrocautery-- burning the warts with electric currents Cryosurgery-- freezing the warts Laser treatments Excision of the warts Can genital warts be prevented? Reducing the number of sexual partners and being vaccinated will help prevent patients from getting genital warts. Using a condom may cut down the risk but not necessarily protect patients from getting genital warts. After explaining the causation of genital warts to E, I prescribed a topical cream for her. The warts disappeared gradually after a week. I told her that she should reveal her condition to her partner and both of them should be vaccinated. She should also have regular pap smear and HPV testing to prevent the development cervical precancer and cancer.