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F had always wondered why she had a “burning sensation” after urination for a few days after sexual intercourse. This had happened soon after she got married 5 years ago. But the symptom had become more frequent for the past six months. She had been treated by the general practitioner for urinary tract infection with antibiotics. Although the symptom had subsided somewhat with treatment, it kept on recurring. F, 35, had also been grappling with a fertility issue. She had been admitted to the hospital a year ago for fever and lower abdominal pain, which subsided after conservative treatment. Gynecological examination of her reproductive system was normal. Her husband’s semen analysis showed that the sperm count was slightly below average. The number of motile sperm (motility) and normal-shaped sperm (morphology) were also reduced. Her hysterosalpingogram (HSG), an X-ray test of the uterus and tubes, showed that the uterine cavity was normal but both her fallopian tubes were blocked. The blockage was subsequently confirmed by laparoscopy, a key-hole surgery to examine the organs inside the abdomen. It was due to scar tissue from a previous pelvic infection. Swab test from the cervix indicated that the F had been infected by the bacteria Chlamydia trachomatis. Chlamydia is a very common sexually transmitted disease. The bacteria are passed from one person to another through vaginal, anal and oral sex. Symptoms and signs ( please refer to the article Chlamydia Revisit in this website ) Complications : In four out of 5 women and one in two men, chlamydia infection does not have any obvious signs or symptoms, or may have symptoms that are so mild that they often go unnoticed. In these patients, the bacteria continues to grow and may progressively damage the reproductive system resulting in the following complications: Pelvic inflammatory disease (PID): Up to 30% of women with untreated infection develop PID. Chlamydia spreads from the cervix up to the uterus and fallopian tubes. The infection causes severe abdominal pain and fever in the acute stage. Once the infection is treated with antibiotics, the inflamed tissue may become scarred, resulting in damage to the tubes and ovaries. Infertility: Complete obstruction of the fallopian tubes from scarring will make natural conception impossible. This has happened in F’s case. Ectopic pregnancy: This occurs when there is partial obstruction of the fallopian tube when the fertilized egg implants and grows there. The condition is life-threatening if the tube ruptures with massive internal bleeding. Chronic pelvic pain: Scarring and adhesions of the ovaries and tubes from pelvic infection may result in backache, congestion and lower abdominal pain, especially during menses. Epididymis infection: Chlamydia infection can cause inflammation of the epididymis, the coiled tube at the back of the testicle that stores and carries sperm. The infection can result in fever, scrotal pain and swelling. Sperm production and quality will be affected. Prostate gland infection. Rarely, chlamydia can spread to the prostate gland. Prostatitis can cause pain during or after sex, fever and chills, painful urination, and lower back pain. Diagnosis Culture: Diagnosis can be made by isolating the bacteria from the swab specimen of the discharge from the cervix and penis for men. However, 10 to 30 % of cases may have false negative results. This may be because the bacteria may not survive the transit to the laboratory, the sampling may be inadequate or the number of bacteria is too low in asymptomatic infection. The polymerase chain reaction (PCR) test from the swab samples is usually performed to identify the bacteria in cells and secretions from the genital tracts. This is 95% accurate. Both F and her husband, who had not been treated previously had a full course of antibiotics together. Her urinary symptom did not recur since.

F, 28, was concerned whether oral contraceptive pills could affect her chances of getting pregnant. She had her menses at the age of 12. Her menstrual cycles had been irregular since. It occurred once in one and half months to three months, lasting seven days. Occasionally, the bleeding could drag on for 2 weeks and sometimes, a small amount of vaginal bleeding could happen in between periods. Her menstrual problems were “solved” after her family physician had prescribed oral contraceptive (OC) pills for her. She had been on the pills for the past five years but had decided to stop as she was getting married in a year’s time. Her period had not resumed after cessation of the pills for the past six months. She was worried. F was suffering from a medical condition often referred to as “post-pill amenorrhea.” This term is a misnomer because it implies that the OC pills are responsible for the missing period. In fact, they are not. The pills are usually taken for 3 weeks and stopped for one week. The synthetic hormones in the OC pills cause the lining of the uterus to shed once they are discontinued. The “withdrawal bleeding” gives rise to a fake artificial “period”. Patients with irregular menses may have a wrong impression that their condition is “cured”. Once they stop the pills, the symptoms will reappear as the underlying cause is still not resolved. Studies have shown that in patients with normal menstrual cycles, coming off the pill can delay the return of menstruation for a few weeks in some women. Most women will resume regular cycles within two to three months. If the menses does not resume after 6 months, the patient should be investigated for other causes of amenorrhea. After stopping the pills, about 20% of women will conceive in the first fertile month and 80 % will achieve pregnancy within a year similar to the odds in the general population for conception. However, it should be noted that the first fertile month may occur on the second or third cycle after cessation of the pills. F was reassured that OC pills would not affect her fertility. Her blood hormones were tested. She was found to have polycystic ovarian syndrome (PCOS). Appropriate treatment with metformin was given and her menses became regular after 4 months of treatment.

H, a healthcare worker and mother of two had the first dose of Pfizer's vaccine. Her menstrual period which had been regular was delayed for over a week while awaiting for her second dose of the vaccine. She was much relieved when the blood test of the pregnancy hormone(B-hCG) was negative. As the Singapore government is rolling out the vaccination program against covid-19, many women, like H, are concerned about the safety profiles of the vaccines with regards to fertility, pregnancy and breastfeeding. In December 2020, an article was circulating in the social media which claimed that Pfizer’s vaccine could elicit antibodies that could damage the human placenta and cause infertility. This has caused much concerns of vaccine safety in pregnant mothers and in those women who are trying to conceive. The claim was found to be false and was refuted subsequently by other laboratory and animal studies. Vaccines given to the rodents did not prevent pregnancy or had any harmful effects on the pups. During the vaccine clinical trials in the UK and America where pregnant women were excluded, there was no significant difference in the rate of “Accidental pregnancies” –pregnancies occurring during the trial period--in the vaccinated groups compared with the control groups. The miscarriage rates were also similar between both groups. This suggested that the vaccines do not have any detrimental effects on fertility and early pregnancy. Furthermore, women who are infected with covid-19 shortly before conceiving or early in pregnancy are no more likely to miscarry than their uninfected peers. The following are the update of some of the key messages published by Royal College of Obstetricians and Gynaecologists(UK) on 7 May 2021. The latest advice from the Joint Committee on Vaccination and Immunisation (JCVI) is that COVID-19 vaccines should be offered to pregnant women at the same time as the rest of the population, based on their age and clinical risk group. Women should discuss the benefits and risks of having the vaccine with their healthcare professional and reach a joint decision based on individual circumstances. Women trying to become pregnant do not need to avoid pregnancy after vaccination and there is no evidence to suggest that COVID-19 vaccines will affect fertility. You should not stop breastfeeding in order to be vaccinated against COVID-19. However, until more local data are available, it is prudent to follow the advice by the Ministry of Health, Singapore which states: Women who are planning a pregnancy are advised to consider deferring conception for 1 month after completing the second dose, out of an abundance of caution. This does not apply to male vaccine recipients. There is currently not enough evidence to advise on the use of COVID-19 vaccines during pregnancy. It is recommended that pregnant women defer vaccination until more data become available. They may receive the COVID-19 vaccine after delivery. Women who become pregnant after the first dose and before the second dose should not receive the second dose of vaccine, but should postpone it until after delivery.

He was upset when his recent semen analysis showed a significant decrease in the quantity and quality of his sperm. T, who is 35, and his wife had been trying for a baby the past 6 months. He had been married for a year and his sperm check eight months was normal. “Doc, could the decline in my sperm be due to the covid infection I had 2 months ago?” he asked. A recent study (January 2022) had found that conception was decreased by 18% in the first three months after Covid-19 infection of the male partner. How does Covid-19 affect male reproduction? Although Covid-19 infection primarily affects respiratory tissues, other organs such as the kidney, heart, liver and testes have been found to be invaded by the virus too. As Covid virus shares similarities with SARS virus structurally and the latter has been shown to cause severe damage to the testis, scientists suspect that it may have similar impact on the male reproductive system. The way Covid virus causes damage to the testis is still not fully understood. However, a few possibilities have emerged from recent studies. They include: Direct invasion of testicular tissue by the virus : The virus could enter the testis through the blood. It may attack the hormone producing cells first, resulting in hormone abnormalities, then cause collateral damage to the sperm producing cells by the intense inflammatory response. Young males were found to have more vulnerable sites for the virus to enter compared to older patients. Thus, young people may have a higher chance of testicular damage. Testicular inflammation : Patients with severe illness were found to have some scrotal discomfort. This is due to the inflammation of the testis (orchitis). Postmortem examination of 12 male patients were reported to have inflammation and cell damage of testis in a study from China. Derangement of male sex hormone : In a recent study on 119 men with COVID, it was observed that infected men had slightly lower overall serum testosterone levels, compared to 273 age-matched healthy men. In patients with severe disease, the reduction can be as high as 50%. Disruption to the hormones in the hypothalamus and pituitary gland of the brain can also affect sperm production Virus found in the semen : Although studies have revealed that the virus was present in the semen in about 5% patients, there has been no records on the sexual transmission of the disease to date. American Society for Reproductive Medicine (ASRM), however, had published warnings regarding the possibility of sexual transmission of Covid. The effects of fever : Fever and elevation of testicular temperature contribute to disruption in sperm production. The sperm concentration and motility had been found to decrease for 72 to 90 days after the viral infection. I told T that studies have shown that the effects of Covid on semen parameters may be temporary and male fertility seems to return after a few months. These studies, however, are limited by the small sample size and one should await more robust and long-term studies to know the answer. In the meantime, he should continue taking multi-vitamins, trace elements and antioxidants prescribed, which he diligently complied. In his latest review a month ago, results of his semen analysis showed some improvement. He is still hopeful that the parameters will return to normal soon.

2 years ago, K was getting upset as she was gaining weight even though she worked out regularly and was meticulous about her eating habits. Her menstrual cycle which was regular also became erratic occurring once in 2 to 3 months. The menstrual flow varied from heavy to scanty. Often, she would have post menstrual staining for up to 10 days. She was married a year ago at the age of thirty. She was keen to get pregnant and had missed her period for the past 4 months. But the urine pregnancy test was negative repeatedly. Her husband encouraged her to seek medical advice. K walked into my consultation room. She appeared sluggish and was obese with a BMI of 32. She looked anxious with a slightly puffy face and dry skin. There was no palpable lump in her thyroid gland and her uterus and ovaries were normal on pelvic examination and ultrasound scan. Blood tests reveal that her thyroid hormones were low. K was suffering from hypothyroidism, a condition in which the thyroid gland is under active in producing the hormones. Thyroid gland and metabolism Thyroid is a small, butterfly-shaped gland situated on the front of the neck, just below the Adam's apple. Thyroid hormones— triiodothyronine (T3) and thyroxine (T4) — play an important role in regulating many of the body’s functions, including metabolism, growth, heart rate, and body temperature. If they are deficient, the bodily functions slow down, and one may experience constipation, fatigue, depression, dry skin, thinning hair, intolerance to cold, muscle cramps, joint pain and weight gain. Hypothyroidism and menstruation When thyroid hormone levels decrease, the pituitary gland in the brain starts producing extra hormones to stimulate the thyroid gland to increase its hormone production. This also causes the milk hormone, prolactin from the brain to become excessive. Prolactin suppresses growth of the egg and ovulation. Left untreated, disruption of ovulation may lead to disordered growth and shedding of the uterine lining, causing unpredictable bouts of heavy bleeding from the uterus. Over time, menses can stop completely due to thinning of the uterine lining. Hypothyroidism may not cause noticeable menstrual symptoms in the early stages. Problems tend to develop slowly, often over a number of years. Hypothyroidism and Infertility Hypothyroidism could cause infertility in the following ways. · Disruption of ovulation: To conceive, one needs to ovulate regularly · Disturbance in the lining of the uterus: a good endometrial lining is a prerequisite for an embryo to implant. · Increase the risk of miscarriage in untreated hypothyroidism Diagnosis of Hypothyroidism Hypothyroidism is diagnosed by measuring the blood levels of various thyroid hormones. K was referred to the endocrinologist. Her hypothyroidism was due to an autoimmune disease called Hashimoto's disease. This disease causes a person’s immune system to attack their thyroid gland, preventing it from working properly. She was treated with thyroxine. Her body weight and menstruation gradually returned to normal. She was overjoyed when she conceived naturally 3 months after her menses returned to normal.

M, 30, had been married for the past 3 years and had not been able to conceive. She had her first menstruation at the age of 12. Her menstruation had been irregular, occurring once every month to one and half months. Her periods usually lasted 5 days. Since she got married, the cycle had changed to once in 2 to 3 months lasting between 3 to 12 days. The amount varied from scanty to heavy flow with clots. There were no abdominal cramps or discomfort during menses. She was obese with a BMI of 32. Clinical examination of her reproductive organs was normal. Pelvic ultrasound examination revealed enlarged ovaries with multiple small cysts. Blood hormonal tests confirmed that she had polycystic ovarian syndrome (PCOS). Her spouse, aged 34, was also obese with a BMI of 34. Semen analysis revealed suboptimal numbers of sperm with reduced motility. Prevalence of Obesity Obesity, defined as an excessive accumulation of body fat, is a global health issue. In Singapore, one in 10 adults is considered obese according to the most recent surveys by the Ministry of Health. Besides health risks such as cardiovascular diseases and diabetes, an important but often overlooked consequence of obesity is its impact on fertility.   I mpact of Obesity on female reproductive health Obesity affects female reproduction by the following mechanisms: Excess body fat produces abnormally high levels of female hormone, oestrogen. This results in disruption of hormonal balance and leads to irregular menstrual cycles due to absent or infrequent ovulation. Obesity is closely linked to polycystic ovary syndrome (PCOS).  The increased levels of male hormones and insulin resistance in PCOS make it more difficult for conception to occur. Fat tissues also produce leptin, the hormone that regulates energy balance. High levels of leptin in obesity can cause inhibition of ovulation, resulting in infertility. Moreover, obesity increases the risk of pregnancy complications such as gestational diabetes, preeclampsia, and miscarriage. These complications not only threaten the health of the mother but also reduce the likelihood of a successful pregnancy. The reduced efficacy of in vitro fertilization (IVF) in obese women further underscores the adverse impact of obesity on female reproductive health.   Impact of Obesity on Male Fertility Obesity can affect male fertility in the following ways: Excess body fat can lead to the increased conversion of male hormone, testosterone, to estrogen in the fat tissue, resulting in lower levels of circulating testosterone. This hormonal imbalance can impair the production of sperm and reduce libido. Obesity is associated with erectile dysfunction (ED), which impairs the ability to engage in sexual intercourse and thus decreases the chances of conception. The increased prevalence of diabetes and cardiovascular disease among obese men further contributes to ED. Obesity is also linked to poor semen quality, including reduced sperm concentration, motility, and morphology. The oxidative stress and inflammation associated with obesity can damage sperm DNA, further compromising male fertility.   M and her spouse understood the negative impact of obesity on fertility and general health. They were motivated and expressed the wish to support each other on weight management. Lifestyle changes, including eating a balanced diet and regular exercises, are the mainstay in reducing weight. A reduction of 5-10 % of weight is found to improve both egg and sperm health. M was also given medications to correct her hormonal imbalance and her spouse was prescribed micronutrients to help improve sperm quality. They are progressing well albeit slowly on their long journey to achieve pregnancy.

She was beaming with joy when she walked into my consultation room. “I am pregnant at last," she exclaimed. J, 32, had been married for 5 years with fertility issues. She had regular menses with no abnormal vaginal discharge or menstrual cramps. Pelvic examination and ultrasound scan did not reveal any abnormalities in her reproductive system. Semen analysis of her husband, however, showed a low sperm count with a reduced number of motile sperm. J sought medical help 2 years after her marriage. She did not get pregnant after three attempts with IUI (intrauterine insemination) and twice with IVF (in-vitro fertilisation). Feeling dejected and depressed, she went back to her home country to have a respite. She decided to have another attempt at the IVF clinic in her hometown. She had acupuncture treatment prior to the fertility treatment there. What Is Acupuncture? Acupuncture is a form of traditional Chinese medicine (TCM) that has been practised for centuries. It is based on the theory that illness or disease is the consequence of blockage or change in the flow of life energy, called “qi”, that flows through the body in specific channels. Acupuncture tries to rebalance this flow of energy by inserting fine sterile metal needles into the skin at specific places on the body to stimulate the flow of "qi". Acupuncture for IVF In 2008, research from the University of Maryland School of Medicine, USA, reviewed a number of randomized controlled trials and found that acupuncture significantly improved pregnancy rates in IVF. Other studies also showed that men could also benefit from acupuncture with an increase in the number of sperm and a reduction in abnormalities of sperm. Women experienced best results from acupuncture three to four months before IVF. Since then, dozens of trials have been conducted to examine the effects of acupuncture on the outcome of IVF treatment. The results have been inconsistent, leaving the efficacy of adjunctive acupuncture open to debate. How does acupuncture for fertility treatment work? How acupuncture works for fertility is not well understood. It is thought that by stimulating the nerve endings under the skin, the body may release chemical substances called neuro-transmitters, which may have positive effects on fertility. These include relieving stress, improving ovarian and follicular function, increasing blood flow to the uterus and facilitating a thick, rich lining of the uterus for the embryo to implant. Acupuncture has also been shown to help reduce depression, which can be a problem for women struggling with infertility. It can alleviate anxiety that may further contribute to fertility problems. Acupuncture for other causes of female infertility Other than blocked fallopian tubes which will not respond to therapy, acupuncture has been used to treat other causes of female fertility. As acupuncture is generally individualized, there have been no large rigorous studies to show conclusively that it will improve pregnancy rates. What are the risks of acupuncture? Acupuncture, if done by a certified and licensed professional is generally safe. J believed that her successful IVF was partly due to acupuncture treatment. But she was not comfortable continuing the treatment during pregnancy. Her antenatal course remained uncomplicated. She is awaiting the arrival of her baby early next year.

N,34, had been grappling with fertility issues for the past 2 years. Her reproductive system was normal with no obvious pelvic masses such as fibroids or ovarian cysts. Her menstrual cycles were regular, occurring every 28 to 30 days. There was no menstrual discomfort or pain and her vaginal discharge was normal without any foul odor. N could identify transparent, clear egg-white vaginal discharge during ovulation quite accurately.  She had regular sexual intercourse during this period. Her husband, however, refused to be checked initially as he thought there was nothing wrong with him. With much persuasion, he finally turned up for a consultation albeit reluctantly. N’s husband, 37, was a relationship manager in a bank. He was under a lot of “work stress” for the past years and went for sauna baths regularly with friends for relaxation. There was no significant medical, surgical or family history of note. He was overweight with a BMI of 28 as he ate most of his meals outside. He smoked more than 20 cigarettes a day and drank 3-4 cans of beer every weekend with friends to “de-stress”. Semen analysis revealed that his sperm count was on the low normal range and the quality of the sperm was slightly below par. Why Male fertility checks? About one in 5 to 6 couples in Singapore has fertility issues and about 50%  are due to male disorders. Male fertility checks may help identify the underlying problems. These problems  affect not only conception but may also pose risks to the mother and the baby during pregnancy. What are the Male Fertility Checks? Clinical assessment: This includes medical history taking and physical examination. A review of medical history, including past illnesses, surgeries, medications, and family history of genetic disorders or fertility problems, can provide valuable insights into potential risk factors. A comprehensive physical examination can assess overall health and identify any underlying medical conditions that may affect fertility or pregnancy. Examination of the reproductive organs may detect abnormalities such as varicoceles (enlarged veins in the scrotum) or other structural issues. Lifestyle Assessment: Lifestyle factors such as smoking, alcohol consumption, recreational drug use (e.g. Marijuana), diet, exercise habits and exposure to environmental toxins can impact fertility as they can contribute to oxidative stress, inflammation, hormonal imbalances and DNA damage in sperm cells. Prolonged exposure to heat, such as sauna or wearing tight underwear, may also negatively impact sperm quality. A thorough assessment of lifestyle habits can identify areas for improvement to optimize reproductive health. Chronic stress can disrupt hormonal balance and negatively affect fertility. Practicing stress-reduction techniques such as mindfulness, meditation, yoga, or counseling can help alleviate stress and improve reproductive health. Semen Analysis: Semen analysis is important to assess sperm quantity and quality. It evaluates various parameters such as sperm count, morphology (shape), and motility (movement). Abnormalities in any of these parameters can indicate potential fertility issues. Hormone Testing: Hormones play a critical role in sperm production and reproductive function. Imbalances in hormone levels can affect sperm production and its quality. Tests include measuring levels of testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin. STD Testing: Sexually transmitted infections (STDs) can impact fertility and pose risks to pregnancy and the unborn baby. Tests for common STDs such as chlamydia, gonorrhea, syphilis, and HIV are usually recommended. Prompt treatment of STDs can prevent complications and protect reproductive health. Genetic Screening: Genetic testing can identify inherited conditions or chromosomal abnormalities that may affect fertility or increase the risk of passing genetic disorders to the offspring. Tests may include screening for conditions such as chromosomal abnormalities (e.g., Klinefelter syndrome), and genetic mutations linked to infertility. Counseling and Education: N was counselled on various aspects of sperm care and educated on how to modify his lifestyle habits. He was given supplements and antioxidants including vitamin C, vitamin E, selenium, and coenzyme Q10. These micronutrients help reduce oxidative stress and improve sperm quality. He subsequently changed to a less stressful job in the financial industry and six months after he stopped smoking, his sperm parameters improved to normal levels.  The couple was overjoyed when they saw the baby’s heart beating regularly at 6 weeks gestation at the last review a few weeks ago.

He was baffled why the results of his semen analysis had been poor.  S, 34, had been bothered by fertility issues for the past 4 years since marriage. His wife, who is 30 years old, had her fertility checks which included physical examination and ultrasound scan of her reproductive organs and they were normal. S led a healthy lifestyle and exercised regularly. He did not smoke and only drank occasionally. As an engineer, he did not feel “stressed” at work. Clinical examination, blood hormone tests and ultrasound scan of testes were normal. "Doc," he asked," is there anything I can do to help improve the sperm quality and quantity?" Importance of dietary nutrients Semen analysis can be affected by various factors, including genetics, lifestyle, and dietary habits. While dietary nutrients alone may not be the sole cause of impaired sperm function, they can play a role in improving sperm health and potentially increase the chances of conception. Dietary nutrients for sperm Omega-3 fatty acids: Omega-3 fatty acids are essential for sperm production and function. Many studies have demonstrated that increased intake of this essential fatty acid significantly improved testosterone levels in men. Testosterone is the hormone which drives sperm production in men. Omega-3 at 0.5–2 g/day has been shown to have a beneficial effect on sperm motility. Sperm quality could also improve with reduction of oxidative stress to the sperm and less damage to its DNA. The cell membrane of sperm could also be strengthened by taking omega-3. Sources of omega fatty acids include fatty fish (such as salmon, and sardines), flaxseeds, chia seeds, walnuts, and soybeans. Micronutrients : Micronutrients refer to essential vitamins and minerals required by the body in small amounts for optimal functioning. Vitamins are organic compounds made by plants and animals whereas minerals are inorganic and they exist in soil or water. Micronutrient content of each food varies. It is best to eat a balanced diet in order to get sufficient vitamins and minerals. Vitamins: Folic acid: Folic acid, also known as vitamin B9, is not only beneficial for female fertility. It has also been linked to improved sperm health and fertility. Foods rich in folic acid include leafy greens (such as spinach and kale), legumes (like lentils and chickpeas), and fortified grains. Vitamin B12:  Vitamin B12 has significant effects on sperm function and semen quality. It helps in increasing sperm motility, sperm count and diminishing sperm DNA damage. Fish and red meat are excellent sources of vitamin B12. Other vitamins that are important for sperm production and function include  vitamin C (found in citrus fruits, strawberries, and bell peppers), vitamin E (found in nuts, seeds, and vegetable oils), and vitamin D (obtained from sunlight exposure and fortified foods like dairy products and cereals). Minerals: Zinc  plays an important role in sperm production and maturation and is involved in testosterone metabolism.  It is crucial in maintaining the structural integrity of sperm cells and for sperm motility. Good sources of zinc include oysters, poultry, beans, nuts, and whole grains. Selenium  is a micronutrient with antioxidant properties that help protect sperm cells from oxidative damage. Adequate selenium levels have been linked to improved sperm motility and morphology. Fish, egg and Brazil nuts are rich in selenium. Antioxidants: Antioxidants help protect sperm from oxidative stress, which can damage sperm DNA. Foods rich in antioxidants include fruits (such as berries, citrus fruits, and kiwi), vegetables (like spinach and broccoli), nuts (such as almonds and walnuts), and seeds (like flaxseed and chia seeds). Coenzyme Q10 (CoQ10) is an antioxidant that may improve sperm motility and sperm count. It can be found in foods like fish and whole grains. L-Carnitine: L-Carnitine has been found to positively impact male fertility, even at a relatively low dose of 2 g/day. This supplement enhances sperm parameters, regulates hormone levels and reduces oxidative damage to sperm. Lycopene , a carotenoid antioxidant found in tomatoes, watermelon, and pink grapefruit, has been associated with improved sperm quality and motility. Conclusion :   Dietary nutrients are crucial in maintaining optimal sperm production and function. Ensuring adequate intake of these nutrients through a balanced diet and/or with supplementation can improve chances of conception and help achieve better reproductive outcomes. S was counselled on the importance of dietary nutrients. He made some dietary modifications and took supplements. He was hopeful that the quality and quantity of sperm would improve with time.

“How much weight should I gain during pregnancy?” she asked. T, 28, was a first-time mum in her second trimester. Her appetite had just returned after she had quite a bad experience of morning sickness in the early stages of pregnancy. Her antenatal course had been otherwise uneventful. Why weight gain matters One of the many changes in the body during pregnancy is weight gain. Knowing the weight gain during pregnancy is important for the following reasons: Monitoring Fetal Growth : Appropriate weight gain is important for the healthy growth and development of the fetus. Insufficient or excessive weight gain can lead to a baby with low birth weight or an overly big baby which may cause delivery issues. Maternal Health : The right amount of weight gain helps maintain the mother's health. Excessive weight gain can increase the risk of gestational diabetes, preeclampsia, and long-term obesity, while too little can lead to maternal malnourishment and anemia (low haemoglobin level). Guiding Nutritional Needs : Tracking weight gain helps the obstetrician offer personalized dietary advice to ensure that the mother and baby are getting the necessary nutrients. Preventing Complications : By monitoring maternal weight, potential complications can be identified and managed early. This includes managing risks like hypertension, premature birth, and the need for cesarean delivery. What factors contribute to Weight Gain These include: Baby’s Growth : The baby itself contributes significantly to the weight gain. Placenta : The placenta, which nourishes the baby, adds to the overall weight. Amniotic Fluid : The fluid which surrounds and protects the baby also adds to the weight. Blood Volume of the mother increases during pregnancy : This is due to the extra oxygen and nutritional demand of both the mother and baby. Breast Tissue : The breasts grow larger to prepare for breastfeeding. Fat Stores : Extra fat is stored to provide energy for labor, delivery, and breastfeeding. Uterus Growth : The uterus expands to accommodate the growing baby, contributing to weight gain. The uterus typically weighs about 50-100 grams before pregnancy. By the end of pregnancy, it weighs around 1,000 grams. General pattern of weight gain First Trimester : Weight gain is minimal as many women suffer morning sickness with a reduced appetite. Some may even lose a small amount of weight, which can be normal. Second Trimester : Weight gain is steady and rapid. This is the period of significant weight gain as the baby begins to grow more rapidly. Third Trimester : Weight gain starts to plateau off and may slow slightly towards the end. Weight gain recommendations during pregnancy The amount of weight gain depends on the pre-pregnancy weight and Body Mass Index (BMI). Here are the general guidelines: Underweight (BMI < 18.5): Gain about 13 to 18 kg Normal weight (BMI 18.5-24.9): Gain about 11 to 16 kg Overweight (BMI 25-29.9): Gain about 7 to 11 kg Obese (BMI ≥ 30): Gain about 5-9 kg It's important to note that these are general recommendations. For Asian women, there is a tendency to recommend a slightly lower weight gain because Asian populations may have a higher body fat percentage at a lower BMI compared to other populations. Traditional diets and nutritional habits can also affect weight gain. It is important to have individualized recommendations from the obstetrician as he may consider factors like the mother's health, nutritional status, and pregnancy complications. What factors may influence weight gain Several factors can influence maternal weight gain. Multiple Pregnancies : In twin or multiple pregnancies, maternal weight gain is more. The recommended gain for twins is 16.8-24.5 kg for women with a normal BMI. Health Conditions : Conditions such as diabetes or hypertension can impact weight gain recommendations. Nutrition and activity levels : Eating a balanced diet and staying active are crucial for healthy weight gain. Regular antenatal check-ups are essential to monitor your weight gain and overall health. Conclusion Gaining the appropriate amount of weight during pregnancy is vital for the health of both mother and baby. By following the guidelines, maintaining a healthy lifestyle with balanced diet and regular antenatal visits, a smoother pregnancy journey can be ensured. T was progressing well in her pregnancy with no complications. She put on weight well within the normal range and is eagerly awaiting the arrival of her bundle of joy.

Tears of joy rolled down her cheeks as she watched her baby‘s heart beating strongly inside her womb during the ultrasound scan. J, 32, was diagnosed with polycystic ovarian syndrome (PCOS) five years ago. When she consulted me, she had already been actively trying to conceive for the past 3 years. Initial failed treatment with traditional Chinese medicine (TCM) led her to explore assisted reproductive procedures. When she tried both IUI (intrauterine insemination) and IVF (in-vitro fertilization) unsuccessfully, she became depressed. On examination, J had features of PCOS according to Rotterdam criteria. She was obese with a BMI of 33 and her menstrual cycle was irregular. It occurred every 37 to 60 days. Pelvic ultrasound examination revealed many small follicular cysts in both ovaries. A blood test confirmed elevated levels of male hormones. Her husband’s semen analysis was normal. Preconception management of PCOS J was advised that she had to reduce her weight in a gradual and sustainable way. This will be beneficial for her general as well as reproductive health. She had to change her lifestyle by adopting a low glycemic index diet and had to exercise, preferably daily. She was prescribed an anti-diabetic medication, metformin, in incremental doses to reduce insulin resistance and to restore ovulation. Response to treatment With the support and encouragement from her husband, J lost 8% of her body weight over 9 months and her menstrual cycle became more regular, occurring every 26 days to 32 days. The couple were overjoyed when her period was overdue and the pregnancy test was positive one year after treatment. Management during pregnancy Women with PCOS may face several challenges and risks during pregnancy. These include: 1. Increased risk of miscarriage This is related to the hormonal and metabolic issues associated with PCOS. 2. Gestational diabetes (GDM) The risk of GDM is higher in pregnant women with PCOS. This condition requires careful monitoring and management with a diabetic physician and paediatrician to prevent complications for both the mother and the baby. 3. Hypertensive disorders in pregnancy The risk of hypertension during pregnancy (pre-eclampsia) is increased. Careful monitoring is important for optimal outcome for both mother and child. 4. Premature delivery PCOS is associated with higher risk of premature birth which can lead to various neonatal complications. Due to the increased risk of various complications, the likelihood of Cesarean section is higher. The baby can be small and growth restricted or larger than the average (macrosomia). As a result, the risk of admission of baby to neonatal intensive care unit (NICU) is increased. J’s blood sugar and blood pressure were monitored closely during each antenatal visit. A balanced diet and regular exercise tailored to her pregnancy were prescribed to ensure adequate but not excessive weight gain. Thankfully, J did not develop any of the obstetric complications mentioned. She had a spontaneous vaginal delivery at 38 weeks gestation. The baby girl was born weighing 3.2 kg with no complications. Both the mother and child were discharged well on the 3rd day after delivery.

S, a first-time mother, was admitted to the hospital due to high blood pressure and excessive protein in her urine (proteinuria). She was at 37 weeks gestation. Her pregnancy had been smooth sailing at first, but as she entered her third trimester, ominous signs began to appear. She experienced excessive weight gain accompanied by swelling in her hands and feet. Her blood pressure rose from 110/70mm Hg to 150/95 mm Hg prior to admission to the hospital. Additionally, she experienced occasional headaches and felt nauseous. S was diagnosed with preeclampsia, a serious complication of pregnancy. What Is Preeclampsia? Preeclampsia is characterized by elevated blood pressure, high levels of protein in the urine indicating kidney damage (proteinuria), or other signs of organ damage. Preeclampsia typically arises after 20 weeks of pregnancy in women whose blood pressure had previously been within normal limits. Its onset is often subtle, with symptoms varying from mild to severe, making timely diagnosis and intervention challenging. If left untreated, preeclampsia can lead to severe—even fatal—complications for both the mother and baby. What Causes Preeclampsia? The exact cause is not fully understood. Experts believe that it is probably due to multiple factors including abnormal functions of the placenta, aberrant immune response, genetic factors, and dysfunction of the cells lining the blood vessels. This complexity makes early identification difficult. Early Detection of Preeclampsia Early detection of preeclampsia relies on antenatal screening aimed at identifying women at risk. These include ·        Women who became pregnant via in vitro fertilization, ·        Multiple pregnancy (twins and triplets), ·        Women with gestational diabetes, ·        Women over age 35, ·        Women with chronic hypertension, obesity, polycystic ovary syndrome(PCOS) ·        Previous pregnancy with preeclampsia ·        Family history The measurement of blood pressure and urinary protein levels during routine antenatal visits serves as a cornerstone in the surveillance of preeclampsia. Recent advancements in using blood biomarkers like placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFLT-1), and uterine artery Doppler ultrasound have improved early detection and risk assessment. PlGF, produced by the placenta, helps identify individuals at risk by measuring its levels in maternal serum. Elevated levels of sFLT-1, combined with decreased PlGF levels, are predictive markers for preeclampsia. Doppler ultrasound checks placental blood flow, which can be impaired in preeclampsia. Patient education is vital for pregnant mums to recognize warning signs and seek early medical help, leading to better outcomes for both mother and baby. Conclusion With a combination of screening methods and patient education, preeclampsia can be detected early, leading to improved pregnancy outcomes. S had her labor induced shortly after admission and delivered a healthy baby boy weighing 3 kg. Her blood pressure gradually returned to normal a week after delivery.