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K, 34, was confused and worried when her pap smear results showed reactive changes associated with inflammation. She had been married for 7 years and had delivered two children. The marital relationship had been good. There was no vaginal discharge or abnormal bleeding in between periods or after sexual intercourse. Clinical examination and ultrasound scan of her reproductive organs were normal. What is a pap smear test? A Pap smear test is a routine screening procedure used to detect precancerous changes in the cervix or early cervical cancer.  It involves collecting a sample of cells from the cervix, which is the lower part of the uterus. These cells are then examined under a microscope to look for any abnormalities. Proper interpretation of Pap smear results is essential for appropriate management. Reactive changes in pap smear: Reactive changes in Pap smear results can often cause confusion and concern to the patients. They refer to changes in cervical cells in response to infection, hormonal changes, or mechanical irritation. Despite their benign nature, reactive changes can mimic or coexist with abnormal cellular features, making interpretation challenging. Causes of Reactive Changes in pap smear: Inflammation: Conditions like infection of cervix, vagina or sexually transmitted infections (STIs) including bacterial or viral infections such as those caused by human papillomavirus (HPV), can induce cellular alterations in the cervix. Hormonal Factors: Fluctuations in hormonal levels, such as those occurring during pregnancy or menopause, can influence cervical cell morphology. Mechanical Irritation: Trauma from intercourse, contraceptive devices, or cervical procedures may induce reactive changes in Pap smear results. Clinical Significance of reactive changes: While reactive changes themselves are non-cancerous, they can obscure the detection of underlying cervical abnormalities, such as precancerous or cancerous lesions. Thus, it is important to differentiate between reactive changes and genuine abnormal or cancerous cellular features to avoid unnecessary interventions or misdiagnosis. Management and Follow-Up: Clinical History: Detailed patient history regarding recent infections, hormonal status, sexual activity, and contraceptive use can help in elucidating the cause of reactive changes. Repeat Testing: In cases where reactive changes are suspected to mask abnormal findings, repeat Pap smears may be recommended after treating underlying infections or resolving inflammatory processes. HPV Testing: Concurrent HPV testing can help assess the risk of underlying cervical pre-cancer or cancer, especially in the presence of reactive changes. Colposcopy: Persistent or concerning reactive changes may warrant colposcopy evaluation with directed biopsies to rule out significant cervical abnormalities. Patient Education: Clear communication with patients about the benign nature of reactive changes, the need for follow-up testing, and preventive measures against infections can alleviate anxiety and promote informed decision-making. Reactive changes in Pap smear results are common and often a result of benign responses to various physiological or pathological stimuli. However, their interpretation requires careful consideration to distinguish them from true cervical abnormalities. By understanding the causes, clinical significance, and appropriate management of reactive changes, optimal patient care can be achieved. K was given a course of probiotics and antibacterial vaginal pessaries. No reactive changes were seen in the repeat Pap smear test after treatment. HPV test was also negative for high-risk HPV.

H, 24, was diagnosed to have polycystic ovarian syndrome (PCOS) 3 years ago. Her menses were very irregular, occurring once in 2 to 3 months and lasting one to two weeks at times. The amount varied from spotting to heavy flow with clots. She also noticed that her body weight was increasing gradually and she had difficulty losing weight. Her BMI had increased from 26 to 31 over the last 3 years. Obesity has long been a medical concern globally, as it is associated with the risk of developing medical probles such as diabetes and cardiovascular diseases. In Singapore, it has been increasing at a rapid rate in recent years. It is a problem in about 80% of PCOS patients. Diet and exercise have been the mainstay in the treatment of obesity. A weight loss of 5% or more in PCOS patients has been shown to have a significant positive effect on the return of menstruation. Recently, liraglutide, a medication that has been used to treat type 2 diabetes, has been introduced in the management of obese PCOS patients with promising results. What is Liraglutide? Liraglutide is a medication used for the treatment of type 2 diabetes and obesity. For obese patients, it is most effective when combined with intensive lifestyle intervention such as calorie reduction diet and appropriate exercise. It also helps keep the weight that has been lost from returning. How does Liraglutide work? Liraglutide is a modified form of a gut hormone called GLP1 (glucagon-like peptide-1), and works like the natural hormone. GLP1 is produced by the cells in the small intestines after food is digested. This hormone acts on the hunger-satiety center in the brain and slows down the passage of food in the stomach leading to an increased feeling of fullness. The appetite is thus suppressed and the patient feels sated. GLP1 also stimulates the pancreas to increase the secretion of insulin and helps in maintaining the glucose levels in the body How is Liraglutide given? For treatment of obesity, it is given by injection under the skin once a day and the dosage is adjusted accordingly for optimal results. What are the side effects of Liraglutide? Common side effects include: Gastrointestinal: Nausea, vomiting, diarrhea, constipation Urinary: Bladder pain, bloody or cloudy urine, difficult, burning, or painful urination Palpitation Fever and chills Headache, muscle aches and pains How effective is Liraglutide in treating PCOS with obesity? Current clinical studies have shown that liraglutide therapy achieved significant reduction in body weight, body mass index (BMI), and abdominal circumference in overweight and obese women with polycystic ovary syndrome. Liraglutide treatment also improved the metabolic and hormonal parameters in the body resulting in the return of regular menstrual periods. H was counseled on dietary changes and exercise, and was put on metformin. After 6 months of therapy, she did not lose much weight and her periods remained irregular. She is currently contemplating liraglutide therapy.

For the past three years,K,35, had been suffering from lower abdominal discomfort and backache after the birth of her second child. The pain was worse on the first 2 days of menstruation. It was aggravated by prolonged standing and exercise but was relieved when she lay down especially in a prone position. The menstrual pain was accompanied by abdominal bloating, constipation and frequent urination occasionally. She also experienced pain during sexual intercourse. She had been seen by many health professionals. Various investigations including endoscopic examinations of the gut (gastroscopy and colonoscopy), bladder (cystoscopy) and reproductive organs(laparoscopy) were normal. Eventually, an MRI of the pelvis revealed that K’s veins in the pelvis were abnormally engorged . K had been suffering from a medical condition called pelvic congestion syndrome or pelvic venous disorder (PVD) . What is PVD? PVD is a condition which is characterised by pelvic pain lasting more than 6 months. It is due to engorged varicose veins in the pelvis. Varicose veins are veins with faulty valves. These valves direct blood flow towards the heart. When they are not functional, blood flows backwards and pools lower down in the veins. Extra blood will pool in the pelvis causing pressure, pain and heaviness in the lower abdomen. PVD usually affects women of reproductive age. It is rare after menopause. What causes PVD? The cause of PVD is not well understood. It is likely due to hormonal changes in the veins which expand about 50% in size during pregnancy. These changes may cause long-term damage to the walls of the blood vessels, causing veins to remain dilated. As PVD is uncommon among menopausal women, it is also suggested that female hormone, estrogen, may play a role in making the valves of the vein more susceptible to defects. What are the risk factors of PVD? Risk factors include · Women who have given birth · Presence of varicose veins elsewhere in the body. · Family history of varicose veins. · Polycystic ovarian syndrome (PCOS). What are the symptoms of PVD? Symptoms include: · Pelvic Pain: Dull and achy pain. Occasionally, pain may be sharp and intense. The pain is felt more commonly on the left side. Often, pain starts during or soon after pregnancy. · Pain is worst · at the end of the day after prolonged sitting or standing · during sexual intercourse · before and during menses. · Painful or frequent urination · Frequent bouts of diarrhea and constipation · Urinary incontinence How is PVD diagnosed? Diagnosing PVD can be challenging because many people without pelvic pain can also have dilated veins. As a result, PVD is sometimes underdiagnosed. It is a diagnosis of exclusion, and should be diagnosed after all other causes of pelvic pain have been ruled out. Various imaging techniques are used for the diagnosis. Pelvic venography is the gold standard for diagnosing PVD. It is an invasive procedure in which a small catheter is inserted into a vein in either the neck or groin. X-ray is used to guide the catheter into the pelvic veins and dye is injected. Venography shows where the dilated veins are, how the blood is flowing and where the blood is pooling. Other modalities include ultrasound examination, CT scan and MRI. How is PVD treated? Medications that reduce the oestrogen production have been used to relieve pain in PVD, but a more definitive treatment is to block the defective vessels using metal coils or foams by a procedure called embolization. This has a cure rate of 75 to 80 %. K was referred to the interventional radiologist. She had the embolization procedure done and her pain has since subsided.

E, 32, was eagerly awaiting the arrival of her first child. Her excitement was palpable as she had been trying to conceive for the past 4 years since she got married. As she entered the 36th week of her pregnancy, a mix of joy and anticipation filled her days. On the day of her routine antenatal check-up, she felt that her baby did not move as much as on the previous day. “Doc, my baby’s movement has a pattern that I can almost predict every day. But today, somehow, I feel his movements have reduced a lot,” she said anxiously. She was put on the CTG machine immediately. CTG recording revealed an abnormal tracing of the fetal heartbeat pattern, indicating signs of fetal distress. She was admitted to the hospital right away for further monitoring. What is CTG? CTG or Cardiotocograph is a non-invasive medical procedure in which a continuous electronic record of the fetal heart rate is obtained by an ultrasound transducer placed on the mother’s abdomen. It measures the response of fetal heart rate during different phases of the uterine contractions. Thus, it is very useful in assessing the well-being of the unborn baby and in identifying any potential issues that may require obstetrical intervention.  It can be used during the antenatal period as well as when a patient is in labour. How is CTG done? Two transducers are strapped around the women’s abdomen. One transducer monitors the fetal heart rate while the other records the uterine contractions (Fig. 1). Fig 1 The fetal heart rate is calculated from fetal heart motion determined by ultrasound, and uterine contractions are measured by a tocodynamometer. The data obtained from the transducers is printed out as graphs on a running piece of paper. (fig 2) Fig 2 When should Antenatal CTG  be done? Antenatal CTG is commonly used in the third trimester of pregnancy to assess fetal wellbeing in high-risk pregnancies. These include: Maternal conditions: Essential hypertension, pre-eclampsia, kidney disease, diabetes and thyroid disease Pregnancy complications: Reduced fetal movement, vaginal bleeding Fetal conditions: Intrauterine growth restriction (IUGR), fetal infection and multiple pregnancies CTG can also be used in combination with other methods of fetal assessment such as ultrasound Doppler measurements of the placental, umbilical and fetal blood flow and amniotic fluid volume measurement. Conclusion: Antenatal CTG provides valuable data that can be used to make informed decisions regarding the management of labour and delivery. This information helps determine whether the fetus can tolerate the labour process well or if any medical interventions are needed. In managing high-risk pregnancies, such timely decisions are important for optimal outcomes. While CTG is a valuable tool, it is important to note that its interpretation requires the expertise of trained healthcare professionals. Otherwise, it may cause much anxiety to the mothers and also many unnecessary instrumental deliveries and cesarean sections. After admission to the hospital, E's CTG recording remained abnormal. An emergency caesarean section was done immediately.  Thick meconium was found in the amniotic fluid indicating insufficient oxygenation to the fetus antenatally. A male fetus weighing 2.5 kg was delivered. He was slightly feeble at delivery but recovered well shortly after resuscitation.

H, 55, had been menopausal for the past 5 years. She was taken aback one morning when she discovered her underwear was stained with a patch of fresh blood. She was anxious and wanted to know the cause of the bleeding. Examination revealed that she had a small urethral caruncle which is a non-cancerous fleshy growth at the opening of the urinary passage. She was treated conservatively and recovered well. “Doc," she said, " I should have come for an annual checkup which I stopped for the past few years as I thought I had entered menopause and I don’t need to see a gynae anymore.” H is not alone in her thinking. Many women stop seeing their gynaecologist as they get older and are no longer in their reproductive years. In fact, regular gynaecological checkups are important for a woman's health at this stage of life. An annual visit would have given women the chance to get educated about the changes in their body, be screened for certain cancers and chronic conditions, and get advice on adopting a healthy lifestyle. The following are the reasons why women should see their gynaecologist post-menopause. 1. Screening for cancer The risk of female cancer, such as uterine and ovarian cancers increases with age. An annual visit to the gynaecologist helps provide early detection for these cancers. A pelvic exam can also check for other noncancerous conditions such as ovarian cysts and fibroids as well as a variety of conditions that may develop with age. It is advisable for women to get a pelvic exam every year so that they can be checked for early signs of disease. The risk of breast cancer also increases with age. A breast examination to detect abnormal lumps is usually performed during the check up and mammogram is advised as a screening test. 2. Treating menopausal symptoms Menopause can cause uncomfortable symptoms like hot flashes, mood swings, insomnia, night sweats, vaginal dryness, and weight gain. The visit is an ideal time to discuss and learn about these changes and appropriate treatment strategies including options for hormone replacement therapy could be instituted. 3. Emotional Well-being Menopause can also affect emotional and mental health. Gynaecologists can offer advice and support for managing mood changes, anxiety, or depression associated with this phase of life. 4. Sexual health and intimacy counseling Declining estrogen levels are a major factor behind low libido as well as vaginal dryness and vaginal thinning. These changes can cause pain during sex. Sexual health is usually overlooked during health checkups, but it’s an area that is important to overall well-being. Treatment options can be discussed during the visit so that these problems could be resolved. Tests for sexually transmitted infections can also be done. 5 Urinary and pelvic floor disorders Many women may have urinary problems after menopause, like urge and stress incontinence. There may be other pelvic floor disorders, such as uterine prolapse, which is when the pelvic floor muscles are weak and the pelvic organs slip down from their normal position. A gynaecologist can help educate the woman about these issues and advise on what kind of exercises, strategies, and treatment methods can help. 6. Screening for Health Issues Post-menopausal women are at higher risk for certain health conditions such as osteoporosis, metabolic and heart diseases. At the gynae visit, basic preventive screenings and tests can be done so that these conditions can be detected early when they are more treatable. 7. Lifestyle Guidance Gynaecologists can provide advice on healthy lifestyle habits, including diet, exercise, and managing stress, which becomes especially important after menopause to maintain overall health and well-being. These can help women stay healthy and active as they age. Conclusion In conclusion, regular gynaecological checkups after menopause play a vital role in maintaining overall health, detecting any potential issues early, and receiving guidance on managing the changes associated with this phase of life.

G,37, had fertility issues for the past five years. She had a successful IVF pregnancy on her second attempt and was at her 30 weeks of pregnancy. Her antenatal course was uncomplicated until a week ago when she felt her hands and feet become swollen. She thought this was quite common in the last trimester. Her face was getting puffy too. At her recent antenatal checkup, she also complained of occasional headaches. Her urine was found to have a substantial amount of protein. Her weight gain of 1 kg within a week was excessive. Her blood pressure had shot up from the usual reading of 100/70mmHg to 145/95mmHg. G was suffering from pre-eclampsia. Consequences of preeclampsia Pre-eclampsia is a life-threatening complication of pregnancy and a leading cause of ill health and death of both the mother and her unborn child. Worldwide, an estimated 4 million women are diagnosed with preeclampsia (previously called toxemia) every year, causing the deaths of more than 70,000 women and 500,000 babies. Pre-eclampsia is characterized by the mother having high blood pressure, high levels of protein in urine indicating kidney damage (proteinuria), and signs of damage to other organs such as liver, lung, heart, or brain when the condition deteriorates. The fetus may be born prematurely or may suffer from intrauterine growth restriction (small for dates) or may be delivered as stillborn. (Please refer to the article “High Blood Pressure in Pregnancy: Pre-eclampsia” in the website). Mothers who have a history of preeclampsia may have their life expectancy reduced as they have increased risks of heart disease, stroke and diabetes. Babies from a pre-eclamptic pregnancy may also have increased risks of brain developmental delay and cardiovascular and metabolic disease later in life. Early detection of pre-eclampsia Early detection of pre-eclampsia is thus important in ensuring the well-being of both the mother and the developing fetus. Following strategies are helpful. 1. Identifying Risks Factors: While the exact cause of pre-eclampsia remains unclear, there are several risk factors associated with its development. Pregnant mothers should be educated and be aware of the risk factors. These include: First pregnancy Pre-eclampsia in a previous pregnancy High blood pressure before pregnancy Diabetes before pregnancy History of kidney disease History of autoimmune disorders Obesity Maternal age of 35 or older IVF (In vitro fertilization) 2. Early regular antenatal care: Receiving proper antenatal care is essential in identifying and managing risk factors. Attending regular check-ups can help detect and manage the condition early. 3. Healthy lifestyle: Maintaining a healthy lifestyle by eating a balanced diet, exercising regularly, and avoiding excessive weight gain during pregnancy can reduce the risk of pre-eclampsia. 4. Aspirin therapy: Low-dose aspirin in pregnant women at high risk of pre-eclampsia may reduce the chances of its development. Monitoring pre-eclampsia Monitor blood pressure: Regularly measuring and monitoring of blood pressure during antenatal visits is crucial in identifying the symptoms of preeclampsia. A significant increase in blood pressure can be an early warning sign. Monitor symptoms: It is important for pregnant women to be vigilant about symptoms such as severe headaches, blurred vision, abdominal pain, swelling in the hands and face, and rapid weight gain. These can be early warning signs of pre-eclampsia. Urine testing: Routine urine tests can help detect the presence of protein, which is a common indicator of pre-eclampsia. Blood tests: Blood tests can be used to assess liver and kidney function and detect abnormalities in blood platelet levels. Some chemicals released by the placenta into the blood have been used as biomarkers in predicting the development of pre-eclampsia. Ultrasound: This is used to monitor the baby’s growth including measuring the amniotic fluid levels and the blood flow of the placenta and the foetus. Antenatal cardiotocography: This nonstress test is a simple procedure that checks the baby's heart rate to detect early signs of fetal distress. G was put on medications to control her hypertension immediately. Both the mother and foetus were monitored closely. She was induced at 38 weeks of pregnancy and delivered a healthy boy weighing 3 kg. normally.

Something was off when she brought her first newborn son home 3 weeks ago. Instead of enjoying the intimate time to care for and bond with her baby, she struggled with terrible feelings of helplessness and the inability to cope with the new arrival. R, 30, had a cesarean section for prolonged labour. The initial symptoms of the “baby blues” had become worse. Whatever things her husband did to please her did not work. She felt sad and would not talk to her husband most of the time. She had difficulties with breastfeeding as both her breasts were engorged and painful and the abdominal scar was hurting whenever she moved. She began to alienate herself from her family members. She also suffered from insomnia. R had suffered from postnatal depression (PD). Prevalence of PD Postnatal depression is a form of depression that occurs within the first year after childbirth. It is a serious mental health condition that affects mothers shortly after childbirth. This condition can have significant and lasting impacts on the mother, her child and her family. In Singapore, PD affects about one in 10 to 15 mums. Causes of PD The cause of postnatal depression is not completely understood. The following are some of the contributory factors: Genetics: Studies have shown that patients with a family history of postpartum depression have an increased risk of experiencing the same condition. Hormonal Changes: The dramatic hormonal fluctuations during pregnancy and after childbirth can trigger PD. Emotional Stress: The transition to motherhood is often accompanied by overwhelming emotions, stress, and sleep deprivation, which can exacerbate depression. History of mental health issues: Women with a history of depression or anxiety before and during pregnancy are more susceptible to PD. Social and Relationship Factors: Lack of support, relationship problems with the partner and in-laws, domestic violence and financial stress can increase the risk of PD. Symptoms of PD Many new mums experience "baby blues" after childbirth, which commonly includes mood swings, feeling a bit down, anxiety and difficulty sleeping. Baby blues usually begin within the first 2 to 3 days after delivery and may last for up to two weeks. However, if the symptoms persist or become more severe or start much later, one may have to suspect PD. Common symptoms include · Persistent sadness or low mood · Loss of interest or pleasure in looking after the baby · Feelings of guilt, worthlessness, or hopelessness · Withdrawal from family and friends · Sleep disturbances: Insomnia at night and feeling sleepy during the day · Changes in appetite · Lack of energy and fatigue all the time · Difficulty in looking after herself and her baby · Difficulty concentrating · Thoughts of self-harm or harming the baby Diagnosis Postnatal depression can be diagnosed by observing the behavior of the mother, talking to her about her emotional feelings and doing a depression screening test using a questionnaire. Treatments Postnatal depression is a treatable condition, and seeking help is crucial for the well-being of the mother and the family. Treatment includes: Psychotherapy or talk therapy with a psychiatrist, psychologist or other mental health professionals. Through therapy, patients may find better ways to cope with their feelings, solve problems, set realistic goals and respond to situations in a positive way. Sometimes family or relationship therapy also helps. Antidepressants: Most antidepressants can be used during breastfeeding with little risk of side effects for the baby. Coping strategies: Seek Support: Reach out to a trusted friend or family member, a therapist, or a support group. Self-Care: Getting adequate sleep, eating well, and engaging in gentle exercise when possible. Share Responsibilities: Involve the partner and other family members in the care of the baby to lessen the burden. Set Realistic Expectations: Accept that perfection is not attainable, and it is okay to ask for help when needed. Fortunately, R’s husband alerted me to her condition. She was immediately referred to the psychiatrist. Together with therapy and medications, her condition improved and is now under continuous monitoring. Important note for Mothers Postnatal depression is a serious condition that affects a significant portion of new mothers. By understanding its causes, recognizing the symptoms, and seeking help, we can provide the necessary support and treatment to help mothers recover and provide a healthy and nurturing environment for their children. Family and community support, combined with professional help, can make a significant difference in the lives of those affected. It is essential to raise awareness about this condition and encourage open discussions to remove the stigma surrounding it, ultimately fostering a healthier and happier postpartum period for all mothers and their children.

J, 39, was upset when he was told that his wife had a high-risk Human Papilloma Virus (HPV) in her cervical screening test recently. “Doc, how could she get the virus when we are in a stable relationship?” he asked. “Can I have the HPV test done on me? What impact will the infection have on my health should I get it?” Prevalence of HPV in Men HPV infection is the most common sexually transmitted infection in the world. Much of the information about HPV centres on women, since having the virus increases their risk of getting cervical cancer. In fact, research studies have found that men are more likely to be infected with HPV than women, and they are more likely to be infected with high-risk HPV. A new study published in The Lancet Global Health in 2023 has shown that almost 1 in 3 men over the age of 15 are infected with at least one genital human papillomavirus (HPV) type, and 1 in 5 are infected with one or more of high-risk HPV that can cause cancer. Transmission of HPV HPV is highly contagious. It is transmitted through skin-to-skin contact during vaginal, anal, or oral sex with someone who has the virus. It can also be transmitted through non-penetrative sex. Rarely, it can spread via fomites such as contaminated toilet seats or towels. HPV infection can occur even in a monogamous marriage. For some unknown reasons, the virus can remain dormant and become active years later by showing up at the cervical screening test. It is thus impossible to work out when someone first came into contact with it, and/or when it became an active infection. Symptoms of HPV infection HPV infection usually does not have symptoms. The infection usually goes away by itself. But, if infection persists, it can cause genital warts or cancer of the throat, penis or anus. Symptoms include: Genital warts Lumps or sores around the head and neck region e.g. throat, and at the anus and external genitalia While penile and anal cancers are rare, cancers in the throat are the most common HPV-related cancers found in men. Tests for HPV Infection in Men There is currently no routine HPV test available for men as the test has yielded inconsistent results. This is because it is difficult to get a good cell sample to test from the thick skin on the penis. Most people will not have visible symptoms. Prevention of HPV infection Abstinence is the only sure way to prevent HPV transmission. Risk of transmission can be lowered if a person has sex only with one person who is not infected and who is also monogamous. Condoms can provide some protection against HPV transmission. Unfortunately, they are not 100% effective, since HPV is transmitted primarily by skin-to-skin contact. The virus can still infect skin which is not covered by the condom. HPV vaccination. At present, the vaccine available is Gardasil 9. It protects against seven out of twenty high-risk types of HPV associated with cancer (types 16, 18, 31, 33, 45, 52, and 58) and two low-risk types associated with genital warts (types 6 and 11). Thus, it does not offer full protection for cancer. Continuous surveillance is still important. J understood the implications and impact of HPV infection on reproductive health. He requested vaccination to improve his immunity against the virus and would update me should he discover any unusual sores or lumps in his external genitalia.

Despite her preventative measures, K was shocked to find that she was pregnant. K, 33, had a copper-T intrauterine contraceptive device (IUCD) fitted 2 months after she gave birth to her second child a year ago. She knew something was awry when she felt ill for a few weeks. “I was feeling nauseous and I would just throw up once in a while,” said K. She then decided to take a pregnancy test to see what was amiss. She was calm and cheerful when she came for the consultation. There was no abdominal pain or vaginal bleeding. Pelvic examination revealed that she was 6 weeks pregnant. The strings that were attached to the IUCD could be seen protruding slightly out from the cervix. Vaginal ultrasound showed a gestation sac of 6 weeks wedged between the cervix and the IUCD in the upper part of the uterus. What is IUCD? IUCD is a popular, reliable and reversible form of contraception. It is a small T-shaped plastic device with two strings attached and is inserted through the cervix into the uterus. About 15% of women of reproductive age worldwide are using this method of contraception . Types of IUCD There are two types of IUCD: 1) Non-hormonal (Copper device) (fig 1) It acts by releasing copper ions which are toxic to the sperm and makes the cervical mucus unfavorable for the sperm to move up the genital tract. It also acts as a physical barrier in the uterus preventing implantation of the fertilized egg. 2) Hormonal (Mirena) (fig 2) It works by releasing the hormone, progestogen into the cervix, which thickens the cervical mucus and prevents the sperm from entering the uterus. It alters the uterine lining chemically and acts as a physical barrier preventing fertilized ovum from implantation. How is insertion of the IUCD done? Insertion of IUCD is a simple procedure that can be done by the doctor in the clinic. No general anesthesia or sedation is required and the procedure takes no more than 15 minutes. It is best inserted during the menstrual periods as it is at this time that pregnancy is unlikely to occur and the cervix, being softer and slightly open, makes insertion easier. Oral painkillers may be given to help with the slight abdominal cramps that may occur during and after the procedure. What Causes an IUCD to Fail? According to the Centers for Disease Control and Prevention (CDC) of USA, copper IUD has a failure rate of 0.8%, while the hormonal IUCD has a failure rate of 0.1–0.4% Failure in IUCD could be due to the following: Expulsion: IUCD could fall out of the vagina during menstruation. . According to the American College of Obstetricians and Gynecologists (ACOG), the expulsion rate is 2–10% within 1 year of IUCD insertion. Expulsion usually occurs unnoticed. Thus, it is important for the patient to be reviewed by a doctor regularly to check the placement of the device. Expiry: If the device is kept longer than the suggested duration of 3-5 years, chances of getting pregnant increase. Translocation: Women who breastfeed or who have an IUCD inserted shortly after giving birth are more likely to have the IUCD shifted out of position in the uterus, a condition called translocation. The woman may be unaware that translocation has taken place as this usually occurs without any sign. Types of pregnancy when IUCD fails? 2 types of pregnancy can happen. Intrauterine pregnancy which is a normal pregnancy. Ectopic pregnancy in which the embryo grows outside the uterus usually in the fallopian tubes. This condition can be life threatening. How to manage intrauterine pregnancy with IUCD? Intrauterine pregnancy in the presence of IUCD is known to have increased risks of complications such as uterine infection, miscarriage, premature birth, bleeding from placenta and cesarean section delivery. However, termination of pregnancy is not a necessary option. If the mother chooses to continue the pregnancy, an ultrasound examination should be done to determine whether the IUCD is still in the uterus. If the IUCD strings are visible and the pregnancy is less than 13 weeks, early retrieval with or without a hysteroscope should be done to minimize complications. If the strings are not visible or the mother is more than 13 weeks pregnant, removal may be difficult. She should be counseled regarding the risk of complications. Proper antenatal follow-up is essential to reduce the risk. K was counseled and she was quite happy to continue with the pregnancy. The IUCD was removed with ease without hysteroscopy. There was slight vaginal bleeding for 2 days. The pregnancy progressed normally without complications. She is in her last trimester now.

What do the following conditions: low sperm count, menstrual irregularities and premature births have in common? These conditions are a reflection of disruptive changes in our reproductive system. Among the many factors that can cause these changes, an environmental factor which many people may not be aware of is air pollution (AP). What are the common air pollutants? Due to human activities and industrialization, our environment has been contaminated with pollutants harmful to our body. The common air pollutants identified so far include the following: Carbon monoxide: A colorless, odorless gas that is produced by incomplete combustion of petrol or diesel Sulfur dioxide: A pungent, corrosive gas that is emitted by industrial activities. Nitrogen oxides: A group of gases formed by high-temperature combustion of petrol in vehicles, power plants, and factories. Ozone: A byproduct of other pollutants Particulate matter: Tiny solid or liquid particles that are suspended in the air. They are usually composed of substances such as dust, smoke, soot and chemicals. They can vary in size from less than 2.5 micrometers (PM2.5) to 10 micrometers (PM10) in diameter. What are the effects of AP on reproduction? AP can increase the risk of infertility. A study of 18,000 couples in China found that those living with moderately higher levels of small-particle pollution had a 20% greater risk of infertility. Another study of 600 women attending a US infertility clinic found that increased exposure to air pollution was associated with a lower number of maturing eggs in the ovaries. AR can also impair semen quality by reducing sperm morphology, concentration, motility, and DNA integrity. Polluted air can cause complications during pregnancy and childbirth. Pregnant mums have increased risks of miscarriage, preterm birth, low birth weight, and stillbirth. AP can also affect the development and health of the fetus and the newborn. These babies are at risk of having chronic diseases such as respiratory and cardiac diseases later in life How does AP affect reproduction? Possible mechanisms are as follows: Air pollutants induce oxidative stress in cells and tissues. As a result, DNA and membranes of the egg and sperm cells may be damaged. Their viability and function will be impaired. Oxidative stress can also affect implantation of the foetus in the uterus and the development of the placenta resulting in miscarriages and premature births. AP contains substances which are hormone-disrupting chemicals. They interfere with the normal functioning of hormones that regulate reproduction. AP can cause inflammation in the cells. This can affect the maturation and ovulation of the egg in women, and the production and transport of sperm in men. Inflammation can also trigger immune reactions that can harm the foetus, The final impact of AP on the individual will also depend on other factors, such as genetic susceptibility, lifestyle habits, nutrition, and exposure to other environmental toxins. How to reduce AP at home? The following measures may be helpful: Adequate ventilation by opening the windows is key to promoting clean air provided our environment is clean. Quit smoking: one of the most common indoor air pollutants is cigarette smoke. Minimize carpeting Use a dehumidifier and/or air conditioner to reduce moisture Avoid air fresheners, scented candles and incense Dust surfaces and vacuum frequently Ensure exhaust fans are functioning in the bathrooms and kitchen Bathe the pets and wash their bedding often AP has a significant effect on our health including reproduction. As individuals, we should cooperate in whatever way we can with our government and public health agencies who are working very hard to ensure a clean and healthy environment. Pregnant mums and those planning to conceive should be aware of the air quality and take necessary precautions to minimize exposure to pollutants.

N, 32, had fertility issues. She had been married for the past 4 years and was diagnosed as having polycystic ovarian syndrome (PCOS). She was obese with a BMI of 30. Her menses were irregular, occurring once every 2 to 3 months. The menstrual flow was heavy at times and could last for between 10 to 14 days. Her blood Vitamin D level was low (< 20ng/ml). Vitamin D deficiency in PCOS Studies have shown that PCOS is associated with vitamin D deficiency in 67–85% of cases. The more obese the patient, the lower the blood vitamin levels will be. The low vitamin D levels is thought to be due to the trapping of the vitamin in the fatty tissue. In a local population, 54.5% of females were classified as having vitamin D deficiency, according to a study published in 2016. Thus, it is important to assess blood vitamin D level in the management of PCOS. Vitamin D in Fertility and In Vitro Fertilisation Animal experiments have demonstrated that vitamin D has a positive influence on the growth and development of both the egg and sperm as well as the process of fertilization. Similar results have been shown in human studies. Vitamin D also improves the outcomes of in vitro fertilization (IVF) in healthy women as well as in those with PCOS. In addition, vitamin D supplementation and optimal vitamin D levels reduce pregnancy- related complications and adverse events in PCOS patients. What Is Vitamin D? Vitamin D is an important micronutrient for our health. It helps keep our bones strong, supports the immune system, regulates blood sugar levels and improves our cognitive function and mood. It plays an important role in cardiovascular health as well as reproductive health. Vitamin D2 and Vitamin D3 Vitamin D exists in two primary forms, D2 and D3. D2 or ergocalciferol, is found in mushrooms and yeasts. Once consumed, it is absorbed in the small intestine and transported to the liver and kidneys where it is converted into the active form of vitamin D (calcitriol). D3, or cholecalciferol, is produced by the body when the skin is exposed to sunlight. It is also found in fatty fish such as salmon, egg yolks, and animal’s liver. It is metabolized in the liver and kidneys to calcitriol. Ways to Get Vitamin D Sunlight exposure and dietary sources are the best ways to get vitamin D. Sunlight exposure: Spending about 10–15 minutes in the sun without sunscreen a few times a week can help the body produce adequate amounts of vitamin D. Dietary sources: Vitamin D can be found in fatty fish, egg yolks, organ meats, and fortified foods like milk and cereal. Vitamin D supplements are easily available in pharmacies if a patient has limited sun exposure or has difficulty absorbing vitamin D from food sources. N was advised to reduce weight by diet and exercise. Besides being treated with medications, vitamin D supplementation was given. Her menstrual regularity improved. She conceived naturally after being on the treatment for 9 months.

L, 40, had Covid 6 months ago. She was admitted to the hospital for a week for the treatment of her respiratory symptoms. After discharge, she still felt tired and listless with occasional headaches. She also had difficulty thinking clearly and likened it to a brain fog. Before the infection, she was always on the go, balancing a busy career as a banker and looking after her family with two children, aged ten and eight. “Normally I am a very energetic and analytical person,” she said. “But now, I have problems doing simple tasks and basic logic problems. I would normally do this easily.” Her menstruation was also getting irregular with scanty prolonged periods. Occasionally, her menses were heavy with clots. What is Long Covid? Most people infected with the recent strain of Covid recover quickly. But in some, the effects of the virus can last for much longer and new symptoms can also develop. The World Health Organization (WHO) defines long Covid as symptoms that start usually within three months of having Covid, last for at least two months, and cannot be explained by another condition. Symptoms can fluctuate or relapse over time. What Are the Symptoms of Long COVID? According to the American Medical Association, there are over 200 symptoms that have been associated with long Covid. Common symptoms are: • Feeling extremely tired • Feeling lethargic after exertion • Brain fog characterized by forgetfulness, and a lack of focus and mental clarity. • Palpitation when heart beats over 100 times a minute What are the effects of Long covid on ovarian functions? Although most studies have shown that Covid did not infect the female reproductive system, patients with long Covid have reported an upsurge of menstrual abnormalities such as prolonged cycles and decreased volume of menstruation. A few patients also experienced shortened or disordered menstrual cycles as well as increased volume of menses. Disruption in ovarian hormone concentrations is hypothesized to be the cause. As hormone production by the ovary is controlled by the brain centers such as hypothalamus and pituitary gland, researchers thought that these hormonal changes are due to the chronic inflammatory changes of the brain tissues brought about by the virus. Fortunately, the ovarian reserve as measured by the blood levels of AMH (anti-Mullerian Hormone) does not seem to be affected by the infection. How long the virus will suppress ovarian functions remains unclear. Recent studies have found that middle-aged women and those who are near menopause or already menopausal appear to experience more serious complications from the virus. They seem to get specific, and severe symptoms such as brain fog, fatigue, new-onset dizziness, and insomnia. These symptoms are probably related to the reduced levels of female hormone, oestrogen. L’s irregular menses were monitored and managed with oral oestrogen therapy. She was advised to have adequate rest with at least 7 hours of sleep. Regular exercise, reducing stress, and avoiding excess alcohol help normalize her ovarian function. L felt much better after treatment. Frequency of other symptoms had been reduced. She hoped to recover soon.