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

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

I am 34 and have been married for 3 years. I am trying to conceived for the past 2 years without success. I am told that the baldness medicine, propecia, which my husband has been taking for the last few years could affect fertility, Is it true? A Propesia contains the drug called finasteride which acts by causing a decline in the male hormonal activity and thus reducing hair loss. Previous studies have shown that it does not affect male fertility. However, recent findings have indicated otherwise. This drug does cause infertility and sexual problems. By reducing the blood levels of the male hormone, testosterone it may result in the following: · Erectile dysfunction · Loss of sexual desire · Inability to ejaculate to reach orgasm. · Reduction in the sperm count · Poor semen quality Studies have also shown that after stop consuming the medication, sexual functions and sperm quality may gradually restored in most patients. As you are trying to conceive, it is advisable to discontinue the medication especially if his reproductive functions are compromised.

I have been smoking for the past 15 years. I just got married and intend to start a family soon. Can smoking affect my sperm? Will my wife’s fertility be affected also? She is a non-smoker. Yes. Smoking can negatively affect your fertility as well as your wife's. Research studies have shown that smoking is associated with: · Reduced sperm count: Sperm count refers to the number of sperm found in a measured quantity of semen. · Decreased sperm motility: Sperm motility indicates the swimming capabilities of the sperm. If sperm cannot swim properly, fertilisation of the egg will be affected. · Fewer normal shaped sperm: Normal shaped sperm is necessary for the conception of a healthy baby. · Increased incidence of damage to the sperm DNA: Sperm with damaged DNA may lead to problems with fertilization, embryo development and implantation, resulting in an increased risk of miscarriage. All these negative effects are attributed to the toxins found in cigarettes,the lower the zinc levels in the semen and the reduced production of male hormones by the testis. Scientists have also demonstrated that the effects of smoking are proportionate to the number of cigarettes smoked. The heavier the smoker, the worse the semen quality. But if he quits smoking, chances of successful fertility treatment may improve. A lower rate of success for IVF (in-vitro fertilization) treatment is found in couples if the male partner smokes. The miscarriage rate is higher and there are increased risks of birth defects and cancer in the offspring. Damaged sperm DNA is probably the cause. Fertility of the wife may also decrease because of the exposure to the second-hand smoke. The quality and quantity of the eggs are affected by the toxins in the cigarette smoke. One study found that second- hand smoke reduced the number of eggs retrieved in an IVF cycle by 46 percent. If you intend to start a family, you should stop smoking straightaway. 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/ .

I am 31 year old male and have been suffering from gout for the past 5 years. I am on colchicine, a long term medication. Will the disease affect my sexual health and fertility? Gout is a condition where the joint is inflamed due to deposits of sharp, crystallized uric acid. Uric acid is a by-product when our body breaks down purines, the type of proteins found in some foods and beverages like liver, red meat, seafood, peas, and beer. Uric acid is usually absorbed in the blood, processed by the kidneys, and eliminated in the urine. But when we eat too much food containing purines or when the kidneys are malfunctioned and do not excrete the uric acid properly, it starts to accumulate in the blood. Eventually, this build-up leads to deposition of uric acid crystals in the joint causing pain, redness, heat, and swelling. The joint commonly affected is the big toe. But other joints in the knees, wrists, fingers, and elbows can be affected as well. Generally, gout does not affect sexual health and fertility. Occasionally, it can cause erectile dysfunction (ED) and the medication used in the treatment may result in infertility. Studies have shown that men with gout are at higher risk of developing ED. Should ED develop, it is also more likely to be severe. Scientists believe that the lining cells of the blood vessels in the penis are damaged by the high blood uric acid levels. Men with gout are also more likely to drink more alcohol, be overweight, or have medical conditions like diabetes, high blood pressure, heart disease, chronic kidney disease, and depression. All these conditions are linked to ED. Besides, pain from gout also makes sexual intimacy uncomfortable, further aggravating fertility issues. Colchicine, which is the drug of choice in the treatment of gout, can cause suppression of the production and maturation of the sperm and the egg. There are scientific reports suggesting that long term consumption of colchicine can lead to azoospermia (absence of sperm). 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/ .

Pre-pregnancy check assesses whether the mother is fit to carry the pregnancy to term, whereas fertility health check examines the various fertility-related issues of the husband and wife and evaluates their fertility potentials. Fertility health check involves an in-depth interview of the couple on the age, duration of trying for a baby, frequency of intercourse, contraceptive method used, sexual history including exposure of sexually transmitted diseases, and lifestyle habits such as drinking and smoking. The man will also be asked on previous surgery or injury to the testes. The woman will be asked if she had previous termination of pregnancies, ectopic pregnancies, miscarriages, or previous pelvic surgery as well as the menstrual history. A physical examination of the couple will be done with special emphasis on the reproductive system. This is followed by a pelvic scan with ultrasound in the female. After the consultation, blood tests (including hormonal profile) according to the woman’s menstrual cycle will be taken and an appointment for semen analysis given. The results will be reviewed with the couple within 2 weeks of the first consultation. Additional tests may be customised depending on the profile of the couple. With the interviews, physical examination and detailed investigations and analyses of the results, the fertility potential of the couple can then be ascertained. If there are any cause of concern, fertility treatment options will then be discussed

I work near radars. Does the exposure affect fertility? Does it increase the chances of getting a male foetus? To understand how radio-frequency radiation emitted by the radar affects a man's fertility, it is important to know how sperm is produced . Sperm is produced in small coiled tubes in the testicles . These tubes packed like coiled spaghetti and number more than 750, may reach up to 50 cm in length when dissected out . Sperm takes about 72 days to grow and they are stored in another part of the testicle called epididymis. They remain there for about 15 to 25 days, mature and develop the ability to swim. If the sperm are not ejaculated, they eventually die and are absorbed by the body. In theory, radar irradiation can affect fertility in the following ways: · It can stop or slow the production of sperm. · It may change the shape of sperm . These sperm may have trouble swimming or lack the ability to fertilize the egg. · It can cause changes in the DNA of the sperm. Sperm with damaged DNA may not be able to fertilize an egg; even if it does fertilize the egg, the development of thefoetus may be affected resulting in a miscarriage or foetal abnormalities. Large research studies of the effects of radar irradiation on the sperm and fertility are very few . Some scientists found lower sperm counts in personnel exposed to radar, but others did not findsuch effect. Recent studies by researchers in China concluded that radar radiation inflicted damage to the male reproduction system by causing significant changes to sperm motility and shape, butsuggested that when the exposure stopped, the sperm quality would return to normal. Another study also found that navy personnel working with radar and/or sonar were more than twice as likely to have reduced fertility. Whether radar exposure would increase the chances of getting a male offspring, limited studies suggest that there is no such gender bias.

My husband was diagnosed as having diabetes 1 years ago. He is 35 and is on diet control with oral medications. Will diabetes affect his fertility? A. Diabetes can affect male fertility in various ways. They include: · Reduced sperm quality: Studies have shown that diabetes can cause damage to the genetic materials of the sperm. This will reduce the chances of fertilisation and increase the risks of miscarriage and foetal abnormalities even when conception occurs. · Erectile dysfunction(ED): Diabetes affects the nerve supply and blood circulation to the penis. This results in difficulty in getting or maintaining an erection. Some of the medications used in the treatment of diabetes may also cause ED. · Retarded ejaculation or delayed ejaculation: The loss or reduced sensitivity in the penis as the result of nerve damage from diabetes will lead to ejaculation problems. · Low testosterone levels in the blood have been shown in one out of four men with type 2 diabetes. This can lead to low sperm count, ED and decreased sexual drive. · Retrograde ejaculation: The damage to the nerve supply of the bladder muscles that control the opening of the urinary passage causes the backflow of the semen into the bladder. Hence,the sperm may not be able to deposit in the vagina during ejaculation.

I am 34 years old and trying to conceive. I am diagnosed as having type 2 diabetes. My doctor has been monitoring my blood levels of HbA1c which is 9.6 % at present. He told me I should wait a while till the levels drop to 6.5% or lower before I try to get pregnant. Why should it be so? What is HbA1c? What does the percentage represent? Keeping the blood sugar levels under control is very important for diabetic patients who are trying to conceive. This is because uncontrolled diabetes during pregnancy may have serious consequences affecting the baby such as miscarriage, premature birth, stillbirth and having a big baby requiring Caesarean section. When sugar is absorbed into the body from the food, it is circulated in the bloodstream as glucose . A certain amount of glucose gets attached to the haemoglobin, a protein in the red blood cell that carries oxygen. The compound formed is called “glycated” haemoglobin or HbA1c. The amount attached is directly proportional to the total amount of blood glucose present in the body and is expressed as a percentage of the total haemoglobin. As the life span of the red blood cells is 8-12 weeks, measurement of HbA1c is used to assess the average blood glucose levels over that duration. This provides a useful gauge of blood sugar control in diabetic patient. In healthy people, the HbA1c level is less than 6% of total haemoglobin. Your level of 9.5% is high and indicates that your diabetes is not well controlled. Studies have demonstrated that the complications of diabetes can be reduced or prevented if the HbA1c level can be kept below 6.5%. Since you are planning to become pregnant, you should be monitored with HbA1c monthly to help monitor your diabetes control. Meeting the target of 6.5% or below will help minimise the risk of the baby developing congenital malformations or ​other complications during pregnancy. As your level of HbA1c still high, you are advised to avoid becoming pregnant until good diabetes control is achieved and sustained.

My previous boyfriend infected me with gonorrhoea for which I have been treated. I am now married and have been trying to have a baby without success. Could the cause of infertility be due to gonorrhoea? Gonorrhoea is a common sexually transmitted disease cause by a bacterium Neisseria gonorrhoeae. It can infect both men and women. In many women, the infection can occur without much symptoms. The symptoms, if present, may include Painful or burning sensation while passing urine Increased vaginal discharge Painful sex Irregular periods Abdominal pain Fever Gonorrhoea can be treated successfully with antibiotics. But if left untreated or if the treatment is inadequate, the infection can cause serious consequences such as pelvic inflammatory disease. The bacteria can travel from the cervix (neck of the womb) up the womb to the fallopian tubes, causing inflammation and scars in and around the tubes. This leads to tubal blockage which prevents the sperm from fertilizing the egg resulting in infertility.

My wife and I have been married for 3 years with no children. We are trying to conceive. What are the nutrients in my diet that can boost my fertility? Eating a balanced and nutritious diet can boost your fertility by maintaining a healthy reproductive system. The following nutrients are known to help or improve sperm health. Vitamins: Vitamins are powerful antioxidants that protect the sperm from the damaging effects of free radicals, the unstable molecules linked with cell destruction. High levels of free radicals will affect sperm function and viability. The following vitamins are important for sperm health: Vitamin A is important in preventing sluggish sperm. It is found in leafy greens, carrots, red peppers, and apricots. Vitamin B : o Folic acid can boost sperm health. Food sources include liver, lentils, beans, asparagus, spinach, collard greens. o B12 has been shown to increase sperm counts. Food sources include fish, crab, clams, oysters, liver, beef, and eggs. Vitamin C has been shown to improve sperm quality, preventing them from clumping together, making them more motile. It is abundant in vegetables and fruits. Vitamin E is found in nuts, seeds, vegetable oils, leafy greens and fortified cereals Coenzyme Q-10 is a vitamin-like substance found in oily fish, like salmon and tuna, meats, and whole grains. Amino acid: L-carnitine is an antioxidant important for normal sperm function. It has been shown to help normalize sperm motility in men with low sperm quality. Food rich in L-Carnitine are found in meat, poultry, fish,nuts, seeds, and vegetables, including artichokes, asparagus, broccoli, Brussels sprouts, garlic and parsley. Trace minerals: Zinc is important for male fertility. Increasing zinc levels in infertile men has been shown to boost the sperm number and quality and improve its function. It can be found in oyster, shellfish, beef, pork, sesame seeds, pumpkin seeds or green peas. As zinc can be damaged by cooking it may be consumed by eating the food raw. Selenium is an antioxidant involved in the motility of the sperm. It is found in whole grains, lentils, fish, meat and eggs. Omega-3 fatty acids: Fatty fish like salmon and sardines are rich sources of omega-3 fatty acids. You can also get omega-3 in plant-based foods, like flaxseed, walnuts, canola oil, and fortified products such as eggs.

Are there any early “warning” signs that could indicate a potential fertility issue later on? Though not specific, some early warning signs that could signal a potential fertility issue later include the following: If the woman · Has very irregular periods, · Has menstrual pain which gets worse in severity and duration with time · Has smelly and yellowish discharge · Has persistent spotting in between periods · Has severe discomfort or pain during sexual intimacy · Has had abdominal surgery Or if the man · Has had many sexual partners before marriage · Has had Sexually transmitted infections · Has had previous surgery for hernia or undescended testis · Is a heavy smokers or alcoholic These are conditions that might affect the couple’s future fertility. They should go for early fertility checks. You can also check your “fertility potential” by doing a fertility index test (a self-test) on our home page.