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Hysterosalpingogram (HSG) is a procedure in which an X-ray is used to look at the internal shape of the womb(uterus) and to show whether the fallopian tubes are blocked. It is commonly carried out in the investigation of infertility. During the procedure, a speculum is inserted into the vagina to keep it open. The cervix is then cleansed with an antiseptic solution. A thin tube called a cannula is then placed in the cervix and a radio-opaque dye known as contrast material is gradually injected into the uterus. A series of X-rays, or fluoroscopy, is done to follow the dye, which appears white on X-ray, as it flows into the uterus and the tubes. If there is an abnormality in the cavity of the womb such as a fibroid or septum, it will be shown in the x-ray images. If the tube is blocked, the dye will stop flowing. If the tube is open, the dye will fill it gradually and spill into the pelvic cavity. The procedure usually takes about 10-15 minutes to complete. It is usually done in the period after menses and before ovulation so that the chances of the patient being pregnant are low. There may be abdominal cramps or discomfort during and after the procedure. A pain killer taken an hour before the procedure usually suffices. Slight vaginal bleeding or spotting for a few days is also common. After the procedure, a course of antibiotics is given to prevent pelvic infection. HSG is relatively safe. Occasionally, there may be an allergic reaction to the dye. Pelvic infection and injury to the uterus are rare. Although HSG is commonly used as a first-line diagnostic test for infertility, it has some limitations. It only visualizes the interior of the uterus and the fallopian tubes. Abnormalities of the ovaries, the wall of the uterus, pelvic infection and menstrual backflow(endometriosis) may not be assessed by this imaging technique. Studies have also shown that if an occlusion is detected in HSG, there is a 60% possibility that the tubes are actually patent. This apparent blockage is due to the spasm of the fallopian tubes from the pain experienced by the patient during the procedure.

MR FOR Wei Chek, a nutrition and dietetics services manager at Mount Alvernia Hospital, offers some tips on picking healthier options while grocery shopping: 1. Look out for the Health Promotion Board’s Healthier Choice symbol, which indicates that the product has lower fat, saturated fat, sodium and sugar, and contains higher dietary fibre, calcium and whole grains, when compared to other products in the same category. 2.Wholemeal bread is particularly good for glucose-intolerant mums-to-be as it is high in fibre, which slows down glucose absorption. Those who dislike wholemeal bread can choose high-fibre white bread instead, which means that it contains more than 6g of dietary fibre per 100g 3.Pick low-fat or non-fat yoghurt for a snack, instead of a yoghurt drink as the latter contains higher amounts of sugar and lower calcium. 4.“No sugar added” claims on fruit juices do not mean that the products are free of sugar—they can still contain fructose, which is the sugar from the fruit they were made from. The best juice is made at home from fresh fruit, using a blender instead of a juicer, so that the pulp is retained. 5.Choose brown rice as it contains more fibre and nutrients like vitamin B. Mix brown rice into white rice in increasing ratios, if you are not used to taste and texture of brown rice. 6.Biscuits that are high in fibre could also be high in fat, so choose one that is high-fibre, low-fat and low-salt. Planning to become a mum? Watch your diet by Rachel ChanWorking women who plan to start a family should pay more attention to their nutritional intake, since most of them eat out during the weekA woman who eats well is less likely to have morning sickness, said Dr. Peter Chew, senior consultant obstetrician and gynaecologist at Gleneagles Hospital.Good eating habits are all the more crucial for Singaporean women, considering that many do not go for health checks before trying for a baby, said Dr. Chew. In his survey of about 300 women in June last year, nine in 10 did not go for preconception health checks.Such a check would pick up on risk factors and nutritional deficiencies that could adversely affect a child in-utero. Said Dr.Chew: While Singaporeans are not refugees, I see a lot of expectant women who were not conscious of their nutritional intake until they found out, they were pregnant.“It is important to start eating well before pregnancy to minimize the possibilities of  a miscarriage or stillbirth”This is because a foetus’ vital organs are formed during the first eight weeks of pregnancy, which is usually before the mother realizes that she is pregnancy, Dr.Chew explained. Poor nutrition can result in changes to foetal genetic material, which can lead to the development of chronic diseases, he added.For those who constantly eat out, their doctors might recommend a health supplement to ensure adequate intake of folic acid, choline, iron, calcium and DHA, a type of omega-3 fatty acid. Mr. For Wei Chek, a nutrition and dietetics services manager at Mount Alvernia Hospital, pointed out that an expectant woman’s diet prepared not only for the physical demands of delivery, but also the successful production of breaks milk for her newborn baby.Those planning for a baby should increase their intake of folic acid and eat more fruit, vegetables and fortified cereal three months before they try to conceive. “It is important to start eating well before pregnancy to minimize the possibility of a miscarriage or stillbirth” DR PETER CHEW, SENIOR CONSULTANT OBSTETRICIAN AND GYNAECOLOGIST AT GLENEAGLES HOSPITAL Such healthy eating habits should also continue post-delivery, to provide for the mother’s nutritional needs as well as that of the baby’s Mr For added. But he stressed that expectant women should not eat for two- they should take in only an extra 200 to 300 kilocalories per day, while lactating mums need only an extra 500 kilocalories a day.Pregnant and lactating women need more protein. The former needs an extra 9g, about a serving of meat approximately half the size of one’s palm. Breastfeeding mums need an extra 25g of protein a day for the first six months, said Mr For.To ensure a healthy weight gain, they should eat more nutrient-dense foods instead of calorie-dense foods. Red bean soup  is an example of nutrient-dense food, while ice kacangis a calorie dense food as it is laden with sugar.Other better food choices include a chick or egg sandwich, rather than roti prata. Fresh fruit juice and low-fat milk are also better than soft drinks and coffee. Both pregnant and lactating women should also consume a serving of dairy product daily, said Mr For.This can be fresh low fat milk, UHT milk or powdered milk.rachchan@sph.com.sg

Starting a family was furthest from Celia’s mind when she got married at 30. She was a banker and her career was going at full steam then. She was happy with living a ‘double-income-no-kids’ life .Having a baby would mean the end of  cosy  tete-a tetes, candle-light dinners and twice-yearly holidays. She was not willing to give up this sort of life style. But things took a turn after she hit 35. “My husband and I had a serious talk about where our lives were heading,” she shared. “After much soul-searching, we decided that parenthood was something we really wanted and we did not want to regret missing out on it.” She tried to conceive for about six months without success. This was when she decided to see me. After the initial consultations and investigations, Celia was found to have multiple fibroids, a condition where there are benign growths in the muscle wall of the womb. These were removed successfully by key-hole surgery. Four months after the surgery, she was overjoyed when I showed her an ultrasound image of a foetus with its heart pulsating inside her womb after her period was overdue for 2 weeks. Her pregnancy progressed smoothly and she delivered a healthy girl by Caesarean section in December last year. Like Celia, more and more Singaporean women are starting a family late when they are in their mid-30s or older. Studies show that these mothers have more problems during pregnancy compared with their younger peers. There is an increased risk of miscarriage, most of which occur in the first trimester. About 10 percent of pregnancies for women in their 20s end in miscarriage. The risk rises to 20 percent after 35 and 35 per cent after 40. An older mum also has a higher chance of having an abnormal baby from chromosomal defects. The most common is Down’s syndrome, when affected children have varying degrees of mental retardation and physical birth defects.  The risk of a mother having a baby with Down’s syndrome increases from 1 in 1250 at the age of 25 to 1 in 400 at 35. There is also an increased incidence of coexisting medical conditions such as high blood pressure, diabetes and gynaecological problems such as ovarian cysts or uterine fibroids as in Celia’s case. These conditions have a negative impact on the the pregnancy outcome. For example, untreated diabetes can cause birth defects and miscarriage. Poorly controlled hypertension can result in stillbirth. Other complications that are more common in pregnant women over 35 include multiple pregnancy, placenta previa (low lying placenta), premature birth, intrauterine growth restriction and stillbirth. There is also an increased incidence of induced birth, assisted delivery using forceps or vacuum and Caesarean birth. Although Celia’s pregnancy was relatively smooth, she was monitored very closely during her prenatal period. To couples who have not embarked on the journey of parenthood, Celia has this to say:” Don’t wait too long to try. Fertility and pregnancy is not as easy as you would like to think. Allow ample time for the unexpected. Watch your biological clock!”

I intend to have epidural anaesthesia for pain relief during labour. I would like to know more about it. Is it effective? Any side effects or risks? What can be done if the pain relief is not complete? Answer: Epidural anaesthesia is done by anaesthetist for pain relief during labour. It is done by introducing a fine tube (epidural catheter) into a space at the back of the spine called epidural space. A local anaesthetic agent is then given via this epidural catheter and can be topped up intermittently or continuously, with the dosage adjusted accordingly, till the baby is delivered. If Caesarean section is required, the dosage can be topped up to provide anaesthesia throughout the operation. The side effects and risks of epidural anaesthesia are as follows: a) Common side effects: 1) Shivering – harmless and self-limiting. 2) Transient drop in blood pressure – correctable with intravenous infusion. 3) Nausea and vomiting – short term. b) Less common side effects 1) Infection – This is very rare as epidural and spinal procedures are done under strict aseptic conditions. 2) Puncture into vessels giving rise to haematoma (blood clot) that may press on the nerves causing persistent paralysis. This is very rare (0.001%) and will require surgical procedure to remove the clot and reverse the paralysis. If an aberrant nerve is injured during the epidural procedure foot drop may result. This will require supportive and sometimes prolonged physiotherapy. 3) Severe drop in blood pressure and difficulty in breathing when the effect of the local anaesthetic goes too far up the spine to affect the respiration. This can be damaging. 4) Delayed recovery of part of the numbness of the lower limbs caused by the anaesthesia – may take weeks or months. This incidence risk is about 0.001% 5) Puncturing of the dura membrane during the epidural procedure (0.5%). Patient will suffer severe post-delivery headache. This usually takes about a week to recover with the help of painkillers. Relief of headache can be achieved by a procedure instilling a blood patch to the same epidural space the next day to seal up the puncture in the dura membrane. 6) Persistent foetal heart rate changes requiring some intervention such as caesarean section. 7) Rapid absorption of the local anaesthetic, usually through a vein to cause a seizure – very, very rare. 8) Respiratory and cardiac arrest leading to fatality has been reported but is again extremely rare. 80% of patients who have had an epidural successfully inserted will get complete nerve block and pain relief. 15% of patients may get one-sided or partial nerve block and about 5% may not get any pain relief at all. This may be due to some anomaly of the patient’s spine, causing the epidural to be deviated to one side or even be displaced in the course of labour. Sometimes when the labour is too advanced or cervical dilatation is too rapid, epidural anaesthesia given at this stage may not act in time to alleviate pain. If the pain relief is not complete, the following steps can be taken to try to rectify it: 1) Adjust the posture of the patient, e.g. turn the patient to one side or sit the patient in a more upright position. 2) Adjust the epidural catheter, and 3) If above procedures fail the final solution is to re-do the epidural at a new space. This usually gives good results but still there is no guarantee of 100% success.

I am infertile. Recently, I was diagnosed with endometriosis. My gynaecologist suggested treatment with GnRH agonist. Can you explain how the medicine works? Any side effects? Answer: Endometriosis is a disorder of the female reproductive system in which there is a backflow of the menstrual blood (endometrial tissue) into the pelvic cavity. The endometrial tissue responds to the female sex hormone oestrogen and grows with each menstrual cycle (please refer to “Endometriosis” article on the website under Home > Articles > Gynae Conditions > Endometriosis). GnRH agonist is a drug modified from the naturally occurring hormone known as gonadotropin releasing hormone (GnRH), which controls the menstrual cycle. It stops the production of oestrogen by a series of mechanisms. This deprives the endometrial tissues of oestrogen, causing them to shrink and become inactive. This may help the reproductive organs to regain their function and allow the woman to get pregnant after the treatment is stopped. The usual length of treatment with a GnRH agonist is 3–6 months. You should notice an improvement in your symptoms within 4–8 weeks of treatment. The side effects are largely the result of the low oestrogen in the body. They are usually the symptoms associated with the menopause. Common side effects are: • Insomnia • Decreased libido • Headaches • Vaginal dryness • Mood swing The more serious side effect is thinning of the bones, particularly the bones of the spine. The decrease in bone density is usually about 5% if the treatment is prolonged for more than 6 months. Most of the bone lost during treatment regenerates within 6 months of completing treatment. GnRH agonist has been used to treat women with endometriosis for over 20 years. It is safe, effective and generally well tolerated when used in combination with add-back therapy which involves taking a low-dose oestrogen. This reduces the menopausal symptoms and prevents or minimises the thinning of the bones.

M could not control her emotions. She gave me a big hug. With tears rolling down her cheeks, she exclaimed, “Doc, thank you for presenting me with such a wonderful gift.”  This was the first time she was pregnant after a first attempt on intrauterine insemination, an assisted reproductive technique. M ,a 38 year-old lawyer  had been married for 8 years and trying to conceive naturally but unsuccessfully for the past 7 years. She had a mild degree of endometriosis, a condition where there is a back flow of menstrual blood in the pelvic cavity. The endometriosis was treated with laparoscopic surgery, in which a telescope is introduced into the abdomen. She  had medications subsequently for 3 months. Her husband’s sperm  count was normal except for a slight decrease in the sperm motility.After numerous failed attempts with fertility drug treatment and timed sexual intercourse at the ovulation period, the couple decided on the regime of superovulation and intrauterine Insemination (SO-IUI) What Is SO-IUI? It is an assisted reproductive technique in which two to three ovarian follicles (watery sacs in the ovary containing the eggs) are stimulated and brought to maturation and ovulation. A sample of prepared sperm is then placed directly into the uterus for the sperm to swim up the fallopian tube and fertilize the egg. This procedure will enhance conception for couples with mild endometriosis and mild sperm problem as in M’s case. It is also suitable for the patient whose cervix (neck of the womb) does not secrete good mucus during ovulation. The patient must have normal and patent fallopian tubes Fertility drugs are usually given for 10 days or more to produce between two to three mature follicles. These drugs(gonadotrophins) are given as injections alone or in combination with oral fertility drug such as Clomiphene. Ultrasound scans are done at intervals to determine the number and size of the follicles before another injection (HCG) is given for final maturation and subsequent ovulation of these follicles. On the day of the insemination, the semenis prepared in the laboratory and the motile fraction harvested and placed into the uterus using a fine catheter through the cervix. Occasionally, the procedure may be discontinued because of poor response or over response of the ovary. Whilst M was jubilant with the pregnancy, I warned her about the risks of miscarriages, foetal abnormalities and premature birth which are increased in older mother. She is now in her second trimester and the pregnancy is normal so far. The couple feel reassured every time I show them the baby moving inside the womb using the ultrasound machine.

Beads of cold sweat dripped from her forehead. Her face was as white as a sheet. Her extremities were cold and clammy.  Her pulse was rapid and blood pressure was low. She was bleeding profusely from the vagina. L, a 43 year- old housewife was rushed to the hospital by her husband in a state of ” shock”. She had been having “menstrual bleeding” on and off for a month and had passed out clots for the past 5 days. She felt very weak and collapsed at home. After resuscitation with intravenous fluid and blood transfusion, L’s condition improved.  Ultrasound examination of her uterus showed a huge fibroid about 10 cm in diameter. “Doc, I should have it removed 4  years ago when it was only 5 cm," she sighed. “ I was so scared of having an operation that  I avoided seeing the doctor after that and  only took some Chinese herbal  tonics every month after my menses.” When her condition stabilized, I discussed various options of treatment with her and her spouse. She finally decided to have her womb removed with conservation of the ovaries. This was performed successfully by key-hole surgery.  She was discharged well on the third day after operation. Removal of the womb or hysterectomy is a common gynaecological operation. It is done for the following conditions: •             Cancer of the uterus, cervix, or ovaries •             Uterine fibroids: These are non-cancerous growths in the muscle wall of the womb causing pain, bleeding, or pressure symptoms •             Uterine prolapse: The womb protrudes out of the vagina causing severe discomfort •             Endometriosis: Backflow of menstrual blood into the pelvic cavity causing severe menstrual cramps and/or pain during sexual intimacy •             Chronic pelvic infection: Usually from sexually transmitted diseases- with severe menstrual pain and pain during sexual intimacy •             Adenomyosis: This occurs when the lining of the womb grows into its muscular wall and causes severe menstrual pain and heavy bleeding TYPES OF HYSTERECTOMY There are 3 types of hysterectomy: 1.   Total hysterectomy: The whole womb is removed together with the neck of the womb (cervix) 2.   Subtotal hysterectomy or partial hysterectomy: Only the upper part of the womb is removed, leaving the cervix behind 3. Radical hysterectomy: The whole womb, tissue on the sides of the womb, the neck of the womb (cervix) and the top part of the vagina are removed. This operation is done when cervical cancer is present. APPROACHES OF HYSTERECTOMY Hysterectomy can be done through the abdomen or vagina depending on the surgeon’s experience, previous history of abdominal surgery, the reason for the hysterectomy, and the overall health of the patient. 1. Abdominal approach: This can be done through open surgery or key-hole surgery. Open surgery is the traditional approach. An incision of 10 to 20 cm is made either vertically or horizontally across the abdomen. The pelvic cavity is entered and the uterus removed. The hospital stay is about 3-4 days if there are no complications. Key-hole surgery is done using a laparoscope ( a telescope with a lighted camera) and delicate surgical tools. These are inserted through several small cuts, measuring 0.5 cm to 1 cm in diameter, in the abdomen. The surgeon performs the operation from outside the body, viewing through a video screen or a sophisticated robotic system. Key-hole surgery offers a number of benefits compared to the traditional open surgery. Recovery is faster with shorter hospital stays. Scars are smaller and post-operative pain is much less. There are less chances of wound infection and adhesions from the intestines and other abdominal organs 2.Vaginal approach: The surgeon makes a cut in the vagina and removes the uterus through the incision which is then closed, leaving no visible scar. RISKS OF HYSTERECTOMY Most women who undergo hysterectomy have no serious complications. However, as with any surgery, complications may arise in a small minority of women. These include: •             Excessive bleeding •             Wound infection •             Adverse reaction to anaesthesia •             Damage to the urinary tract, bladder, rectum or other pelvic structures during surgery, which may require further surgical repair •             Urinary incontinence •             Vaginal prolapse (part of the vagina "prolapsing" out ) •             Chronic pain in the abdomen •             Pulmonary embolism from blood clots in the veins of the pelvis If the ovaries are removed together with the womb, the patient will experience menopausal symptoms straight away. She may require hormone replacement therapy or alternative treatment to manage her menopause. If the ovaries are conserved, studies have suggested that the patient may enter menopause earlier. Full recovery usually takes several weeks. Activities such as lifting heavy objects should be avoided.

Q. I am 35 years old with 2 children. For the past 6 months, my menses are getting very heavy with the passage of large blood clots.  Is it normal? What are the causes? I consulted my family physician, who gave me iron supplements. How does iron help?A. If you notice a change in the amount of menstrual bleeding and pass out large blood clots, you probably realise  that something is not right.There are many causes of heavy menses. Common causes include: Hormonal  imbalance. In a normal menstrual cycle, there is a balance between 2 hormones secreted by the ovary, namely oestrogen and progesterone. These hormones regulate the lining of the womb (endometrium), which is shed during menstruation. If hormonal imbalance occurs -which may be due to the ovary not producing and releasing the egg (anovulation), the endometrium grows in excess and finally sheds by way of heavy bleeding. Uterine fibroids. These are common noncancerous growths of the womb, being present in 25% of women age 35and above.   They can cause heavy or prolonged menstrual bleeding by increasing the surface area of the endometrium. Adenomyosis. This condition occurs when glands from the endometrium become embedded in the uterine muscle, causing enlargement of the uterine cavity. Endometriosis: This condition is due to the backflow of the menstrual blood into the pelvis. Chronic pelvic infection: This  condition usually results from sexually transmitted diseases Polyps: These are small, non-cancerous growths on the  endometrium, usually a result of high hormone levels. Intrauterine device (IUD). Heavy menses is a side effect of the non-hormonal intrauterine contraceptive device. Cancer. Uterine cancer, ovarian cancer and cervical cancer are occasional causes of excessive menstrual bleeding. Other  medical conditions including thyroid problems, bleeding disorders, liver and kidney diseases may be associated with heavy menses Iron supplements will not relieve heavy periods. You were given the supplements because the doctor suspected that you might have anaemia, a condition in which you don't have enough red blood cells to carry adequate oxygen in your body. With heavy periods and blood loss over a long time, your body’s iron stores would be depleted. The iron supplements rebuild your body's iron stores. You may also want to take vitamins containing folic acid, vitamin C, and vitamin B-12 to help build red blood cells. Please consult your doctor for further investigations and treatment.

My wife is feeling anxious during her pregnancy. This is our first pregnancy. Is this normal? Any other symptoms I should look out for?Anxiety and even some moodiness  are normal emotions that all mothers experience during and after pregnancy. But some women may have an increased risk of depression if the anxiety is left unrecognized. The warning symptoms  are as follows: Physical symptoms: Poor appetite Disturbed sleep, Low energy levels Breathlessness Chest discomfort Headaches Mental or Emotional symptoms Poor concentration Irritability Feeling weepy Gloominess Worrying and obsessing over things Thinking of worst-case scenarios Source: Dr. Adrian  Wang, Consultant Psychiatrist

Cervical mucus (CM) is the secretion produced by the glands in the cervix, the neck of the womb. It is important for conception as it is the entry point for the sperm to swim up the womb and fallopian tube in search of the egg. It usually forms a thick plug preventing the sperm from entering the womb. But during ovulation, instead of being a barrier, it helps accelerate the passage of the sperm through the cervix and prolong the life of the sperm, allowing them to live for up to five days. CM also helps screen the sperm allowing the active and apparently “normal” sperm to pass through.  In addition, it acts as an anti-bacterial barrier for the cervix. Distinct from other vaginal discharge, CM is odourless, colourless and does not cause any vaginal irritation. In response to the ovarian hormones, the amount, consistency and composition of CM show cyclical changes throughout the menstrual cycle Women can see and feel CM when it moistens their underwear, or when they wipe themselves with toilet paper. Soon after the menses, the vaginal discharge is scanty with no visible mucus. As ovulation approaches, the vagina feels moist with increasing amount of sticky, white or creamy discharge .The mucus is slightly stretchy but breaks easily when stretched. During ovulation, the vagina feels slippery, wet and lubricated. The mucus is copious, thin, stretchable and transparent like the raw egg white.  After ovulation, the mucus becomes scanty, thick, opaque and sticky again. By observing these changes in the CM, women can boost their chances of conception by timing intimacy during ovulation.

Q. I am 54 year old and menopausal. Recently I had some vague lower abdominal discomfort.  I went for a gynaecological check-up. My gynaecologist suggested CT scan of the pelvis. Is it safe? I heard that the scan may increase my risk of cancer. A. CT scan is one of the common medical imaging techniques. It helps create images of structures in your body by using a small, targeted amount of ionizing radiation. It provides much clearer and more detailed images than traditional X-rays do. It helps doctors diagnose and detect growths and many medical conditions. With such low doses of radiation used in a CT scan, your risk of developing cancer is small. But according to the American College of Radiology, this imaging examination should be done with good medical reasons. Since minimal radiation is used when performing CT scan, the benefits outweigh the small potential risk of cancer.

If you use nail polish and the remover once in a while, the chemicals probably would not have any negative impact. Studies so far have not revealed any adverse outcome in the baby.Many of the chemicals are organic solvents which are volatile and can be toxic if inhaled in high concentration. The extent of the exposures varies greatly, depending on the ventilation available and care taken in the application of the nail products. A recent report from the FDA, United States indicates that these chemicals can cause skin irritation, allergic rashes and death.If you are working as a nail technician in a busy nail salon, repeated exposure at work may pose a risk.    You can reduce your exposure by the following measures: Keep the place well ventilated before you put on the nail polish. Dry the polish by keeping the client’s arms away from you. Do not blow on the nails. This will minimize breathing in the fumes. After painting the nails or removing nail polish, always wash your hands with soap and water to remove any chemical residue.