What is Infertility?

What is Infertility?

1.What is infertility ? Infertility is defined as inability to conceive after 1 year of unprotected sexual intercourse.

2.How do I know if I have problem of infertility? If you have difficulty to get pregnant after having unprotected sexual intercourse with your partner over the last 1 year, you may have problem with infertility. However, you must bear in mind that if given more time (ie another 1 more year), you may have a chance to get pregnant on your own. This time limit will also depend on your age. If you are younger (ie age less than 25 years), you may want to give a bit more time to yourself. If you are older, then seeking medical advice earlier than later may benefit you. If you are known to have medical condition that predisposes you to infertility (ie endometriosis), you may want to seek a fertility specialist earlier (ie after 6 months of trying to conceive on your own).

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4. Where do I find the right Fertility Consultant?
There are many Fertility consultants. The right one for you will depend on your expectation of the doctor and what the doctor can actually offer you. The set-up of a fertility clinic can differ widely. Some are stand alone clinic with or without fertility laboratory (fertility laboratory is needed for treatments such as Intra-utrine Insemination/IUI and In-vitro Fertilization/IVF) .

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Some are within a hospital with fertility laboratory. If the fertility clinic has a in-house fertility laboratory and operating theatre, it may be of benefit to you. This is because many woman with infertility has endometriosis or adenomyosis and surgery may be needed in the treatment of infertility for those woman. So, the right fertility consultant for you will depend on the cause of your infertility and the treatments that are needed.

5. Can I just see a family doctor / general doctor in clinic?

You can see a general practitioner (GP) who knows which initial investigation to be done correctly. If initial investigations are not done at the appropriate time (ie some blood test are done on Day 2 of menses), you may end up repeating fertility investigation when you see a fertility consultant.

6. Should I do anything before seeing a Fertility Consultant?

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You just have to relax! A fertility consultant will be able to guide you through your journey to parenthood. However, if you have your previous fertility investigations or treatment records, please bring it along.

7. What test(s) my partner and I will need?
For male partner, a semen analysis will be done to assess the sperm count, how fast sperm moves, how normal are the sperms and the viability of sperms. Depending on semen analysis results, further test may or may not be needed.

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For female partner, blood tests are usually done on day 2 or 3 of menses to assess ‘ovarian reserve’ (ovarian reserve means ability of the ovary to produce female eggs). Blood test also may be done around day 21 (mid-cycle) of menses to asses ovulation. A test to assess patency of fallopian tube will be arranged around after your menses. Ultrasound scan to look at your womb and ovaries will be done routinely. Further test such as hysteroscopy (looking into the womb with a telescope) may be needed. Your fertility consultant will advise you.

8. What are the treatment options?

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Treatments options depend on the cause of infertility. For male infertility, depending on the sperm count, treatments such as IUI or IVF maybe needed. If there is no sperms for male partner and its probably due to obstruction, sperm can be retrieved via a minor surgery to the testis (TESA/TESE), and IVF/ICSI can be done. For female infertility, bilateral blocked fallopian tubes will need IVF/ICSI. If ovulation is the cause, ovulation pills or even IUI can be done. However, there are couples with unexplained infertility, in such a case, IUI or IVF maybe needed. 9. Can I do anything to improve my chances of getting pregnant?

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Yes you can! There are some lifestyle modifications that you can do to improve your chances of getting pregnant. The important thing to remember is that you and your fertility consultant need to work together to achieve success.

Read more on the next article on ‘How To Improve My Chances of Getting Pregnant’.

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Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

Normal Fertility

Normal Fertility

1.Normal Pelvic Anatomy

Female reproductive organs consist of uterus (womb), Fallopian tubes and ovary. The uterus / womb is a hollow, peared-shaped organ with thick muscular wall. It is subdivided into corpus (body) and cervix (neck). The top portion of corpus is called fundus. The inner part of corpus is the cavity, where the embryo/foetus develops during pregnancy. The inner lining of the cavity is called the endometrium.

Every month, endometrium thickened in preparation for potential pregnancy and sheds during menstruation if pregnancy does not occur. The cervix (neck) allows sperm to enter the corpus during fertile period of a woman. The Fallopian tubes are the channel that connects the ovaries to the uterus.

The inner lining of the fallopian tubes is made up of finger like projections called the cilia. These cilia are important in assisting the movement of the female eggs (oocyte) towards the uterine cavity and the sperms towards the oocytes. The ovary are oval-shaped paired glands that are attached to each sides of the uterus. Every month, one of the ovaries releases an oocyte/female egg. The ovary also produces female hormones oestrogen and progesterone.

2. Normal menstrual cycle

Normal menstrual cycle length (from beginning of one period till the beginning of next period) average between 21-35 days. If you are menstruating regularly, most probably you are ovulating.

The first day of your bleed is considered Day 1 of your menses. A woman may bleed for 4-7 days, but it varies for every woman. During the bleeding phase of your menses, the endometrial lining is shed and becomes thin. The ovary now produces female hormone called Oestrogen, which slowly thickens the endometrial lining. At the same time, the ovary also produces and develops few early stage eggs or oocytes.

Subsequently, only 1 egg or oocyte will mature every month. By mid-cycle (approximately day 14 in a woman with 28 days menstrual cycle), the matured egg or oocyte will be released into the Fallopian tube. This is also called ovulation. The ovary now will secrete female hormone called Progesterone, which will support the pregnancy if it happens. If there is no pregnancy, the endometrial lining will began to shed and menstrual bleeding will start and the woman will be in her Day 1 menses again.

 3. How Do I Get Pregnant?

Pregnancy occurs when the sperm meets the egg or oocyte in the fallopian tube. Out of millions of sperms that reaches the oocyte, only 1 sperm gain entry into the oocyte. Once inside, the genetic materials (building blocks for human beings) of the sperm and the oocyte will merge to form the embryo (early stage baby). The embryo will then move through the fallopian tube to get implanted in the endometrial cavity.

4. What is my chances of getting pregnant?

Generally, the chances of getting pregnant decline with age. The older the women gets, the lesser her chances of getting pregnant, even with advanced techniques like IVF (test tube).

5.If I don’t get pregnant, is there a problem with me?

Not necessarily. Nearly half of infertility are caused by male/husband’s problem(male infertility). Thus, it is important that both partners undergo evaluation for infertility.

6.How long should I be trying before getting help to get pregnant?

If you do not have any known factors that can lead to difficulty in getting pregnant, you and your partner can try up to 1 year before getting some help. You should try to have regular unprotected sexual intercourse around the time of ovulation.

7.Where can i get help?

You could see your own family doctor to get initial advise. You could also get an appointment to see a fertility specialist. There are abundance of information available in the internet about infertility.

Download Teleme’s mobile app and consult Dr Agilan, Obstetrician & Gynaecologist (infertility)

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

Sleep Disorders

Sleep Disorders

The normal sleep cycle consists 4 stages of non-REM sleep cycles and 1 cycle of REM (Rapid Eye Movement) sleep throughout the night. When your sleep cycles are disturbed, you wake up feeling tired and difficulty concentrating during the day.

  • NREM sleep. These four stages start from very light sleep during Stage 1 down to very deep sleep in Stage 4. Throughout NREM sleep, there is little muscle activity and it is very difficult to wake someone in stage 4 sleep. Deep sleep helps to restore your body and muscles from stresses of the day
  • REM sleep: This is the stage of sleep in which most dreaming occurs and our eyes are thought to move in relation to the visual images of our dreams

Each cycle lasts around 90 minutes consisting of the 5 stages of sleep.

During the night, the amount of time spent in each stage varies; we spend more time in stages 3 & 4 in the beginning of the night and more time in REM stage towards the morning. Increasing age also changes our sleep patterns as we require less time sleeping while babies spend 50% sleep time in REM stage.

Our internal clock situated at the hypothalamus dictates our normal circadian rhythm which helps us stay awake during the day and gets us ready to sleep at night. However, this rhythm can be disturbed by travelling through different time zones (jet lag) or doing shift work. Psychological issues such as stress or depression can also disturb your sleep pattern.

How can sleep deprivation affect health or quality of life?

  1. Good sleep is important for healthy brain function such as thinking, memory, learning, decision making and creativity
  2. Important for physical health such as:
  • Healing and repair of the body
  • Growing in children
  • Maintaining balance hormones (growth hormone)
  • Sleep deprivation results in poor blood sugar control
  • Obesity risk in sleep deficiency
  • Ensuring good immune system

Common Sleep Disorders
Common sleep disorders include insomnia and Obstructive Sleep Apnoea (OSA)

  1. Insomnia

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Insomnia is the inability to fall asleep or maintain sleep or wake up too early in the morning and feeling tired. The usual time to fall asleep is 10-20 minutes.

The causes can be:

  • Primary (not related to any medical issues)
  • Secondary (related to medical issues such as depression, stress, anxiety, chronic pain from arthritis, asthma, cancer or side-effects of medication)

Treatment involves practising good sleeping habits such as:

  • Going to bed (and waking) at the same time every night
  • Follow the same routine to help you relax before sleep
  • Avoid playing with light emitting devices just before sleep as they stimulate the brain and makes it harder to fall asleep
  • Try to avoid a heavy meal prior to bedtime
  • Avoid caffeine 3-4 hours before sleep
  • Avoid vigorous exercise close to bedtime as the adrenaline release stimulates the brain and body making it difficult to fall asleep
  1. Obstructive sleep apnoea (OSA)

OSA is the most common type of sleep apnoea. Around 15-20% of adults experience OSA and it is associated with being overweight, older age groups, smokers, rhinitis, pharyngeal reflux and in males. During sleep, our muscle tone relaxes and the airway lumen diminishes which requires more respiratory effort. This increase in respiratory effort results in negative airway pressure causing the airway soft tissue to flop back and obstruct the airway.

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Symptoms of OSA

Most common symptoms include snoring and restless sleep with periods of silence (apnoea) followed by sudden gasping and even arousal from sleep. This causes poor quality sleep which results in early morning headache, unexplained daytime sleepiness, trouble concentrating, mood changes such as irritability and poor work performance.

There are also heath implications as they are more likely to get hypertension, heart disease, stroke, diabetes and involved in accidents.

Investigations

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Important to have a complete examination by an ENT doctor to check BMI, neck circumference, nose and oral cavity to look for any anatomical obstruction by any polyp, septum deviation, tongue or lymphoid tissue.

Sleep study (PolySomnoGram or PSG) is the ‘gold standard’ to diagnose OSA and can be done at home by technicians who will do a home visit. Some other parameters which can be measured include heart rate, oxygen saturation, airflow and sleeping position. The Apnoea: Hyponoea Index (AHI) is used to grade the severity of the sleep apnoea depending on the number of ‘events’ detected per hour of sleep.

An ‘apnoea event’ is defined as complete cessation of airflow for at least 10 seconds while ‘hyponoea event’ is defined as 50% decrease in airflow for at least 10 seconds or 30% decrease in airflow with associated decrease in oxygen saturation or an arousal from sleep.

Treatment options

  • Lifestyle modification such as losing weight, gentle regular exercise (read ‘How much should we exercise daily?’) and avoid stimulants such as caffeine, alcohol or light emitting devices before sleep.
  • Treat any nasal symptoms such as allergic rhinitis
  • Continuous Positive Airway Pressure (CPAP) device
  • Surgery such as Cautery Assisted Palatal Stiffening Operation (CAPSO) or mandibular advancement procedure may be helpful

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One at a Time

One at a Time

Conceiving a child and procreating is a natural human tendency. Many of us  are blessed with children. However, some couples do face obstacles in their journey towards parenthood.

Modern fertility treatment such as an in-vitro fertilisation (IVF) has helped many couples to conceive. Current IVF technology had seen many advancements, thus achieving a higher pregnancy rate. IVF has also become safer for patients.

Common risks associated with an IVF procedure are ovarian hyperstimulation (OHSS) and multiple pregnancy.

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The risk of OHSS has reduced dramatically with the current IVF protocols. However, the risk of multiple pregnancy varies depending on several factors such as the age of the woman, quality of the embryo and number of embryo transferred into the womb. 

A well established IVF centre have their own medical guidelines pertaining to number of embryos to be transferred into the womb. Some countries have their own national guidelines which advises fertility specialists on number of embryos to be transferred based on patient and embryo factors.

So, why are IVF doctors concerned about the number of embryos transferred ?

As a fertility doctor , we aim for the couple to have a healthy baby at the end of their journey and not only rejoicing over a positive pregnancy test.

The journey towards parenthood does not stop with a positive pregnancy test, it’s only the beginning of the journey.

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If the pregnancy conceived is a twin or a triplets , it carries a significantly higher risk during pregnancy which can lead to pregnancy loss and a great emotional scar for the couple.

What are the risks of multiple pregnancy?

1) Miscarriage
Twin and higher order multiple pregnancies poses a higher risk of miscarriage than a singleton pregnancy. First trimester complications such as bleeding and severe morning sickness are more common in a multiple pregnancy. These complications can lead to higher miscarriage risk.

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2) Prematurity

Prematurity is when the baby is born before 37 weeks of gestation. In a multiple pregnancy, the risk of the babies being born prematurely is significantly high.

The complications to the babies born prematurely depends on their birth weight and how soon they were born. Common complications are  breathing difficulty (may need breathing support in an intensive care unit, ICU), infections of their guts, vision and hearing problem and long term mental retardation (cerebral palsy). The risks of these complications gets lower when the babies are born closer to term or when their weight is heavier.    

3) Growth restriction (low birth weight)

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Low birth weight in a multiple pregnancy is commonly due to prematurity.

In a multiple pregnancy , babies are fighting for nutrition and the placenta may not be able to cope with the demand.

Nutrition may not be equally distributed between babies , thus a growth discrepancy is common.

Babies of a multiple pregnancy are typically smaller than a singleton baby.

4) Medical conditions during pregnancy

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Risks of developing medical complications such as high blood pressure, pre-eclampsia and gestational diabetes in a multiple pregnancy is about two to three times higher.

Risk of gestational diabetes (GDM) if higher due to more than one placenta which can increase insulin resistance. GDM, if not controlled from early on, can lead to a big baby (macrosomia). This in turn leads to increased risk of birth trauma .

High blood pressure in a more severe form in pregnancy is known as pre-eclampsia (PE).

PE leads to growth restriction and also can damage the mother’s kidney and liver.

5) Caesarean section

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The risk of a cesarean delivery increases in multiple pregnancy.

This does not mean that twin pregnancies are only delivered by a caesarean section . An obstetrician will determine the best mode of delivery of a twin pregnancy based on several factors.

However, in the presence of complications of multiple pregnancy such as gestational diabetes, pre-eclampsia and growth restriction, the risk of delivering via a caesarean section is higher.   

What is the solution ?

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As a fertility doctor, I always advise couples to aim for a singleton pregnancy, one at a time. The dilemma is always on how to balance between the success rate of an IVF treatment and risk of multiple pregnancy.

This is how it can be done:

1) Go for blastocyst embryo transfer (day 5 embryo transfer)

Image Source: Indira IVF

In an IVF treatment , embryo/s can be replaced back into the womb at 2 stages , namely at cleavage stage ( 2 to 3 days old embryo) or at blastocyst stage ( 5 to 6 days old embryo).

An embryo at blastocyst stage gives a higher pregnancy rate because they are the better embryos. Only a good quality embryo can grow from cleavage stage to a blastocyst stage.

When embryo transfer is done with a blastocyst, ideally one embryo is selected to be transferred into the womb. This strategy gives a good pregnancy rate and minimises the risk of twin pregnancy . However, there is a very small chance that the blastocyst can still spilt into twins .

2) Pre-implantation genetic diagnosis (PGS)

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Genetic testing can be done on the embryos (PGS) to choose the embryo which is genetically normal. This strategy helps the doctor and also the couple to choose the best embryo for embryo transfer, thus minimising the risk of a multiple pregnancy while maximising their chance of getting pregnant.

Download Teleme’s mobile app and consult Dr Agilan, Obstetrician & Gynaecologist (infertility).

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

Hydrocele and Inguinal Hernias in Children

Hydrocele and Inguinal Hernias in Children

Hernias and hydrocoeles are the commonest conditions seen by paediatric surgeons as they occur in about 3-5% of children. The cause for both these conditions is the failure of the processus vaginalis to close before or just after birth (see Figure 1).

  • If the processus vaginalis is small, there is a passage between the abdominal peritoneum and the tunica vaginalis of the testis may allow fluid from the abdomen to trickle down and collect as a hydrocoele around the testis. This is called a HYDROCELE
  • If the tract is larger, the bowel or momentum can also go into This is called an INGUINAL HERNIA

Hydrocoeles are harmless and majority spontaneously resolve by 2 years of age or require surgical closure if they persist beyond 3 years of age.

Figure 1: Hydrocele

Figure 2: Inguinal Hernia

Indirect inguinal hernias on the other hand, do not go away and can cause problems to the child especially for the under 1 year-old.

The risks are:

  • Incarceration where the hernia is stuck causing bowel obstruction
  • Strangulation of the hernia where the blood supply to the herniated bowel is cut off causing necrosis and perforation of the bowel
  • The hernia may compress on the blood vessels to the testis at the inguinal ring and cause testicular atrophy (and loss of sperm production) in boys

Image Source: US News

Hernias must be corrected as soon as possible, especially in the under 1 year-old. When the hernia is stuck (incarcerated) or strangulated, they will need urgent reduction or emergency surgery to prevent damage to the bowel or testis.

How to distinguish a hydrocele from an inguinal hernia

  • Age of onset: hydroceles can be seen soon after birth as a non-tender scrotal swelling whereas hernias usually presents early in premature infants but usually within the first 2 years of life in term babies

Image Source: Getty Images

  • Constancy: hydroceles are seen most of the time and often smaller in the mornings and gradually increase in size as the day passes. Hernias on the other hand, comes and goes and often appears when the child cries. It helps if the parent can take a photo to show the doctor
  • Location: hydroceles are usually located are in the scrotum except for encysted hydroceles of the cord (see Figure 3 below) whereas hernias extend can from the inguinal area to anywhere down towards the scrotum
  • Physical exam: one can get above a hydroceles whereas one cannot get above hernias
  • Reducibility: Non-incarcerated hernias can often be reduced (made smaller in size) while hydroceles cannot
  • Transilluminate: Hydrocoeles generally can transilluminate with a light while hernias look opaque

How the bowel gets stuck in the inguinal hernia

Figure 3

A painful non-reducible groin swelling associated with vomiting and constipation is an emergency and the child must to referred to a paediatric surgeon for reduction or surgery to prevent the bowel from getting strangulated.

Surgical Treatment of Hernias and Hydrocele

Treatment of inguinal hernias is surgery to prevent complications mentioned above. There is no role for any conservative treatment or bandages (Truss) to contain the hernia.

Image: US News

Hernias can be repaired by an open procedure or using laparoscopic (keyhole) surgery. In up to 15% of children, a hernia can also be found on the opposite side. Laparoscopy allows for the contralateral side to be examined and repaired at the same time using the same incision.

Hydroceles that persist beyond 3 years of age also need surgery. There is no role of aspiration of the hydrocele as they often recur or can lead to an infection.

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 Dr. Nada Sudhakaran

Dr. Nada Sudhakaran

Paediatric surgeon

 

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