PolyCystic Ovarian Syndrome and Fertility Series Part 1

PolyCystic Ovarian Syndrome and Fertility Series Part 1

PolyCystic Ovarian Syndrome (PCOS) is a condition that has been diagnosed for over 75 years ago but yet many women still has little understanding of PCOS, let alone combat it.

“Just a few days ago I saw a couple who were married for 8 years and trying to conceive for nearly 6 years. She had seen a few general doctors over the years and was told that she has ‘imbalanced hormones’. She was given tablets to induce her periods and to make her ‘eggs’ to grow.”

This simple real life example illustrates how much PCOS can affect a women’s life on a long term basis. Appropriate diagnosis and treatment can save time, money and most importantly avoid unnecessary emotional trauma and guilt.

Many women have been diagnosed with ‘imbalanced hormones’ when they have irregular periods. Many of them probably have PCOS but undiagnosed. So what is PCOS ?

Image Source: Abounding Hope

PCOS is a condition in which female and male hormones are not in their usual balance. PCOS is one of the most common hormonal endocrine disorder in women. Let’s look at some facts:

1. It affects about 5-10% of women. However, less than 50% of this women were diagnosed correctly.

2. Studies has shown that nearly 70% of women suffering from infertility (due to difficulty ovulating) have PCOS.

3. In addition, nearly 40% of women who suffer from Diabetes / glucose intolerance have PCOS.

How do you know if you have PCOS ?

Image Source: iStock

The diagnostic criteria for PCOS has evolved over time as we gain more insight into this condition. Currently, PCOS is diagnosed based on your medical history, physical examination, ultrasound scan of your ovaries and with/without a blood test.

What are the common complaints a women with PCOS tells her doctor ?

  1. “Doc, I have very few periods in a year or a long interval between periods.”
  2. “I’ve been putting on weight even with careful diet and exercise! It’s like my body is resistance to exercise.”
  3. “I have put on weight since marriage. I used to weigh 55kgs and nows I’m 70kgs!”
  4. “I’m getting bit worried doc. My friends said that I have more facial hairs now than before. I realised that too cause even my regular hairdresser had pointed it out!”
  5. “We are married for 3 years now and no luck with pregnancy.”
  6. “The other doctor told me that I have many cysts in my ovary. Do I need a surgery?

These are some of the common worries that a woman with PCOS has.
The doctor would then proceed to examine the women. What are we expecting to see?

Image Source: Tribun News

An ultrasound scan of the ovaries may show ‘high number of  resting eggs’, usually more than 10-12 on each ovary. The resting eggs are arranged in a particular fashion known as ‘Ring of Pearls’.

Sometimes your doctor will arrange a blood test to look at female hormone imbalance and also at the level of male hormone (Yes, you read it correctly. Women have male hormone in them but in a low level). In PCOS, the male hormone level can be higher than usual.

“Mrs JC visited me for inability to get pregnant for 4 years. She has been putting on weight for the last 2 years despite on diet control. She has been noticing that she needs to shave and thread her facial hair more frequently now than before. She has sometimes missed her periods and her average period cycle length (from Day 1 to Day 1 of next period) is about 30-40 days. She used to have regular monthly periods at her teenage years. Her ultrasound scan of her ovaries showed a typical ‘Ring Of Pearls’ ”.

Image Source: News Karnataka

The problems of PCOS may not necessarily manifest itself early in life.  Sometimes the symptoms begin in late teenage years or more often in their 20s-30s. Many only knew they are suffering from PCOS once they have visited their fertility doctor.

It’s scary isn’t it? To live with a condition and never knew you ever had it. However, you won’t be terrified once you know what is PCOS, what are the health consequences and how to minimise or overcome the consequences.

Read about PCOS and Fertility Part 2 here.

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Which Infertility Treatment Will I Need?

Which Infertility Treatment Will I Need?

Treatment options can be divided into treatment for male infertility and treatment for female infertility.

Male Infertility:

Reduced sperm quality. 

According to world standard (World Health Organization) , sperm quality is taken as ‘normal’ when the sperm concentration is > 15 million/ml, motility is  > 40% , normal form is > 4% , vitality > 58%.

When the semen analysis shows values less than this, it is considered ‘low’ in sperm quality. How to improve sperm quality?

Treatments that can be offered are lifestyle changes (such as stop smoking, reduce alcohol intake, reduce weight and stress) and oral medication called anti-oxidants.

Image Source: Genetic Literacy Project

Research had shown that high level of reactive oxygen spesis (ROS) and low level of antioxidant in the semen reduces sperm quality. Supplementing men with oral antioxidants improves sperm quality especially motility. There are many antioxidant such as vitamin C, vitamin E, L-carnitine, Co-enzyme Q, zink and selenium. Your doctor will give a combination of these antioxidants.

2. Azospermia ( no sperm)

When there is no sperm found, it could be due to obstruction in the channel that sperm passes through (vas deferans) or due to low or no sperm production in the testis. Your doctor will do some blood test on male partner and examine the testicles to arrive to a diagnosis.

Obstruction can be caused by infection or injury to testicles . Sometimes the men is born without vas deferens. It can also be due to previous vasectomy (male sterility procedure).

There are several options to retrieve the sperm:

Image Source: Southern California Reproductive Center

For men with previous vasectomy, a vasectomy reversal surgery can be done. However, the success rate is low. If the reversal surgery failed, PESA or TESE / TESA can be done .

If obstruction is diagnosed, PESA (Percutaneous Epididymal Sperm Aspiration) can be done. In this procedure, sperm is directly aspirated from epididymis (where sperm is stored in the testis) using a fine needle.

If obstruction or low sperm production is suspected, TESE ( Testicular Sperm Extraction)  or TESA (Testicular Sperm Aspiration) can be done, where a biopsy or several biopsies taken directly from the testis after making a small incision in the scrotal skin.

Female infertility:

1.Tubal Factor

Tubal factor infertility means that there is a problem for the egg / oocyte to pass through the Fallopian tube to meet the sperm. It includes a diseased or surgically removed) unilateral (one) / bilateral (both) Fallopian Tubes or absence of Fallopian tubes. If 1 (one) of the fallopian tubes are open/patent, much simpler treatments such as Timed-sexual intercourse or Intrauterine Insemination (IUI) can be done. If both the Fallopian tubes are not patent or absent, IVF is needed.

Image Source: Fight Your Infertility

If the fallopian tubes are swollen, you may need a laparoscopic (keyhole) surgery to remove the diseased fallopian tube.

2.Ovulation Factor

If the woman is not ovulating, such as in women with Polycystic Ovarian Syndrome (PCOS), fertility pills (ie Clomid) can help. It is normally taken for 5 days starting on Day 2 of menses. Together with fertility pills, Timed Sexual intercourse or IUI can be done. If these methods are not successful, IVF/ICSI is needed.

3. Uterine / Ovarian / factor

 

Image Source: Momtastic

Sometimes there is a problem or pathology with uterus or ovary. Problems with uterus are presence of uterine fibroid , abnormal uterine shape (ie bicornuate uterus), presence of intrauterine adhesions (synaechia) or intrauterine septum. Problems with ovary could be presence of ovarian cyst or polycystic ovary (PCO). Many of these conditions are treatable with surgery, especially laparoscopic (keyhole) surgery. Depending on the problem and the success of surgical treatment, Timed Sexual Intercourse , IUI or IVF/ICSI can be tried.

4. Unexplained Infertility 

This is a little bit more tricky to treat since there is no cause found. Generally treatment will depend on the female partner’s age, duration of infertility and the couple’s wishes. Generally, IUI or IVF/ICSI will be needed in this situation. More detailed discussion of the treatment options for couple in this category will be done by your fertility specialist.

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Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

 
How to Improve My Chances of Getting Pregnant

How to Improve My Chances of Getting Pregnant

Treatment options for infertility can not guarantee a 100% success. However, YOU and your partner can help to improve the success rate. Every effort and step to achieving your goal of holding your little sunshine is worth trying. There are some aspects where the male and female partners can play a role.

1. Knowing your most fertile period ( fertile window)

Image Source: icanhelp.in

Fertile window is the time in the month when the women is most likely to become pregnant. This window is usually the 6 days interval ending on the day of ovulation. Ovulation occurs about 14-days prior to next period , so in a woman with 28-days period cycle, ovulation occurs on day 14 of her menses (Day-1 is when the woman starts to bleed).

2. Knowing when you will ovulate (releasing the egg into the Fallopian tube)

The knowledge of when you might ovulate will help you increase your chances of getting pregnant naturally. Methods you can use are:

Image Source: Very Well Family

a) Cervical mucous changes: Cervical mucous and vaginal discharge will increase 5-6 days prior to ovulation and peaks 2-3 days before ovulation. When you are nearing ovulation, cervical mucous will be more abundant, takes on a more raw-egg-white-like consistency. It will also be more stretchy in between your fingers.  This method is easy to do and also helps you know your body better.

b) Basal body temperature: Your body temperature will increase by 0.1 – 0.2 degree celcius once you have ovulated. You need to measure your body temperature everyday at the same time before your are up from your bed and chart it. If your body temperature rises, it indicates that you HAVE OVULATED. It means that this method tell you that ovulation had happened, it does not predict ovulation.

Image Source: Shutterstock

c) Urine Test for ovulation: There are commercial test kits available to test your urine for ovulation.  It measures a hormone called Lutenizing Hormone (LH), a hormone that helps ovulation. The LH hormone peaks in the body about 2 days prior to ovulation. When the LH hormone level is peaks in the body, it is measured in the urine. A positive test indicates that ovulation may occur in 24-48 hours.

d) Other general signs:

i) Increased sexual drive: This is nature’s way of telling you when you are fertile. However, sexual drive can also be provoked by many other factors.

ii) Breast tenderness: It can occur just before or after ovulation. Just like increased sexual drive, breast tenderness can be due to other reasons such as it can occur just before menstruation.

iii) Position of your cervix: Cervix is also known as neck of womb. Cervix, at the time you are not fertile, is easily felt vaginally, firm and closed. During fertile period, cervix will move higher, soft and open. Some says it feels firm like tip of your nose when you are not fertile and soft like your lips when fertile. Cervix is felt by inserting your clean middle or index finger gently into vagina. Find a comfortable position to do this such as sitting on a toilet bowl, equating or placing one leg up on the edge of a toilet seat.

3. General health

Image Source: iStock

You must make sure that you are healthy enough before a pregnancy. If you have any underlying illnesses such as Diabetes Mellitus or high blood pressure, make sure it is well controlled. Uncontrolled illnesses not only makes it difficult to get pregnant, but you run a higher risk of complication during pregnancy. You should also take pre-conception vitamins such as folic acid. You should stop smoking and stop consumption of any recreational drugs (ie marijuana, cocaine).

4. Give more time

Sometime, just giving a little more time is all what you may need. Generally, after 1 year of trying to conceive, 80% of couple will succeed. If given another year , 90% of couples will succeed. However, pregnancy rate reduces in older women and men.

5. Timed sexual intercourse

Research has shown that increasing the frequency of sexual intercourse may improve your chances. You should have sex every 1-2 days during your fertile period.

6. Watch your diet

Image Source: Fit Way

You should aim to maintain an ideal Body Mass Index (BMI) of 24kg/m2 or less, if possible. Obesity and being underweight has been shown to have adverse effect on fertility. Foods high in Mercury (seafood such as shark, swordfish and king mackerel) can reduce fertility. Heavy alcohol and caffeine intake are also shown to affect fertility.

7. Does sex position matters?

Well, this a question that has been asked time and again. Research did not find any relation between sex position and fertility. Resting on bed after sex are also not shown to affect fertility. However, usage of certain lubricants can reduce your fertility due to their chemical contents.

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

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

10 Myths About Palliative Care

10 Myths About Palliative Care

Palliative care is a multidisciplinary approach to specialised medical, dietary, physiotherapy and nursing care for people with life-limiting illnesses such as end-stage cancer or stroke or conditions requiring long term care such as Parkinson’s disease or dementia. The care focuses on providing relief from their symptoms, pain, physical and mental stress.

The goal of palliative care is to improve quality of life for both the person AND their family by providing comfort care and supportive care. This care can be given in the hospital, at a hospice or in the comfort of the patient’s home.

Here are some myths and facts surrounding palliative care.

Image: Shutterstock

1.

Myth: Palliative care is only for people dying of cancer

Fact: Palliative care can benefit patients and their families from the time of diagnosis of any illness that may shorten or disrupt their quality of life

2.

Myth: Palliative care hastens death

Fact: Palliative care does NOT hasten death. It provides comfort and improved quality of life from diagnosis of an advanced illness until the end of life

Image Source: iStock

3.

Myth: Palliative care is often expensive and unaffordable

Fact: There are a range of care services catering to different needs and budget. You can choose to stay in a nursing home, join a shared-living community or even receive care at home from visiting palliative healthcare team which usually includes a doctor, nurse, dietician and physiotherapist

Image Source: Solace Hospice

4.

Myth: People in palliative care who stop eating die of starvation

Fact: People with advanced illness usually lose their appetite. Palliative healthcare team includes a dietician who prepares a nutrition plan for the patient. Terminal patients die from their illness and not from starvation

Image Source: Visiting Nurse Association of Staten Island

5.

Myth: Palliative care is only provided in hospitals

Fact: Palliative care can be provided wherever the patients live – at nursing homes, long-term care facilities and even at home

Image Source: iStock

6.

Myth: Morphine is administered to hasten death

Fact: Patient are kept comfortable from their pain using pain medication (analgesia) but they do not hasten death

Image Source: US News

7.

Myth: Taking pain medication in palliative care leads to addiction

Fact: Keeping patients comfortable often requires increasing doses of pain medication with time because of tolerance as well as disease progression. This is NOT due to addiction

8.

Myth: Pain is part of dying

Fact: Although pain occurs in patients with advanced disease, they do not need to suffer this pain unnecessarily because pain can be controlled using pain medication

Image Source: Kiplinger

9.

Myth: I have let my family member down because he/she did not die at home

Fact: Sometimes the healthcare needs of the patient is more than what can be provided at home.  Providing the best care for the patient regardless of setting is not a failure

10.

Myth: Palliative care means my doctor has given up hope on me

Fact: Palliative care provides comfortable and supportive care to ensure the patient is pain-free and lives a dignified quality of life

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Age and Fertility in Male

Age and Fertility in Male

For many years we have known the importance of age and female fertility. A woman’s chances to get pregnant decline with advancing age.

As for men, we used to think that he can reproduce as long as he can produce sperm. That’s not the entire truth. Men’s fertility also decline with age. However, the decline is much more subtle. In the last 5-10 years , we are seeing a rapid decline in male fertility, i.e. the sperm quantity and quality is poorer even in a younger men.

In my daily practice, I too have noticed the same trend in male fertility.

Image Source: iStock

Scientific research over the last decade has shown that children born to older men has higher risk of certain condition such as autism and schizophrenia. This again reminds us that men should not delay his first child.

Interestingly, a recent research found that older men maybe can produce smarter kids! When the researchers looked at relationship between father’s age and certain features in their son, they noticed that older father’s have a more ‘intelligent’ sons.

Image Source: Entrepreneur 

This intelligence is measured in an index called geek index. “Geekiness” is linked to higher intelligence and better academic performance.

So, should men delay their first child just to get a smarter kid ?

I would say NO. The relationship between smarter kid and older fathers is not proven yet. Moreover, the smartness of these kids most probably liked to the autism genes, which we know linked to older fathers.

Image Source: iStock

Remember that the wife’s fertility declines with age and it’s not reversible. In my opinion, better to start your family earlier when your chances are optimal than suffer through infertility later.

A child’s educational success depends mainly on their upbringing and parental/ teacher’s guidance. WE make a difference in how our children turn out to be.

Source: Medical News Today

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

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

 

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).

Image Source: Focus on the Family

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) .

Image Source: Express

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?

Image Source: Boudica

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.

Image Source: 123rf

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?

Image Source: Chapel Hill

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?

Image Source: Shutterstock

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’.

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

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

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