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.

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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.

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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.

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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

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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).

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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’.

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

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)

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)

Silent Pain: Endometriosis Treatment (Part 2)

Silent Pain: Endometriosis Treatment (Part 2)

What are the treatment options

Medical ( non-surgical) Management

The type of medical management depends on the severity of her pain symptom and whether she is trying to conceive.

If she is not planning for a pregnancy, pain killer medication from the group known as non-steroidal anti-inflammatory (NSAIDs) can control her pain symptom.

Usually the pain killers are given in combination with hormonal treatment such as a combined contraceptive pill (birth control pill which has both the oestrogen and progesterone components).

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If the woman can not tolerate side effects of oestrogen , progesterone -only hormonal medications can also be used. These form of medications can be administered orally, in the form of 3-monthly injections, progesterone implant or as a intrauterine device.

In women who has severe symptoms and who are not concern with infertility , monthly or 3-monthly injection to temporarily “stop” her ovarian activity can be given. These injections are known as gonadotrophin releasing hormone analogue (GnRh analogue). These injections are commonly used with oral hormonal supplements to prevent bone loss. It is effective to alleviate pain symptom but the symptoms tend to recur once treatment is stopped.   

The other type of “ovarian blocker” is known as GnRh antagonist. It can be given  orally or as an injectable.

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For women who desire a pregnancy, unfortunately many of the hormonal or ‘ovarian blockers’ are not appropriate as they will prevent ovulation. Oral NSAIDs can be given for pain symptoms.

These woman should seek early advise from a fertility specialist. Many of them may need some form of assisted reproductive treatments to get them pregnant.

Surgical Management

Laparoscopy (keyhole surgery) is needed in most cases of endometriosis either as a diagnostic or a therapeutic tool.

For women with ovarian endometrioma (ovarian cyst resulting form endometriosis) or with deposits of endometriosis outside the uterus, laparascopy can be used to remove the cyst and destroy the endometriotic spots. These intervention may help to reduce pain symptom and is suitable for women who desire a pregnancy.

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A more definitive surgical procedure is to remove a woman’s womb (uterus) with or without removal of her ovaries. This can be done via a laparoscopy or a conventional open surgery.

This is usually offered for a more severe pain symptom and for a woman who has completed her family.

Laparoscopic nerve ablation (destroying the nerve ends) has also been offered to reduce pelvic pain. However, their efficacy has not been established. 

Complementary Therapy

Acupuncture and diet modifications has been advocated as a possible therapy for endometriosis. Research has suggested possible therapeutic effect of acupuncture for period pain.

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Research also suggest some correlation between diet and period pain but so far there is no effective dietary recommendation for prevention or treatment of endometriosis.

Conclusion 

Many women may suffer from a ‘silent pain’ due to undiagnosed endometriosis. Women who suffers from period pain or have difficulty getting pregnant should consult a specialist doctor and seek appropriate advise early, especially if they have endometriosis as no women should suffer in silence. 

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

Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

Silent Pain: Endometriosis (Part 1)

Silent Pain: Endometriosis (Part 1)

Pain relates to a neurological sensation causing emotional or physical discomfort. The endurance of pain not only limits the individuals capabilities but may alter their quality of life. Therefore, the pursue of relief is of outmost importance and need.

Pelvic pain is commonly associated with women and is one of the common reasons for a visit to the gynaecologist. The diligent gynaecologist conducts a through examination, orders several test as required, identifies the root cause and administers appropriate treatment. This task is carried out so that the pelvic pain is relieved and the women is back to her pain free lifestyle.

What if the medical examination and routine test by the gynaecologist yield normal results? In that case, what is the cause of the pelvic pain? Can the pain be relieved?

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I am sure some women have gone through this similar predicament. They are quite familiar with the medical term “Endometriosis”. A condition related to pelvic pain that have silently been endured by these women.

What is Endometriosis ?

Endometriosis is a condition where the cells of the uterus (womb) lining (endometrium) is found outside of the womb. Endometriosis is often associated with cyclical period pain and sometimes  it leads to long term pelvic pain.

Deposits of endometriosis can be found anyway outside of the womb, namely on the innermost layer of the abdomen (peritoneum), ovaries, Fallopian tubes, bladder and large bowels.

In severe cases, it can also be found on the vaginal wall.

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Endometriotic deposits causes inflammatory reaction and causes ‘injury’ to the affected organ. The ‘injury-healing’ cycle can lead to formation of adhesions or ‘stickiness’ within the pelvis. These adhesions can lead to pain symptoms.

The actual prevalence of endometriosis is unknown but it is estimated that between 2% to 10%  of women in general population and up to 50% of women with infertility suffer from endometriosis.

Why is Endometriosis important?

According to a research done overseas, the medical cost for the treatment of endometriosis is comparable to other chronic diseases such as Diabetes Mellitus. In Malaysia, I believe the statistics is similar. This is partly due to the late diagnosis of endometriosis.

Studies in Europe has shown that there is a delay in diagnosis between 4 to 10 years. 

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Amongst the reasons for the delay are intermittent use of contraceptive pills that causes hormonal suppression of the symptoms, use of non-discriminatory examination, misdiagnosis and attitude towards menstruation and normalisation of pain by the women.

Endometriosis could not be reliably diagnosed based on medical history and examination alone. Special investigations in the form of a laparoscopy surgery is needed to confirm the diagnosis.

Early diagnosis of endometriosis is crucial as it can help the women to take steps to reduce the disease burden and  long term complications of endometriosis.

Affects of Endometriosis

Typically, there are two groups of women who presents with symptoms of endometriosis, those who have difficulty conceiving (fertility related) and those with pain symptoms (non-fertility related).

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a) Fertility Related:

Endometriosis causes inflammation of the pelvic organs. Chronic inflammatory process can lead to ‘scarring’ of the affected organs. This can lead to blockage of Fallopian tubes, one or both of it. A blocked or damaged Fallopian tube makes it difficult for the egg to be picked up after an ovulation for fertilisation by the sperm.

Endometriosis is also a common cause of an ovarian cyst formation. Removal of the ovarian cyst, either by a laparoscopy or a conventional surgery, has a risk of reducing the woman’s egg reserve (total number of eggs that she has). Multiple surgeries increase this risk. A woman’s fertility reduces with declining egg reserve.

Endometriosis can also affect the egg quality. Studies conducted among women undergoing an IVF treatment suggest that woman with an endometriosis tend to have a lower quality egg (oocytes). This directly has an impact on the resulting embryos and pregnancy rate.

 

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“Endometriosis of uterus” , more commonly known as adenomyosis may also be present in women suffering from endometriosis. Severe adenomyosis reduces pregnancy rate as it affects embryo implantation in the womb .

b) Non-fertility Related (Pain symptom)

Many women are diagnosed with endometriosis when they present with severe period pain. If fertility is of no concern, period pain can be suppressed with hormonal or non-hormonal medications. Many of these treatment options are not recommended if the women is trying to conceive.

The pain can be due to endometriosis deposits over the undersurface of the abdomen, formation of ovarian cyst or due to ‘scarring’ formation that causes adhesions of the pelvic organs.

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Endometriosis can also cause pain during sexual intercourse .

Coming up next on Healthtips by Teleme: Treatment Options for Endometriosis

 

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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