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.

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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).

Image Source: Reader’s Digest

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.

Image Source: IVF Surrogacy 

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.

Image Source: Politeka

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. 

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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?

Image Source: News Medical

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. 

Image Source: Asia Times

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.

 

Image Source: Adam

“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.

Image Source: Televiziunea Medicala

Endometriosis can also cause pain during sexual intercourse .

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

 

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Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

Irregular Period

Irregular Period

This is a simple basic guide for women with irregular period.

What are absent or irregular periods? 

Absent or irregular periods are periods that do not happen at all or that happen less than 6 to 8 times a year. If a woman does not get her period for a while, it might be because she is pregnant. Or in some cases, it might be that she has a medical condition that affects her reproductive system.

What causes absent or irregular periods? 

Pregnancy

PCOS (which stands for “polycystic ovary syndrome”). In women with this condition, the ovaries make too much male hormone. This can disrupt a woman’s periods and cause excess facial hair, acne, and problems with weight. PCOS is the most common cause of absent or irregular periods.

Image Source: Freepik

Exercising too much

Too much prolactin – Prolactin is a hormone made in the “pituitary gland”, which is a small organ at the base of the brain.

Early menopause – Menopause is the time in a woman’s life when she naturally stops having periods. Menopause usually occurs between the ages of 45 and 55. But in some women, menopause comes early – before the age of 40. Early menopause happens when the ovaries run out of eggs earlier than normal.

Certain types of hormonal birth control – Some forms of birth control can cause absent or irregular periods. This is more common with those that contain only the hormone progestin. Examples include the progestin-only pill (sometimes called the “minipill”), the implant, and hormone-containing intrauterine devices (IUDs).

Should I see a doctor or nurse? 

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See your doctor or nurse if:

You are older than 15 and still have not had your period

You used to get periods, but you have not had a period for more than 3 months

Your periods happen more than 45 days apart

What other symptoms should I watch for? 

 Make sure to tell your doctor if you:

Think you might be pregnant

Have family members with irregular periods

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Have bad acne or hair on your chest or face

Have gained weight and are having trouble losing it

Have hot flashes, which feel like a wave of heat that starts in your chest and face and then moves through your body

Have night sweats, which are hot flashes that happen when you are asleep

Have new headaches or trouble seeing

Notice milky fluid coming out of your breasts

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Are under lots of stress

Have recently lost weight

Are exercising more than you used to

Have changed how much you eat or what kinds of foods you eat

Are taking any medicines, herbs, or vitamins

Are there tests I should have? 

Your doctor or nurse will decide which tests you should have based on your age, other symptoms, and individual situation.

Here are the most common tests doctors use to find the cause of absent or irregular periods:

Pregnancy test – Pregnancy is a common cause of missed periods. Your doctor will want to find out if you are pregnant before doing any other tests.

Image Source: Freepik

Blood tests – These measure hormones that affect the reproductive system.

Pelvic ultrasound – This test uses sound waves to make a picture of your uterus, cervix, and vagina. The picture can show if there is something wrong with these organs.

MRI – This test uses a large magnet to make detailed pictures of the brain. It can show if there is a problem in the part of the brain that controls the body’s hormones.

How are absent and irregular periods treated? 

That depends on what is causing your missed periods, and on whether you want to get pregnant. Possible treatments include:

Birth control pills to make periods regular

Image Source: Freepik

Losing weight if you are overweight

Medicines to help you get pregnant if you are having trouble getting pregnant on your own

Changing the way you eat and exercise, such as:

– Eating more calories

– Gaining weight if you weigh too little

– Easing up on exercise, if you exercise a lot

Image Source: Freepik

Reducing stress

Hormones to treat hot flashes (if you are going through early menopause)

Medicines to lower prolactin levels (if your pituitary gland is making too much prolactin)

Can absent and irregular periods be prevented?

You can reduce your chances of missing periods by eating well and staying at a healthy weight. Being too thin or too heavy can cause irregular periods.

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Dr. Agilan Arjunan

Dr. Agilan Arjunan

Obstetrician & Gynaecologist (infertility)

 
Common Contraception Myths

Common Contraception Myths

We have all heard about different ways to prevent pregnancy from friends, family and the social media. Every culture across the world has their own traditional methods of pregnancy prevention. We take a look at some of the common myths.

1. The contraceptive pills makes you fat

Multiple studies have shown that there is no difference in weight gain compared to women on the pill and those who are not taking it.

2. The contraceptive pill causes cancer

Women on the pill have a 50% reduction in the risk of uterine and ovarian cancer. There is a very small increase in the risk of breast cancer but this risk goes down to normal levels when the pill is stopped.

Image Source: Big Stock

3. You don’t need to be on any contraception if you are breastfeeding

Breastfeeding is only a reliable mode of contraception in the first 6 months after delivery if it is exclusive breastfeeding and no return of periods. Breastfeeding does reduce a woman’s fertility but unless these requirements are met, there is a significant risk of getting pregnant. If you do not fit in this criteria, then another method of contraception is advised.

4. Taking the contraceptive pill or any hormonal contraception will make it harder to get pregnant in the future

All hormonal contraceptives have temporary effects on fertility. Fertility will return with cessation of the contraception, the timing depending on the type of hormonal contraception used. There are no long term effects on fertility.

Image Source: Pregnant SG

5. Accidentally get pregnant while on hormonal contraception (including the pill) will cause birth defects to the baby

There is good evidence that shows hormonal contraceptives (including the pill) does not cause birth defects.

For more information on contraception, please click on the link below:

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Types of Contraception

Types of Contraception

Emergency Contraception

Emergency contraception is for all those ‘oops!’ times when something unforeseen has happened, for example like when a condom has broken, when you have unprotected sex or a missed pill. It should NEVER be used as a regular method of contraception as pregnancy risks increase if used repeatedly.

There are 2 types of Emergency contraception:

A) Intrauterine Contraceptive Device has a success rate of 99% and can be used up to 5 days after intercourse. It can also be left in place and used as long term contraception.

B) Hormonal Emergency Contraception Pills can be used up to 3 or 5 days after intercourse, depending on the type of pill used.

Types of contraception

There are up to many types of contraception available, which means there is definitely one right for you! So discuss with your doctor to help you get the most suitable one.

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The Pill

  • The Pill consist of synthetic hormones with an effective rate of around 91%.  It also helps to regulate periods, especially those with heavy or painful periods
  • Side effects: headache, nausea (feel like vomiting) and breast tenderness.
  • Not suitable for women with history or family history of blood clots in the veins

The Injection (Progesterone only Injectable Contraceptive Methods)

  • Effective rate is around 94%
  • Side effects: Return to fertility may be delayed between 6 months to 1 year

The Intrauterine Device

  • Small T shaped device placed into the uterus by a doctor at the clinic.
  • Effective rate is around 97-98% and safe to use for 3 or 5 years, depending on type and dose
  • Side effects: Periods may be heavier or more painful in the first few months

The Implant

  • Implant is one of the most effective contraceptive methods available.  It consists of synthetic hormone in a small plastic capsule that is placed under the skin of the upper arm. The procedure is done by a doctor at the clinic.
  • Effective rate is almost 100% for up to 3 years
  • Side effects: Periods may be irregular, less than usual or no periods.

Condom

  • Rubber (latex) cover that is placed over the penis during sex and must be removed immediately after ejaculation
  • Ideal for protection against any sexually transmitted diseases
  • Effective rate is around 75%

DUREX Together Easy-On

Durex Extra Safe

Durex Close Fit

For more information on contraception, please click on the link below:

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