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What am I Doing Wrong?

Common issues in getting pregnant

A LOOK AT THE NUMBERS

The Stats on Conception

  • 15% of couples in Singapore do not get pregnant within 1 year
  • 1 in 7 couples worldwide have fertility problems
  • Female factors, male factors and couple factors each contribute to 1/3 of fertility issues

Sub-fertility is a common gynaecological problem, especially with present stress levels and couples starting a family at older ages. In Singapore, it is estimated that 15% of couples trying to conceive do not get pregnant in the first year of trying, and about 1 in 7 couples worldwide are sub-fertile. For a sub-fertile couple, the problem is attributed to female factors a third of the time, male factors another third, and couple factors the last third. It is thus important for the couple to consult a specialist, rather than to have just one partner consulting.

Sperm AttackFor pregnancy to occur, we consider:

  1. the egg
  2. the sperm, and
  3. the environment

Egg

The lady must ovulate for natural conception to occur. Unfortunately, in general, ovulation occurs only once a month, and the egg survives for only about 48 hours. This means that intercourse must occur during the time of ovulation and survival of the egg for conception to occur.

Many couples do not know when ovulation occurs. This is especially so when the lady does not have regular periods. Many may also not know how to assess the ovulation period.

What are the signs of ovulation?

A lady may notice some changes in her body when she ovulates:

  • Vaginal secretion becomes clear, thin and stretchy
  • Body temperature rises by 0.5°C
  • Slight lower abdominal pain lasting for just one day
  • Light bloodstain on the day of ovulation

However, these are not very accurate methods as vaginal discharge can be affected by vaginal infection, and temperature rise, abdominal pain and staining can be due to many other reasons.

How can I track my ovulation?

The time from the first day of menses to ovulation differs in different persons. Once ovulation has occurred, menses will take place 14 days later – this is rather fixed. Hence, if one’s menses is regular, and if one knows when the next expected menses will occur, then the day of ovulation will be 14 days before the next expected menses. Many actually calculate this by adding 14 days from the first day of menses, but this will only be accurate if the person has a 28-day cycle, as adding 14 days from the first day of menses or subtracting 14 days from the next menses will be about the same date.

To know when ovulation has occurred, there are certain aids we can use. The simplest is the Ovulation Test Kit, where testing urine with a kit will let you know if you have a hormonal rise, linked to ovulation occurrence. This is done preferably from one to two days before the expected ovulation date daily. Of course, this will not be as effective or many more such ovulation-tracking kits will have to be used if one has irregular or long cycles.

Doctors can also do an ultrasound scan of the ovaries to track for ovulation. This is more tedious and will entail more visits to the doctor.

What if I have ovulation problems?

If a patient does not ovulate regularly, the chance of conception will logically be lowered. Doctors will assess the reason(s) for this. Some may have PCOS (polycystic ovarian syndrome) where the eggs are immature and require ovulation stimulation to increase the chances of pregnancy. Some have hormonal imbalance and others perhaps endocrine problems such as abnormal thyroid hormones or high prolactin levels (which cause breast milk secretion even though one is not pregnant). Such problems need to be treated, otherwise ovulation induction with medication may not work as the root cause has not been resolved.

The quality of the eggs decreases with age. It is estimated that egg quality starts deteriorating from as early as 25 years of age. Having said this, do not be alarmed as this deterioration is very gradual. Doctors do advise ladies to have children before 35 years of age if possible.

Sperm

While the woman ovulates once a month, the man can provide sperm anytime. It is believed that a man can ejaculate as often as five days in a row, daily, without affecting the quality of sperm for conception.

A sperm test called Semen Analysis can be done to assess the quality of the sperm. It is necessary to abstain for a minimum of three days before doing a sperm test for more accurate results. If the results of the sperm test are abnormal, an ultrasound of the testes can be done to look for abnormalities and the fairly common finding of varicocele – enlarged blood vessels running next to the testes causing increased heat. This increased heat can lead to lower sperm quality.

For severe cases, surgery can be done to tie off some of these enlarged blood vessels to reduce blood flow and hence heat. Supplements and at times, male hormones, especially for those assessed to have low male hormones, can be given to the male partner in an attempt to improve the sperm quality.

Tips for Him

Some advice for male partners:

  • Stop smoking
  • Reduce heat around the testes, such as not going for steam baths and saunas
  • Do not engage in long, strenuous exercises, such as long distance cycling and marathon running
  • Do not wear tight underwear
  • Bathing or showering with cold rather than hot water may be useful too

Environment

While it is ideal to have light music, dim lights and so on for ambience, and not to have kids banging on your bedroom door or have people playing mahjong next to your room, while trying to conceive, when we talk about “environment”, we are looking at the genital areas. These will include whether one has frequent vaginal discharge which can result in sperm not being able to swim through to the fallopian tubes to meet the egg (this is where fertilisation occurs ), or whether the tubes are blocked (which means that natural conception is unlikely to occur ).

C is for Conception!

‘C’ the following handy checklist for four ‘C’s’ to follow for a conception-friendly environment.

  1. Clean Up

For the woman, vaginal infection /discharge should be cleared at every possible opportunity. This is by way of vaginal douching by the doctor, often with vaginal inserts and oral medication.

  1. Get the All Clear

Your doctor can check that your fallopian tubes are not obstructed. This can be done by X-ray (no surgery) or using a laparoscope (key-hole surgery) after pushing methylene blue dye through the cervix.

  1. Make Smart Choices

It is important to stop smoking, not overdrink alcohol and reduce stress. Stress over-rides even the best medication. Couples doing very strenuous exercise, especially the woman, should cut down the intensity and length of exercising.

  1. Consult a Specialist

As a general guide, if a couple have been trying regularly for a child for a year without success, they should consult a specialist. In fact, all couples are encouraged to go for pre-pregnancy well couple checks. I do suggest to my patients to see a specialist for a review if they do not successfully conceive after six months of trying.

What happens during a consultation?

  • Couples will have their medical history taken to assess for pre-existing correctable medical conditions.
  • Both will be examined. Ultrasound of the pelvis will be performed for the woman.
  • If everything is normal, they will be advised the fertile period for intercourse.
  • Supplements will be given to both to help them prepare for pregnancy, improve their health and boost sperm quality.
  • A vaginal gel will be given especially for females with recurrent vaginal discharge so as to improve the environment for the sperm to swim up to the tubes.
  • Ovulation Test Kits will be issued to time for ovulation.
  • The couple will be given an appointment for a review in three months, by which time, it is hoped that they will have succeeded in getting pregnant. At the three-month review, if the woman is not pregnant, then more tests will be done for assessment, such as blood tests and even sperm tests.

What medication can help in conception?

Medication given to the man can include Vitamin E, Co-enzyme A and even male hormones in certain cases. For the woman, medication includes folic acid (this should be taken when preparing for pregnancy as folic acid taken at least two months before pregnancy has been linked to reduced neural tube defects in the baby), and at times Co-enzyme A, Clomiphene (commonly known as Clomid) and Metformin to aid in ovulation, and injections for patients undergoing a fertility programme.

True Story!

Some years ago, I had a patient who had tried all sorts of methods to conceive, including in-vitro fertilisation. After seven years, she gave up trying. She consulted me for a routine well woman check. I noticed that she had thick vaginal discharge and she said that it had been so for years. I washed off her discharge and treated her for lower genital tract infection.

Three months later, she consulted me again – this time because she had missed her menses. I found she was pregnant. Going back to the basics seems to have worked for her – it is possible that she conceived as a result of her recurrent vaginal infection being treated, as well as stress being taken off her as she had given up the idea of conceiving.

The golden advice then, is to start early, reduce stress, prepare for pregnancy, time it well and get treatable conditions treated.

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Dr Christopher Chong is an Obstetrician, Gynaecologist and Urogynaecologist at Gleneagles Hospital, Singapore.
Posted by ezyhealth on Feb 3 2015. Filed under Health. You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.

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