Infertility myths

By Dr. Christopher Ng Chee Mun
Obstetrician and Gynaecologist
MBBS (London, UK), FRANZCOG (Aust-NZ), MMed (S'pore), FAMS (S'pore)

1. Can you debunk some common infertility myths?

Myth: Taking oral contraceptive pills (OCPs) causes infertility

Fact: OCPs do not lead to infertility in the long term. The effects of OCPs are short-acting, so fertility returns almost immediately once a woman comes off the pill, provided there are no underlying background causes of infertility.

Myth: Infertility is a woman’s problem.

Fact: One-third of the causes are entirely due to women, one-third are entirely due to men, and one-third are due to a combination of male and female factors.

2. Does stress cause infertility? Or is it plain psychological? What is the difference?

Yes, stress does decrease fertility. Stress hormones like cortisol or epinephrine, which rise and often remain high during times of chronic stress, play a key role. Stress can affect the functioning of the hypothalamus. This is the part of the brain that controls hunger, feelings, and the hormones that women need to make eggs and men need to make testosterone. This makes it harder for a woman to have an egg and makes a man's sperm less healthy and less of it. In a research published in the journal Human Reproduction, doctors compared pregnancy rates in couples that reported being stressed and those who were not. They found that pregnancy was much more likely to occur during months when couples reported feeling good, happy, and relaxed. It was less likely to happen when they said they were stressed or worried. In my own practice, I similarly find this happening too.

3. In your opinion, how does our modern way of living affect fertility for most couples?

With the hectic lifestyle, career goals, and stresses of modern society, more couples are starting their family only in their mid 30s to early 40s, and this has contributed to the increase in infertility. This is because the risk of genetic abnormalities, miscarriage, and infertility increases after 35 years of age. A woman is in her best physical condition in her 20s. If women are concerned about having enough energy and endurance to chase a toddler, or want to avoid many of the potential health complications that can occur in 30 and 40-something women, they may want to have their children in their 20's. In fact, a woman's fertility peaks before she turns 25 and starts to go down in her early 30s. 10 percent of women under 30 have a miscarriage, but a third of women in their early 40s do, and the risk goes up the most after 35.

The effect of age on men's fertility is less clear. There is a small decline in sperm counts and motility in men over 45. For most men, sperm quality usually remains within normal limits until about age 70.

Although it can sometimes be difficult for busy couples in today’s society, one should try to reduce stress, exercise more regularly, and have a healthy diet. Couples should avoid cigarettes and alcohol, which can contribute to lower sperm production or motility (ability to swim). Studies have traced chromosomal damage in sperm to cigarette smoke and heavy alcohol intake. Low levels of vitamin C and zinc can cause sperm to clump together. Vitamin E can counteract excess free-oxygen radicals, which can also affect sperm quality.  So men should also take their multivitamins.

4. Many specialists have said lifestyle changes are crucial for infertile couples. What are some of the key changes they should adopt and how can they ensure they are on the right track?

Besides sorting out any medical issues, couples who wish to conceive should also have a healthy diet, exercise regularly, stop smoking and drinking alcohol, and reduce their levels of stress. This advice is good for a couple's overall well being, especially if fertility is sought.

1. Watch your weight - aside from the other risks it poses to your health, excess body fat can lead to an overproduction of certain hormones that disrupt ovulation. Your cycles may be less regular, you may ovulate less often, and you lower your chances of getting pregnant. Too little body fat means your body may not produce enough hormones to ovulate each month or to sustain a pregnancy if you do conceive.
   
2. Eat healthy foods - staying well nourished increases your odds of conceiving. Make sure to include enough protein, iron, zinc, and vitamin C, because deficiencies in these nutrients have been linked to decrease fertility and a higher risk of early miscarriage.
   
3. Quit smoking - aside from health concerns, cigarette toxins not only damage a woman's eggs, interfering with the fertilization and implantation process, but also cause the ovaries to age.
   
4. Know your fertile period - when you're ready to conceive, find your "fertile window," during which you should have intercourse regularly. You can try an ovulation test kit, which checks for certain hormones in your urine, or note daily changes in your basal body temperature and cervical mucus.
   
5. Reduce Stress - learning to manage stress through relaxation techniques (such as mindfulness meditation or yoga) or support from counselling.
   
6. Avoid alcohol and reduce caffeine intake - alcohol consumption decreases the ability to get pregnant (not to mention the harm it can cause to a developing fetus). Alcohol alters oestrogen levels, which may interfere with egg implantation. Cutting back on caffeine while you try to conceive and during your pregnancy is encouraged. Women who drink the equivalent of two cups of coffee per day are twice as likely to miscarry as those who didn't consume any.
   
7. Frequent intercourse - during your fertile period, you should try to have intercourse on alternate days. Outside of this, intercourse at least twice a week is advisable. Because mandatory sex on certain days can become a chore, you might also try making love every few days all month long.
   
8. Don’t douche – try not to douche after immediately after intercourse as this may wash away some of the sperm that may be still in the vagina. Give yourself at least 20-30 minute before cleaning yourself to give the healthy sperm time to swim into the uterine cavity. Douching can wipe out normal, protective bacteria in the vagina, shifting the balance and putting you at risk for bacterial vaginosis, a common but often overlooked vaginal infection. A fishy odour and greyish discharge are often the only signs. Untreated vaginal infections have been linked to preterm labour and may be associated with higher risk of miscarriage and infertility.
   
9. Looking after your partner’s health - cigarettes, alcohol and a poor diet can contribute to lower sperm production or motility (ability to swim). Studies have traced chromosomal damage in sperm to cigarette smoke and heavy alcohol intake. Vitamins E and C and the mineral selenium help healthy sperm production so taking a daily multivitamin is advisable. After all, conceiving is a joint effort so both parties should play their part.

5. What are the red flags that couples should look out for before seeking a professional diagnosis?

Infertility according to medical definition is when a couple has been having unprotected regular intercourse for 1 year without achieving pregnancy. So, strictly speaking, after a year of unsuccessfully trying, couples should seek investigations into the cause of their infertility. However, as the risk of genetic disorders, miscarriage, and infertility increases with increasing age, women who are over 35 years old and have been unsuccessful may wish to seek medical help after 6 months of contraceptive-free intercourse for these very reasons.

6. What treatments/medication are available for infertility? Which methods are popular or more effective?

Ovulation induction

If the woman does not ovulate, there are medications she can take to stimulate ovulation. Even if a woman is ovulating, she may need to release more eggs in order to get pregnant. The medication used most often to stimulate ovulation is clomiphene citrate. It may be used for several cycles. The dosage may be increased over time if ovulation does not occur. Ovulation or pregnancy may not occur after treatment with clomiphene citrate. Most women who take drugs to cause ovulation start to ovulate regularly. If there are no other problems, more than half of such women get pregnant within 6 treatment cycles.

Multiple pregnancies may occur with the use of these drugs. That is when more than one fetus grows in the uterus. Rarely, a condition called ovarian hyperstimulation syndrome may occur.

Surgery

If the fallopian tubes are blocked, surgery may be performed to open them. Surgery also may be done to:

• Remove growths such as polyps or fibroids
• Remove scarring from a previous surgery, infection, or endometriosis
• Treat endometriosis (if found)

If the problem is because of a blocked sperm duct, surgery can sometimes fix it. The success of surgery depends on the type and extent of the problem.

Assisted reproductive technologies

1. Superovulation intrauterine insemination (SOIUI) is offered for

• mild male factory infertility
• mild endometriosis
• cervical factor infertility
• unexplained infertility
• after several failed clomiphene citrate cycles

Both tubes must be patent in order for SOIUI to be performed. If women do not ovulate with oral clomiphene citrate, then gonadotropin (GnRH) injections (Puregon, Gonal-F) are given to stimulate several follicles (eggs) to grow and mature. Ultrasound scans are done regularly to determine the number and size of eggs within the ovary.

On the day of insemination, a fresh sample of the husband's sperm is brought to the lab, where it is treated in a certain way. This specially prepared healthy sperm is placed directly into the womb with a fine tube.  Medications are given to improve the chances of implantation and pregnancy. A pregnancy test is performed 14–17 days after insemination.

Live birth rates are around 12-15% per cycle, or 26-36% after 3 cycles. The overall success rate varies with the cause of infertility and the age of the female partner. There is a 15% chance of twin pregnancies and a small risk of hyperstimulation.

2. In vitro fertilization (IVF) uses sperm to fertilize eggs from the woman in a lab. This is offered to women with

• irreparably damaged fallopian tubes
• blocked fallopian tubes
• severe endometriosis
• ovulatory dysfunction
• unexplained infertility
• severe sperm disorders

High-dose gonadotropin (GnRH) injections (Puregon, Gonal-F) are given to stimulate several follicles (eggs) to grow, and their maturation progress is monitored with serial ultrasound scans. This medication stimulates more than one egg to mature. These eggs are removed from the ovaries just before a woman ovulates with a needle that is inserted through the vagina and into the ovary by direct ultrasound guidance. This procedure is called "oocyte pick up". Pain relief or a sedative may be given. The eggs are combined with healthy sperm and monitored in the lab to see if they become fertilized. A few days later, one or more fertilized eggs (embryos) are placed in the woman's uterus through her vagina. This is called embryo transfer. Transferring fewer embryos reduces the risk of a multiple pregnancy. Any extra embryos that are not used may be frozen and stored for later use (embryo freezing).

Overall live birth rates varies with the cause of infertility and the age of female partner (<35 years old better).

Approximate IVF success rates (per cycle)	Age (yrs)
30-35%	<35
25%	35-37
15-20%	38-40
8%	>40

There is a 20% chance of twin and a 3% chance of triplet pregnancies, as well as a higher risk of hyperstimulation.

3. Intracytoplasmic sperm injection (ICSI) is similar to IVF except that a single sperm is injected directly into each individual egg to increase the chances of successful fertilization. This may be a good option if there is a problem with the man's sperm (i.e. very low quality or quantity) because only a few healthy sperm are needed. This can be used alone or in combination with IVF. The disadvantage is that there is no natural selection involved in the fertilization process between the sperm and egg.

7. Do the treatments or medications cause side effects or involve risks (e.g., multiple pregnancies)?

With all these assisted reproductive technologies (ART), there is a risk of multiple pregnancies. This risk is higher with gonadotrophins than with clomiphene citrate. Multiple pregnancies are considered high-risk pregnancies compared to singletons. Women undergoing SOIUI have a 10% chance of having twins when taking clomiphene citrate and less than 1% of triplets or multiples. For IVF, there is a 20% chance of twins and a 3% chance of triplet pregnancies.

Ovarian hyperstimulation syndrome (OHSS) can happen when the fertility drugs make the ovaries work too hard. The ovaries become suddenly very swollen and fluid leaks into the abdomen and chest, resulting in abdominal distention and shortness of breath. OHSS occurs only after the eggs are released from the ovary (ovulation). Again, the risk of OHSS is higher with gonadotrophins than with clomiphene citrate.

OHSS affects up to 10% of women who go through in vitro fertilization. In most cases, the condition is mild, but in some women it can be severe and even dangerous. In this case, they will need close monitoring, hospital admission, and the cycle may need to be cancelled.

8. How long must the average couple seek treatment before successfully conceiving?

This is an impossible question to answer as there are so many variables that can affect a successful outcome. The older the woman, along with the more causes for infertility, the longer it would theoretically take. At the end of the day, keep trying until you are successful if pregnancy is really what a couple truly desires.

Dealing with burnout as a working mother

 By Dr Thong Jiunn Yew

Consultant Psychiatrist

Nobel Psychological Wellness Centre

Working mothers wear many different hats, and this can lead to stress and burnout. We’re talking about burnout and some commonly asked questions about this phenomenon.

What is burnout? How does it differ from stress, or having a breakdown?

There is no formal medical definition of burnout. It is normal for people to feel stressed by changes in the environment, heavy workloads, and multiple commitments, but these reactions are usually not as severe and persistent.

People who have burnout tend to be under constant stress, which makes their symptoms worse and last longer. There are a few main symptoms: Firstly, the person may feel exhausted. She feels very drained, tired and experiences difficulty coping with work or children. Secondly, she may feel resentful or numb towards her job and colleagues, become negative, cynical, and lose enthusiasm for work. She may also feel frustrated with her children, and lose control of her temper. Performance at work may drop.

How common is burnout in working mothers?

Working mothers may have a greater risk of developing burnout if there is little help from their spouses. For example, some mothers still have to do lots of housework and take care of the children (and even elderly members of the household) after returning from work. These mothers receive little help from their husbands, who might also be working late at night or simply choose not to share in the housework. This may be due to the traditional idea that household chores are a woman’s responsibility. Similarly, single mothers are also at higher risk of burnout due to a lack of support.

What other factors contribute to the occurrence of burnout in working mothers?

Besides poor support, as highlighted above, there are other factors that increase the risk of burnout.

One such factor is overly long working hours. Many mothers return home late and still need to be on their laptop to handle work issues. The individual mother’s personality traits also play a part. There are some who are perfectionists and demand high standards both at work and at home. Putting in more work to meet these unrealistically high standards causes more stress and disappointment if they are not met.

Also, mothers with pre-existing mental health conditions like depression, obsessive-compulsive disorder, and anxiety disorder are at an increased risk of burnout and relapse of their conditions.

What practical tips can mothers use to help handle burnout?

A good work-life balance is important. Try not to take work home. Try to reduce over-commitment at work, and have more time to yourself. Be kind to yourself and do not be overly harsh.

Communication is also important. Discuss with your husband how to share housework and childcare. In extreme circumstances that are difficult to change, it helps to re-frame the situation in a more positive way.

And, of course, a healthy diet and regular exercise will keep the mind and body fit and healthy. Talking to loved ones, close friends, members of your own religious group, and counselors is also helpful.

How do you know when it is getting serious, and when mothers should seek professional help?

Burnout symptoms can look like or lead to more serious mental illnesses like depression and anxiety disorders. If the symptoms are severe and getting in the way of work or relationships, mothers should see a doctor.

For example, some mothers may experience low drive and energy, and hence not be able to go to work. Some parents may feel very angry at their kids and be more likely to hit them out of anger or frustration. There may be marital conflicts.

Insomnia is another common symptom that adversely affects the person’s functioning and quality of life. Seeking professional help can help you tell the difference between normal stress or mild burnout and more serious problems like depression and anxiety disorders. It is important to distinguish between these conditions because their treatment is different. A short break from work may help burnout but may not be useful for individuals with depression, who may need medication and/or psychological treatment.

Tips for yoga during pregnancy

The benefits of yoga during pregnancy

Yoga can be beneficial during your pregnancy as it helps you to stay fit, improve your energy level and allows you to become more in tune with your body.

It can also be a great way to stay flexible and prepare you for birth! Through a series of gentle stretches, yoga exercises help tone the reproductive organs, pelvis, and rest of your body to ensure an easier childbirth. Posture is also improved by yoga, and this can help ease back problems, which are common in pregnant women.

However, as with any exercise program, it is always best to consult your physician before beginning!

Should you practice yoga during your pregnancy? 

Yes, mommies-to-be, you should practice yoga during your pregnancy!

Here are the many reasons why you should:

1. Increases overall strength, flexibility and well-being 
When you are practicing yoga, you are not only stretching your muscles! Instead, you are also stretching the tissues that cover your muscles, stimulating your organ systems, improving the flow of blood and oxygen, breathing more deliberately, and focusing your attention inward through imagery and meditation.

2. Reduces low back pain & sciatica 
In yoga, you learn to be very aware of how your body is aligned so that you can carry yourself and your belly as a whole. This helps to reduce the degree of pelvic tilt associated with pregnancy and significantly reduces the lower back pain that it can cause!

3. Reduces aches and fatigue in the thoracic and cervical regions of the spine 
During pregnancy, it can be difficult to find a space for yourself when trying to sleep at night. As a result, spinal alignment can become compromised during the night. This can leave congestion and muscle tension in the middle and upper regions of the spine. Practicing yoga regularly can create more fluidity in the spine by stretching the paraspinal muscles. It also involves very gentle rotation of the upper torso! When these sequences are combined with directed yoga breathing, it can have the effect of relieving stress. Therefore, create more breathing room in these regions of the spine!

4. Reduces swelling and inflammation around your joints
Asana, which is a sitting meditation pose, helps and improves the flow of blood and oxygen throughout your body when you do it regularly and consistently. This, in turn, reduces swelling and inflammation around the ankles and wrists!

5. Aids in digestion
As your little one grows in your belly, your intestinal organs get pushed around, which may affect your regularity and cause indigestion. Regular practice of safe and gentle rotations and forward folds can help to promote regularity and aid in overall digestive flow.

6. Helps prepare you physically for giving birth 
Regular practice of squatting asana helps to tone the muscles of your pelvic floor and helps you gain strength to remain comfortable in a squatting position. You will want to be able to use these muscles efficiently and effectively when nature calls upon you to push your baby into the world!

7. Improves your emotional well-being
When you take a prenatal class, you can get support from other people who know what you're going through. It will be a place to make new friends with whom you feel similarly situated as well. The combination of the physical or asana portion of yoga with the emotional and spiritual components can be an aid in reducing pregnancy-related anxiety. It will also help mommies-to-be to fully experience the miracle and empowerment of pregnancy.

Yoga poses

Yoga poses can help you deal with pregnancy symptoms, making your labour and delivery easier and helping you get better faster after giving birth. Do take note that these poses that put pressure on the abdomen and other difficult poses should not be done during the advanced stages of pregnancy. To begin with, please be seated in a comfortable position.

When to avoid yoga during your pregnancy? 

The different yoga positions that you should avoid during pregnancy depend on the stage of pregnancy you are in!

During the fifth month of pregnancy, the uterus is growing rapidly, and you'll also be gaining more weight. Due to the heaviness of the uterus, lying on your back for more than 10 minutes may cause some compression to the blood vessels, which would decrease blood supply to the uterus and oxygen to the baby.

During the fifth month (or sometimes sooner), it may be uncomfortable to lie on your stomach. Therefore, these types of exercises should be avoided. A good rule to follow is to not try any positions that are uncomfortable or do not feel right for your body during that period.

Ways to reduce stress when you are expecting

Mothers, whether for the first time around or having their fourth and final child, all need to be able to relax. It is important for the health of both the mother and her unborn child because stress can lead to significant health risks. Reducing a pregnant mother's stress level is not only her job, but her partner's as well.

Friends and family

Talk to others about your emotions and how you're feeling. You can talk to your partner, family, friends, or your own doctor. Communication with others and knowing that you have people who are on your side willing to help can go a long way in reducing stress while you're pregnant. Friends are especially helpful in the later months, when it gets harder for the pregnant woman to move around. If there are too many errands to run or the housework is overwhelming, be sure to ask for help. Friends and family are almost as anxious as you are about seeing the new addition and want the baby to arrive as safely as possible, so they'll be more than happy to help out in whatever way they can.

Bubble baths

Bubble baths become quite a chore toward the end of the third trimester, so take advantage as much as possible while you can. Select the soothing music of your choice, light a few candles, turn the lights down low, sprinkle your favorite bubble bath, oil, or bath salts into the tub, close your eyes, and enjoy the tranquility of a long soak.

A bubble bath can do wonders for those aches and sores you have been developing and get rid of all the exhaustion you have been experiencing during pregnancy. It also helps in moisturizing the whole body, which may be difficult during the period of pregnancy.

Leisure time

Minimise your exposure to worrisome issues and you’ll minimise your stress. Sometimes, too much information about pregnancy complications and problems can cause unnecessary stress. If your pregnancy is proceeding along normally without any complications, reading about these possible problems can make you stressed for no real reason. Listening to relaxing music can help you feel better and less stressed during your pregnancy. It can also help you learn how to relax your mind and muscles during labour and birth, which can be very helpful.

Massages

One of the best ways to keep yourself physically relaxed is either by visiting a salon or getting a relaxing massage. Use an aromatherapy oil blend to help influence the senses and ease the stress away. For partners: Careful consideration of her feet, legs, hips, and lower back is a must. Take time to pamper yourself during your pregnancy. Massage is beneficial during pregnancy (be sure to visit professional massage centres who can deal with pregnant mothers) because it:

•   aids circulation, helping with blood pressure control.
•   creates tranquil relaxation to relieve depression, anxiety and reduce stress.
•   alleviates muscle cramp and discomfort.
•   reduces stress on weight-bearing joints.
•   can help the mother sleep more peacefully and restfully.
•   stimulates glandular secretions, which helps stabilize hormone levels.

Exercise

Exercise has huge stress-reducing qualities. It will also leave you feeling more energetic and ready to tackle the day's challenges. Be sure to consult your doctor before doing anything too strenuous, but some simple stretching exercises are a good start. Walking is another activity you can do in order to keep fit and reduce stress. Exercise can also help make labour easier and lessen some of the stress that comes with the thought of giving birth. One more thing to keep in mind is that sex is an exertion as well. The good news is that sex doesn't stop at conception.

Laughter

Laughter is a great way to reduce stress during pregnancy. Laughter releases chemicals in the brain that improve our mood and help us feel better. Take some time during your pregnancy to rent some comedies. Spend a quiet evening or afternoon watching movies that make you laugh. Look for the amusing things that naturally happen around you. Laughter will make you feel happier and more relaxed.

Mini-vacation

With the expenses of having a baby, vacations are typically not feasible. However, you don't have to spend money to go on a short excursion. There are fun things to do all around you, like going to a zoo, a museum, or a free concert. Here's a place to let your creativity flourish. A pretend bed and breakfast get-away for you and your partner is a fabulous idea. Make the provisions a day or two in advance, so there's little to do but enjoy the goodies. Launder your sheets and leave special touches like mints on the pillows and the edges turned down, then stay in bed cuddling the entire morning.

Sleep

Get plenty of sleep. The less sleep you get, the more stressed you are likely to be. If you find you are having trouble sleeping, invest in a comfortable body pillow, some new sheets, and even a white noise machine to help block out outside noises and help promote more restful sleep. A pillow positioned between your knees and thighs will help keep your body aligned properly and aid in sleep. You may find it helpful to take a relaxing bath before bed. Try not to drink beverages in excessive amounts right before bed. It will reduce your trips to the bathroom to a minimum.

Water therapy

Water is highly important for more reasons than just keeping your body hydrated. A common reason for headaches is a lack of water in the system. Your doctor should have prescribed vitamin supplements containing folic acid. The nutrients are important to decrease birth defects, but they're for you as well. The baby is tapping into your resources, so maintaining a healthy diet is crucial. Be sure to reduce your intake of caffeine. Believe it or not, there are stress-reducing foods out there, and they're all in the veggie and fruit section. So, be certain to consume the US Food and Drug Administration recommended requirements.

How to handle work during pregnancy

Bringing a new life to this world can be a full-time job. And this is a problem if you already have a full-time job. We will let you know how to handle some issues in the coming months. And it all starts with:

Making the announcement

It’s going to be difficult not to spill your secret right away. You will have the butterflies to share it with your colleagues, but the conventional wisdom says it’s good to keep the news to yourself until the first trimester is over.

Make sure your boss is the first one to know. You want him/her to hear it directly from you and not from any office grapevine. Keep your tone upbeat and positive when you tell your boss, and avoid giving too many personal details. Do be prepared with a general idea of the company’s maternity leave policy, but don’t talk about the specific time length of the leave. Just provide an assurance to your boss that productivity won’t be hampered. Once you have informed your boss about the situation, go ahead and tell your colleagues and friends.

Managing morning sickness

Many mothers in the first trimester experience nausea, vomiting, and other discomforts. If you have morning sickness (up to 85% of pregnant women do, though not necessarily only in the morning), the best advice is to eat, eat, eat. Small healthy snacks throughout the day can keep your blood sugar steady and curb nausea. Just in case, try and grab a seat near the door during meetings, so you can do the disappearing act when time calls. You may also put a few plastic bags or packets inside to prepare for vomiting emergencies.

Fighting fatigue

Your biggest challenge will probably be fighting fatigue. A brisk walk at lunchtime can do wonders, as chewing mint-flavoured gum is instantly refreshing. Be careful not to work for long hours in the office; take time to walk outdoors every single day; and have more supplemental oxygen, thus keeping off sleepiness, which also benefits the unborn baby.

Stretching out

If you are in a sitting job, stand up every 20 minutes and walk around the office. Go see a co-worker instead of sending her an e-mail, go to the drinking fountain to have water, or simply walk around. Since your blood volume has grown a lot, it's important to improve the blood flow in your legs. After a period of time at work, it is important for mothers to do appropriate stretching exercises, get into the habit of leg lifting exercises, etc. These can reduce swelling of the legs and ankles and reduce leg edema.

Safety while commuting

Mothers should also pay special attention to safety while travelling. In the early and mid-pregnancy stages, take precautions such that you do not need to ride for a very long time. Avoid traveling during peak hours as this may result in poorer air quality, making a pregnant woman more nauseated and breathless.

Work conditions

There are professions which may involve more health risks than others, but, as a rule, you must work in a well-ventilated place if you are handling chemical products or have adequate protective equipment to avoid direct contact. Working in places where you may be exposed to biological elements is another situation you must take into account. You must be careful not only if you work in the medical profession but also if you are in contact with a sector of the population that may be more prone to contracting certain illnesses, such as young children in daycare and school, who usually suffer from more illnesses because their immune systems are still developing. Also, if you work with animals, you must take the necessary precautions to avoid contact with viruses or bacteria that could affect you.

Stay hydrated

Stay well hydrated while at work. Drink a lot of water even if you have to go to the bathroom often (those walks will do you good). And don’t forget to follow a well-balanced diet and rest as much as you can at home.

Squeezing in appointments

Try to schedule doctor’s appointments wisely—plan the doctor’s appointment before you report to work. Always try to be the first patient in the morning or in the afternoon session. You may consider doing some light work in case you are stuck in a traffic jam and get frustrated. It’s also important to schedule your appointments according to your work calendar—completely avoid days when you know you have your weekly meetings or monthly presentations. Occasionally, your doctor may need you to stay for additional tests or treatments, and you don’t want to have the added stress of missing an important work function.

Making the grand exit

Before you can say goodbye to work, you need to hammer out all the details of your leave. Notify your boss of the precise day that you expect to leave and the tentative date of your return; this just helps your boss see the light at the end of the tunnel.

Before you make the grand exit to motherhood, do the necessary handover to your colleagues who will be handling your responsibilities while you are away. Do let your boss know about some specific problems which might require special attention while you are away. Just make sure that you don’t stretch yourself by promising too much too soon. And always remember, your priority in the next few weeks will be you and your new baby.

Techniques to lose post pregnancy weight

Having a baby is a wonderful experience for any woman. After enduring nine months of pregnancy symptoms, including five to six months of extra weight, it's quite natural to want to normalize your weight and regain your pre-pregnancy shape as soon as possible. However, it is probably safest for both the mother and child for the mother to wait at least three months before starting out on a weight loss program.

Weight loss after pregnancy is possible, but it requires some realism, patience, and a lot of work. It is reasonable to assume that it may take a new mom about 8 months to a year to get back into your previous shape.

Drink plenty of water

One sure-fire way to begin losing weight is to drink plenty of water. Drink at least 10–12 glasses of water every day. Water will help your body flush itself of excess fat and impurities. Replace your high-sugar beverages such as sodas and juices with some water and a squeeze of fresh lemon. Drinking plenty of water throughout the day prevents you from getting dehydrated. It also fills you up so that you don't eat as much, and some research has found that it may speed up your metabolism.

Adopt a healthy diet

A healthy diet is the best way to lose your pregnancy pounds. Keep healthy snacks such as raisins, popcorn, wheat crackers, and nuts handy. Refuse to buy store-bought baked goods or junk food. Eat whole grains (breads, cereals, pastas) instead of the "white" versions. Talk to your doctor about which foods are important for the continued health of you and your baby. Focus on nutrition, not on weight-loss diets! If you're breastfeeding, your baby's nutritional needs outweigh your need for a slim body.

Start light exercise

As soon as you feel ready, start light exercise. Combined with a healthy diet, exercise is key if you want to lose weight after pregnancy. 3-5 days of cardio (30–40 minutes) and 2–3 days of strength training is ideal. You may also opt for a 10-minute walk with the baby every day and slowly increase your time to 20 minutes per day. Babies can be worn in a sling or you can use a baby jogger or stroller when they get too heavy. During pregnancy, your womb grows to make room for the baby, and so does your skin, which leaves stretch marks. Exercises will slowly bring your stomach back into shape and shrink the skin. Do not overdo any exercise for immediate results. If the delivery was normal, you can start exercising within a few weeks.

Consider joining a gym and trading babysitting hours with a friend so when you each go to do your workout, the other can watch the babies. Some gyms may offer babysitting services as well.

Breastfeeding can help you lose weight as it burns about 500 calories per day. So, the longer you breastfeed, the more calories you burn. However, breastfeeding alone won't bring down your weight.  You need to combine it with a sensible diet and a moderate exercise program.  Now isn't the time to go on a diet; restricting your calories too much can reduce your milk supply, and losing too much weight (more than two pounds a week) can actually release toxins that wind up in your milk. Keep in mind that you need to have at least 1800 calories a day while breastfeeding in order to keep yourself and your baby healthy.  The good news is, you can still exercise if you're breastfeeding. Studies show that moderate exercise won't affect milk production as long as you're giving your body enough calories.

Do pelvic floor strengtheners

Benefits: Pelvic floor strengthening exercises are designed to improve circulation in the pelvic region. It also helps in maintaining your vaginal canal in tip-top shape.

The Process: Lie down on the floor on your back. Now bend your knees, keeping your feet on the floor. Try tightening your vaginal muscles as if you are hindering urinary flow. Hold on for a few seconds. Repeat it two or three times.

Avoid artificial sweeteners 

Avoid artificial sweeteners when you are working to lose pure body fat. That means no candies, no cakes, no soft drinks, and no sugar in your coffee or tea.

Do not even drink diet soda because it contains sugar as well, albeit in a smaller amount. Check food labels carefully during this period to make sure that the foods you eat do not have any sugar content. It is important to completely abstain from refined sugar diets if you want to lose weight after pregnancy as quickly as possible.

Get some sleep

It may seem impossible to get a full eight hours of sleep when you have a baby summoning you like clockwork throughout the night, but being sleep deprived could make it harder for you to shed the baby weight. Studies show that getting at least 7.5 hours of sleep per night can help you lose weight. When you're tired, your body releases cortisol and other stress hormones that can promote weight gain. At least until your baby starts sleeping through the night, try to catch as many naps as you can during the day and go to bed early.

Forget about celebrity moms who lose weight instantly. It's not a good idea to try to look like a celebrity because they often lose their baby fat too quickly by going on strict diets and doing hard workouts. So for these new moms, losing weight after pregnancy is often accomplished much faster than for average women. These are not a good example upon which to base your own postpartum weight loss goals.

Just remember that it took nine months to gain the weight; give yourself at least that long to take it off. So if you are a new mom and you can't wait to get back into shape, take my advice and "Go Easy!" Trying to lose weight too fast can, at times, rebound on you.

Tips to relieve backaches during pregnancy

You may be facing occasional or frequent backaches that disturb your sleep or daily life now that you are in your third trimester with that expanding baby bump. However, the good news is that your baby is growing. It is common for most pregnant women to have lower back pain in the second half of their pregnancy.

Some of the possible reasons are weight gain, posture changes, or muscle separation. Women typically gain 12 to 15 kilos of extra weight during pregnancy, and the spine will have to support that extra weight of a growing baby. Naturally, it puts more pressure on the spine, causing your lower back to hurt. Moreover, hormonal changes can cause loosening of joints and ligaments that are attached from your pelvic bones to your spine, which can cause discomfort or pain when you walk or stand for too long.

Many mothers have gone through these problems during their pregnancy, so fret not. Here are some tips to help you stretch out that lower back pain:

Tip #1: Change your posture

Using proper posture when sitting or standing can make a difference to your backache problems. Although slouching can be a comfortable posture, it puts more strain on your spine. So be sure to sit or stand up straight to lengthen the spine. For instance, if you are standing, try to keep your bottom tucked in and your shoulders back. Even though it can be tiring and requires some time for you to correct your posture, remember that it can help to reduce your backache over time.

Tip #2: Stretching exercises

A good prenatal yoga session can help strengthen and support the core muscles of the lower back. Stretching the muscles will increase flexibility, which will loosen the tightness. It could be a light exercise that can be done at home. You could also ask your partner to help you stretch. This would be a great way for your partner to get to know you and your baby-to-be. Before starting a new or special exercise plan that requires more intense movements and physical strength, you should always talk to your doctor.

Tip #3: Treat yourself to a massage

Massages can help you feel less stressed, help you relax, and help you deal with the pain of backaches. A trained therapist may be able to help with your back pain because they know where a pregnant woman's sore spots are likely to be and what areas and techniques to avoid on a pregnant woman. It is critical to communicate your needs to your therapist, as well as any discomfort caused by the massage and/or positioning.

Gestational diabetes mellitus: what is it?

By Dr. Pamela Tan
Obstetrician and Gynaecologist
MBBS (Singapore), MRCOG (UK), FAMS (Singapore)

Diabetes mellitus, or diabetes, is a chronic condition where the body is unable to produce any or enough insulin, resulting in excess sugar (glucose) levels in the blood. This may sound all too familiar, but it is mainly because of the sobering statistics in Singapore and around the world.

According to the International Diabetes Federation (IDF), there were over 606,000 cases of diabetes in Singapore in 2017. It could be your mom, a friend, or a coworker who has it. However, beyond the numbers is a string of health concerns that come with it and could potentially result in When it affects a woman in a vulnerable state like pregnancy, it warrants immediate attention to ensure the safety of both the mother and the baby.

So, if you’re expecting or planning on getting pregnant soon, it’s important that you’re also aware of the type of diabetes that strikes during pregnancy. It pays to keep your guard up because any woman could potentially develop it.

What is gestational diabetes mellitus?

Gestational diabetes mellitus (GDM) is a type of diabetes that develops during pregnancy, usually during the second or third trimester. Those who develop it usually don’t have diabetes before pregnancy, but it also goes away after giving birth. However, some women go on to develop type 2 diabetes later in life.

While it is true that any complication in pregnancy is a cause for concern, the good news is that gestational diabetes is controllable. Complications are less likely to happen if you eat right, exercise regularly, and take insulin as prescribed.

What causes GDM?

Insulin is the type of hormone that keeps blood sugar levels in check. However, pregnancy hormones can interfere with how the body uses insulin. An example would be the increase of human placental growth hormone at 15 weeks of pregnancy, which increases blood glucose levels.

Normally, the body responds by making more insulin during pregnancy to meet the changing demands of the body. However, for some women, their systems are unable to make enough insulin, causing blood sugar levels to spike, eventually leading to GDM.

Who is at risk of GDM?

Women are considered high-risk candidates for GDM if they fall under any of these:

• Have a pre-pregnancy BMI of more than 30
• Have a GDM history
• Have pre-diabetes history
• Have a history of polycystic ovary syndrome
• Have delivered a baby that is 4 kg and heavier
• Woman is 40 years old or older

Women below the age of 40 can do an online diabetes risk assessment, here.

What are potential complications?

The main reason for controlling GDM is to avoid complications that can range from mild to potentially fatal. It not only affects the mother, but the health and well-being of the baby even beyond the womb.

Maternal

• Pre-eclampsia (high blood pressure during pregnancy)
• Preterm labour
• Polyhydramnios (excessive amniotic fluid)
• Miscarriage
• Severe vaginal tears due to a large baby
• Heavy bleeding after delivery
• Risk of type 2 diabetes in the future

Foetal

• Premature birth
• Stillbirth
• Large for gestational age baby
• Breathing problems
• Jaundice (a condition where the skin, the whites of the eyes and mucous membranes turn yellow)
• Shoulder dystocia (an emergency when the head is delivered but the body is stuck)
• Low glucose levels
• Risk for childhood obesity
• Risk of developing diabetes later in life

How is GDM screening done in Singapore?

First trimester

In Singapore, women who are at high risk are checked during the first trimester to see if they have diabetes that hasn't been diagnosed yet. This is usually done around the 12th week of pregnancy together with routine pregnancy blood tests for infection screen, hemoglobin level, and blood group. If the results are normal, the woman is re-evaluated for GDM at 24-28 weeks of gestation.

24-48 Weeks

It is protocol that all women be screened for GDM within this period, including those who had normal results in the first trimester. It was found that there is increased resistance to gestational insulin at this stage.

To ensure proper monitoring, Universal screening is preferred over risk-based screening because Asians generally have a high incidence rate of GDM. This lets health care workers find more cases of GDM and make things better for both the mother and the baby.

They do the test by using the 3-point 75g Oral Glucose Tolerance Test (OGTT). An OGTT requires you to drink a glucose solution after a night of fasting. After this, a blood sample is taken at the start, an hour later, and then again two hours later. A GDM diagnosis is made if any of the criteria below is met.

GDM diagnostic criteria

Plasma Glucose Levels (values are in mmol/L)	Previous Recommendations	Current Recommendations based on IADPSG
Fasting	More than or equal to 7.0	More than or equal to 5.1
1-Hour Post-OGTT	Not applicable	More than or equal to 10.0
2-Hour Post-OGTT	More than or equal to 7.8	More than or equal to 8.5

Post pregnancy

Postpartum screening is a way to check on women who have had GDM in the past to see if their condition has gone away. Blood glucose levels should go back to where they were before pregnancy six weeks after giving birth. To check if it does, a 2-point (fasting and 2-hr) 75 g OGTT will be done within 6–12 weeks after delivery using non-pregnancy normal values. The same screening process is also done on women who are diagnosed with pre-diabetes or diabetes in their first trimester.

Women who received insulin treatment during pregnancy, or those who have a high risk of developing diabetes (e.g., obese or a family history of diabetes), are also required to have frequent follow-up check-ups. In fact, in Singapore, all women with a history of GDM must be screened for diabetes once every three years.

Why is HbA1c not advised when screening and diagnosing GDM?

HbA1c is a glycemic haemoglobin, which occurs when glucose in the blood sticks to hemoglobin, a protein within red blood cells. The test will reveal a person’s average blood sugar levels for the last 2-3 months.

It should not be used to screen for or diagnose GDM because it is insensitive to high blood sugar levels after meals. HbA1c levels won't give accurate results because they tend to be lower during pregnancy because there are more red blood cells being made and broken down.

How is GDM treated?

Treating GDM comes down to controlling blood sugar levels. This is accomplished through the following:

1. Eating wisely

• Be mindful of your carbohydrate intake
• Choose food options that have low glycaemic index (e.g. wholegrain bread, sweet potato, low fat yogurt, vegetables)
• Go easy on sugar
• Watch your food portions
• Eat meals on a regular basis to control appetite and blood glucose levels

2. Regular physical activity

Physical activity is particularly helpful in controlling blood sugar levels by redirecting resources. It increases the glucose needed by the muscles for energy. An active lifestyle also helps the body use insulin more efficiently. To avoid injuries, be sure to do low-impact exercises that are tailored for pregnancy.

3. Medications

• Metformin – an oral medication to help reduce the amount of glucose the liver produces; it helps insulin to work properly
• Glibenclamide – an oral medication that stimulates the pancreas to make more insulin.
• Insulin – an injectable hormone that allows glucose to enter the cells and be used for energy.

Take note that these medications must only be taken under medical advice. Like any other pharmacologic treatment, they still come with side effects and adverse reactions.

Managing gestational diabetes mellitus improves outcomes for you and your baby. Expectant moms, or even those who are still planning on getting pregnant, should not discount the importance of coming into this journey prepared.

So, if you have more questions, book a consultation here so we can discuss in detail and start with the necessary tests. 

Dispelling pregnancy myths in Singapore

Written by: 

Dr. Heng Tung Lan, Consultant Obstetrician & Gynaecologist

SOG-Heng Clinic for Women

(A member of Singapore O&G Group)

Do not worry, mommies-to-be; it is normal for you to feel overloaded with information and advice from well-meaning friends and relatives! However, you might be wondering what is true and what is not. 

We hope to give you some clarity on the popular pregnancy myths out there. So, let us take a look at some of the common myths in Singapore. 

Myth #1: I have to eat for two! 

Many mommies-to-be will indulge in eating and snacking on whatever they like. This is especially so during the second trimester, when your appetite is at its best.

Fact: It is true that pregnant women need to increase their calorie intake. However, excessive weight gain will be harder to shed off in the future, and this may jeopardise both your and your baby’s health. It is therefore important to focus on the quality of your diet and aim for a gradual increase throughout your pregnancy.

• 1st Trimester: No extra calories needed
• 2nd Trimester: Extra 300 – 400 calories per day is recommended
• 3rd Trimester: Additional of 450 – 500 calories per day 

Avoid taking food that contains a lot of empty calories, even if it tastes good. Instead, incorporate nutrient-dense foods into your diet. 

Myth #2: It's fine to gain weight during pregnancy. That's the only time I can feel fat without feeling bad! 

Fact: There is no recommended fixed weight gain for all pregnant women. The recommended amount of weight gain is different for singleton, twin, and triplet pregnancy. 

If we are looking at a healthy singleton pregnancy, your body mass index (BMI) pre-pregnancy is a key indicator. I personally would recommend my patients to keep their weight gain within 12 kg.

A weight gain of 5 to 9.1 kg is recommended for women with a BMI greater than 30. 

However, you might want to work out a diet plan with your obstetrician if you have other health concerns or ask them what the healthy range of weight that you should be working on. 

^*Information adapted from Institute of Medicine Guidelines (IOM2009)

Myth #3: My mum says I shouldn’t be travelling during my pregnancy? 

Fact: For mommies-to-be with normal and healthy pregnancies, it is generally safe to travel and fly until 28–32 weeks into your pregnancy. But different airlines may have their own rules or need a note from your doctor, so check before you go!

Flying is not recommended if you are facing pregnancy complications like:

•  Preeclampsia
•  Premature rupture of membranes
•  Preterm labour
•  Placenta Previa 

In addition, it is important to always check with your obstetrician before flying, even if you are feeling good. 

Here are some tips for flying while you are pregnant: 

1. If you are planning for a babymoon, plan to travel during your second trimester. This is the period when you are more likely to be over your morning sickness and feeling most energetic. 
2. Try to avoid long haul flights. I would recommend flights not more than eight hours as you will easily feel uncomfortable. Also, there are higher risks of deep vein thrombosis (DVT). So, do remember to stretch your body and move around whenever you can. 
3. Stay hydrated throughout the flight, keep up your water intake gradually.
4.  Always wear the seatbelt low around your pelvis, below your baby bump.

Myth #4: Pregnant women should avoid all types of exercises! 

This is definitely a myth.

Fact: If you did not exercise on a regular basis before your pregnancy, you should discuss with your obstetrician whether your health condition allows you to engage in light-to-moderate activities.

It is safe and healthy to stay active during your pregnancy. This is especially so if you have always been active pre-pregnancy, and if your pregnancy has no complications. 

You can continue to exercise as you did before becoming pregnant, or you can do light-to-moderate exercises like walking and swimming.

However, here are some activities to avoid: 

•  Contact sports like football and basketball
•  Activities with risk of falling like skiing and rock climbing
•  High-risk activities such as scuba diving and skydiving

Myth #5: No more coffee and tea for the next nine months!

While excessive caffeine intake has shown an increase in the risk of low birth weight, this does not mean you need to cut caffeine out totally.

Fact: Moderate consumption is safe. I recommend not more than 200mg/day of caffeine, so a cup of your favourite kopi or teh a day is fine.

However, do note that caffeine can also be found in chocolate, energy drinks, and soft drinks like Coke too. 

Replace your caffeine intake with other alternatives like water, honey lemon, decaffeinated tea or coffee, and reduce your sugar intake as much as possible.