CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

CARING FOR WOMEN

EVERY STEP OF THEIR LIVES

WELCOME TO DR PAMELA TAN MEDICAL CLINIC

FEMALE OBSTETRICS AND GYNAECOLOGY SPECIALIST IN SINGAPORE

OBSTETRICS

View our list of obstetric services available during your pregnancy, birth and beyond. Find out more.

GYNAECOLOGY

Learn about our comprehensive gynecologic care including infertility, bleeding issues and abnormal pap smears, & more.

LIKE YOU, WE CARE

Dr Pamela Tan is an obstetrics and gynaecology specialist practising at Thomson Medical Center in Singapore. Prior to leaving for private practice, Dr Tan was a female Consultant in the Department of Obstetrics and Gynecology, KK Women’s & Children’s Hospital.

She obtained her undergraduate medical degree at the National University of Singapore and her post-graduate MRCOG in London at the Royal College of O&G. She is a specialist accredited with the Specialist Accreditation Board (Ministry of Health) and is a Fellow of the Academy of Medicine, Singapore (FAMS). She is an accredited member of the Society for Colposcopy and Cervical Pathology of Singapore (SCCPS) with a subspecialty interest in colposcopy (for pre-cancer of the cervix and vagina) and vulval disease.

In further pursuing this interest, she was a fellow for pre-invasive disease at the colposcopy and vulval unit at the Whittington Hospital in the United Kingdom. 

While in the United Kingdom, she was also a fellow at the Assisted Conception Unit in Guys Hospital to learn the latest in reproductive techniques and approaches to infertility. She is accredited to perform advanced Level 3 minimally invasive keyhole surgery such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroids and cysts removal).

Her philosophy to doctoring is one that is focused on building relationships with her patients. She strives to deliver patient care that is warm, caring, professional and well advised. She is a believer of pro natural birthing and providing an optimal birthing experience as desired by her patients.

Dr Pamela Tan is an obstetrics and gynaecology specialist practising at Thomson Medical Center in Singapore. Prior to leaving for private practice, Dr Tan was a female Consultant in the Department of Obstetrics and Gynecology, KK Women’s & Children’s Hospital.

She obtained her undergraduate medical degree at the National University of Singapore and her post-graduate MRCOG in London at the Royal College of O&G. She is a specialist accredited with the Specialist Accreditation Board (Ministry of Health) and is a Fellow of the Academy of Medicine, Singapore (FAMS). She is an accredited member of the Society for Colposcopy and Cervical Pathology of Singapore (SCCPS) with a subspecialty interest in colposcopy (for pre-cancer of the cervix and vagina) and vulval disease.

In further pursuing this interest, she was a fellow for pre-invasive disease at the colposcopy and vulval unit at the Whittington Hospital in the United Kingdom. 

While in the United Kingdom, she was also a fellow at the Assisted Conception Unit in Guys Hospital to learn the latest in reproductive techniques and approaches to infertility. She is accredited to perform advanced Level 3 minimally invasive keyhole surgery such as laparoscopic hysterectomy, myomectomy and cystectomy (womb, fibroids and cysts removal).

Her philosophy to doctoring is one that is focused on building relationships with her patients. She strives to deliver patient care that is warm, caring, professional and well advised. She is a believer of pro natural birthing and providing an optimal birthing experience as desired by her patients.

Latest Blogs

Delayed Cord Clamping & Cord Blood Banking in Singapore

Having a new addition to the family is truly something worth celebrating. It’s a journey in which families invest months of preparation and planning. There are important decisions to be made about the birth plan, and the practice of delayed cord clamping and cord blood banking is one in which guidelines have continued to evolve over time.

There is something we need to know about the moment a baby’s umbilical cord is clamped and cut, that is, at birth, a third of their blood is still outside of their body. The blood that has been coursing through them throughout pregnancy is still flowing through the placenta and umbilical cord.

What is so interesting is that a newborn’s first breath initiates placental transfusion. The cord would start to pulse and it would pump and push blood into the baby. This movement can transfer approximately 80 ml of blood by the first minute after birth, and can go up to 100 ml in three minutes. Overall, a baby would get at least 30% more blood or 214 grams of cord blood. With that are iron, antibodies, and other important cellular factors that are beneficial for the baby.

Placental-Circulation-Dr-Pamela-Tan

However, in the 20th century, the established medical protocol was to immediately cut and clamp the cord and whisk the baby away for initial care. Once the placenta is delivered, it is common practice that we just throw it out along with the umbilical cord. Therefore, the baby is missing out on all the potential benefits, and we end up wasting precious material that could potentially save a life; but we’ll talk more on that later.

Delayed Cord Clamping

This is the practice of clamping the cord and cutting it immediately following birth, generally within the first 15 to 20 seconds. However, recent evidence suggests that delaying the clamping and cutting of a newborn’s umbilical cord may be beneficial to them, hence the concept of delayed cord clamping (DCC)

Cutting-Cord

The benefits of delayed cord clamping are clearly understood in premature births. The American College of Obstetricians and Gynaecologists recommend delaying the clamping of the cord in babies born before 34 weeks in part to reduce the risks of complications of premature birth

Delayed cord clamping also benefits full-term babies by increasing blood levels in the newborn and improving their iron stores in the first months of life. The side effects of iron deficiency at birth include cognitive impairment and central nervous system problems. Therefore, ACOG now recommends a delay of clamping the cord for at least 30-60 seconds in most newborns, including full-term, unless medically contraindicated. 

Benefits-of-Delayed-Cord-Clamping-Dr-Pamela-Tan

Source: World Health Organization 

In the actual clinical setting, DCC involves waiting until the cord has stopped pulsating and becomes white before it is severed to enable full benefits to the baby. The midwife or the OB-GYN should be able to feel this when it happens by just touching the cord.

Newbord-Child-Dr-Pamela-Tan

When is Delayed Cord Clamping Not Allowed? 

While delayed cord clamping may have several benefits and is even encouraged today, there are a few circumstances when this practice may not be suitable. It includes the following instances:

  • The mother is experiencing heavy bleeding
  • There are issues with the placenta such as placenta praevia, placental abruption, vasa praevia
  • Umbilical cord bleeding so blood flow to the baby is interrupted
  • If the baby needs resuscitation. In such a case, the cord may have to be clamped early in the absence of facilities in the hospital to do this besides the mother. (DCC should be possible while the baby is assessed and breathing support is initiated)
Clinical-Situations-Considerations-for-Cord-Clamping-Table-Dr-Pamela-Tan

Source: The American College of Obstetricians and Gynaecologists 

Delayed Cord Clamping and C-Section

DCC may still be applied for caesarean deliveries, whether it is planned or an emergency. This has already been practised in several hospitals that recognise its benefits. Specifying this in your birth plan will give you an opportunity to discuss it with your OB-GYN. Data from a 2018 pilot study suggests that cord clamping for two minutes in elective, term caesarean deliveries does not increase the risk of excessive blood loss in the mother. However, as there may be a slight delay in stitching and hence arresting bleeding from the uterine incision, some obstetricians may not be keen to wait. An alternative is to milk the cord such that the blood that is in the cord is massaged towards the direction of the baby and this aids in hastening flow of blood to the baby before clamping. 

Data from a 2018 pilot study suggests that cord clamping for two minutes in elective, term caesarean deliveries does not increase the risk of excessive blood loss in the mother. Click To Tweet

Delayed Cord Clamping and Jaundice 

Jaundice-in-Babies-Dr-Pamela-Tan

There are small studies which show that DCC can slightly increase the likelihood of babies having a higher level of jaundice. This is yellowing of the skin and eyes due to the presence of too much bilirubin (a byproduct of the breakdown of red blood cells) in the baby’s blood. However, there is also strong evidence which shows that the benefits of DCC outweigh it. 

Jaundice is common in newborns and it usually doesn’t need treatment. However, some babies may need phototherapy to help them get rid of jaundice regardless of when the cord was clamped. It is the responsibility of the paediatrician and other neonatal care providers to ensure that mechanisms are in place to monitor and treat neonatal jaundice.

Delayed-Cord-Clamping-Highlights-Dr-Pamela-Tan

Cord Blood Banking 

We know that the value of cord blood goes far beyond the timing of clamping of the cord. Storing it for future use is also a beneficial practice in certain circumstances and has since been adapted in Singapore since 2001. 

Cord blood is a rich source of regenerative factors which can be collected, preserved, and stored for potential future medical uses. After collection, cord blood is frozen and can be safely stored for many years. This method of freezing is called cryopreservation, and it is crucial in maintaining the integrity of the cells. Cord Blood Banking came about because cord blood must be stored carefully.

Many are willing to shell money for storage because cord blood can be used to treat over 80 medical conditions. However, most of these conditions are very rare. The main predominant use currently for cord blood is for treatment of blood cancers. Treatment for autism, cerebral palsy and degenerative diseases in later adult life are still conducted in experimental settings. There have been more than 35,000 cellular transplants worldwide using stem cells collected from cord blood and stored in both public and private family cord blood banks. 

The reason why these cells hold therapeutic benefits is that they are too immature to know that they want to be “when they grow up,” which means that they are adaptable. Hence, they can be used for several functions. 

If you have plans to preserve cord blood, you have the option to go for either private or public cord blood banking. Private banking offers storage that is exclusively for their family’s potential future use, or you may choose to donate to a public bank so you can also save a patient in need. 

Delay Cord Clamping or Bank Cord Blood? 

So, is it really possible to get the best of both worlds? 

One of the commonly asked questions relating to delayed cord clamping is if you can have it done even when you are doing a cord blood collection.

Delayed cord clamping is usually not advised if a couple would opt for blood banking as there may not be enough cord blood available and hence, minimal regenerative factors to store. 

When considering delayed cord clamping or cord blood collection, families should discuss their birth plan in advance with their OB-GYN. If families are interested in public donation, it’s important to know that public banks have different requirements compared to family banks. 

When considering delayed cord clamping or cord blood collection, families should discuss their birth plan in advance with their OB-GYN. Click To Tweet

Public cord blood banks will only accept cord blood donations with higher collection volumes. The reason for this is that high regenerative cell counts are needed in current transplant procedures and hence storing low amounts would not be beneficial for subsequent use. Private banks are motivated by commercial reasons and would more likely bank lower amounts for clients. 

Cord Blood Banking: Covering the Cost

While cord blood banking offers a gamut of benefits, some shy away from it due to the cost. Storing it in a private facility can be costly in the long run, but it is free if you donate it to a public bank.

In families where there is a known genetic problem that puts them at risk of developing an illness that could be treated with cord blood, it makes sense to keep it for family use. In such cases, you can use the Baby Bonus Scheme for cord blood banking. 

If you’re not familiar with it, the Baby Bonus Scheme has two components – a Cash Gift and the Child Development Account (CDA). The CDA is a special savings account which you can use for your child’s educational and healthcare expenses. You can apply online at any OCBC, DBS/POSB or UOB bank for your child who is eligible for CDA.

Under the Scheme, the savings you contributed to your child’s CDA will be matched dollar-for-dollar by the Government. Recently, the CDA First Step Grant is given a boost in the form of $3,000 for eligible Singaporean children—that’s on top of the existing Baby Bonus cash gift.

Another less expensive option is to store it in the Singapore Cord Blood Bank, which is the lone public institution in Singapore established for this purpose. At present, they already offer private cord blood banking, granted that you give birth in a government hospital. But it will also cost you around $5,000 for processing and 21-year storage.

If you choose to go with private cord blood banking (i.e. Cordlife, StemCord, Cryoviva)  you can check if they are an approved institution under the Baby Bonus Scheme. As such, you will be able to use your Baby Bonus to pay for all your cord blood banking fees (enrollment fee & annual storage fee).

Cord-Blood-Banking-in-Singapore-Infographic-Dr-Pamela-Tan

Why Should Parents Consider Donating Cord Blood?

There has been growing evidence which supports the fact the cord blood offers precious benefits that makes it definitely worth keeping. This is why many physicians advise towards cord blood donation. 

It’s always your family’s discretion if you want to go for private blood banking instead of donation. But it’s not hard to miss the wealth of benefits a contribution can do. However, if a family has a known genetic problem that puts them at risk of developing certain illnesses that can be treated with cord blood, then storing it for private use is sensible. However, if there is none, donating just might help save a life.

Blood banking, although good, may not be affordable for some families. So the ones who need it the most won’t have their own supply. Take note that cord blood is not a cure-all. The identified diseases that it can treat are not too common, so the chances that a child may develop them are low, but such conditions affect millions worldwide. This explains why public blood banks are used 30 times more than private ones. 

Imagine the amount of precious material that slipped through our hands by simply discarding cord blood. So think about it. Better yet, consider saving a life today!
If you’re interested in delayed cord clamping or cord blood banking, talk this through with your attending physician.  You may also book a consultation with Dr Pamela Tan today.

Disclaimer:
All attempts to publish accurate information were made but no responsibility can be claimed if facts/costs change.

Infertility Diagnosis: 6 Tests to Check Why You’re Unable to Conceive

Getting pregnant may not always be a walk in the park for a lot of women, including many in Singapore where the total fertility rate continues to decline. Many women are facing roadblocks in trying to conceive and, unfortunately, they are unaware of the importance of fertility health checks. 

Singapore Fertility Rate

Source: Department of Statistics Singapore

An infertility diagnosis, albeit discouraging, is a reality to be reckoned with, especially if you plan on having a baby. Knowing what’s hampering you from getting pregnant will guide you and your doctor toward the right measures for correcting the problem. Since the biological clock waits for no one, it helps greatly when you act as sooner than later.

Before any treatment process can be initiated, the doctor must first arrive at a diagnosis, which we will be discussing in this post. 

What determines female fertility?

Perhaps one important aspect of female fertility is the egg factor. By the time you start menstruating, you will have half a million egg follicles left. 

An egg follicle is a sac that holds one egg. At the beginning of each menstrual cycle, the first few developing follicles are considered candidates for ovulation within that cycle. However, midway through the follicular phase, one follicle becomes dominant—a lot like a star athlete who stands out from the team. All resources go into “grooming” this single follicle while the others are left to die off. Imagine this happening every month, so by the time you hit 30, you lose 90% of your eggs. And by the fourth decade of life, you would’ve lost up to 97%. In time, these eggs will run out, eventually leading to menopause

Egg Follicle

Read: Managing Menopause: A Quick Guide On What To Expect When You’re Expecting

Going back to our “superstar follicle,” once it is ready, it releases the egg, which then travels out of the ovary and into the fallopian tube. After it is released, the egg has about 12-24 hours to be fertilised by sperm. If it doesn’t get fertilised in that short window, the egg begins to degrade. But if it gets fertilised, it travels to the uterus over the next 5-6 days to become a potential implant for pregnancy. 

Menstrual Cycle

What is infertility?

The World Health Organization (WHO) defines infertility as a “disease of the reproductive system” marked by a failure to achieve clinical pregnancy even after a year of trying. It is further classified into two: 

  • Primary infertility – wherein women have not conceived after at least a year of having sex even without the use of birth control methods
  • Secondary infertility – wherein women who have previously given birth are unable to get pregnant again or carry a baby to term 

Infertility diagnosis in women

There’s a variety of diagnostic tests done specifically on women to determine the cause for low fertility or outright infertility. One of the first things that are checked is the ovarian reserve. It sums up a woman’s chances of conceiving based on her current egg supply. Women with low ovarian reserves make fewer eggs. Hence, they have a lower chance of getting pregnant even with fertility treatment. A young woman with a lower than expected ovarian reserve (premature ovarian insufficiency) will menopause earlier than her peers. 

Aside from a diminishing number of eggs, the egg quality also tends to decline. However it is hard to check specifically for egg quality. A healthy egg has the ability to create a chromosomally normal embryo and hence fetus, which reduces miscarriage risk but is heavily dependant on the woman’s age. During an IVF procedure, the egg (and sperm) quality will determine the quality and number of surviving embryos but there isn’t a good predictor outside of the scope of IVF apart from general predictions based on age. At the age of 37 years old, the rate of chromosomal abnormality in the eggs is approximately 40%. The rate rises to 50% at 40 years old and almost 90% by 44 yrs. Hence the rate of decline in egg quality (and hence increase in miscarriage) is exponential. 

Decline in fertility rate

Ovarian reserve and quality can be tested in a variety of ways, mainly through imaging and blood tests. These tests can tell your OB or infertility specialists about your egg quality, egg reserves, and structural problems that may make conception challenging. Take a look at the different investigations below. 

Imaging 

1. Antral Follicle Count (AFC)

Antral (small) follicles measure 2-8 mm in diameter. They can be seen, measured, and counted by ultrasound as part of a fertility workup. To get an accurate assessment of the number of resting follicles, a transvaginal ultrasound (preferably between day 2 to 5 of the cycle) is performed. 

Interpreting the images obtained is fairly straightforward but it’s not possible to determine the total number of follicles since some are too small to be detected by ultrasound. Having just a few antral follicles developing in the ovaries indicates that the corresponding number of eggs are also low. 

Besides evaluating ovarian reserves, an AFC also gives an idea of where fertility stands in relation to age. It also identifies primary ovarian insufficiency (POI), and can help diagnose polycystic ovarian syndrome (PCOS). An ultrasound also screens for uterine polyps and fibroids or abnormal ovarian cysts that impact fertility.

Read: 10 Common Causes of Infertility in Women

2. Hysterosalpingogram (HSG)

Hysterosalpingogram (HSG)

HSG is an X-ray test that can check the size and shape of the uterine cavity, but it is done mainly to check whether the fallopian tubes are partially or fully blocked. 

A blockage is often caused by a scar tissue that may form inside the pelvis or around the fallopian tubes due to endometriosis, pelvic infection or previous abdominal or gynaecological surgery causing scarring. Any obstruction in the tubes inhibits the sperm from reaching the egg, which is one of the common reasons why women find it hard to get pregnant.

In HSG, a thin tube is threaded through the vagina and cervix. A contrast medium, or a dyed solution, is introduced into the uterus and fallopian tubes. When viewed on an X-ray screen, the dye shows up in contrast to the body structures as it outlines the inner size and shape of the uterus and fallopian tubes. Women with open tubes will have what’s called a free spill. The dye will spill from the ends of the fallopian tubes–showing that they are open or patent. Any blockage or stoppage of the dye, which can also be seen also through x-ray, indicates occlusion of one or both tubes. The HSG may also detect uterine polyps or scarred tissue within the cavity that can affect implantation.

3. Saline Hysterosonogram

Saline Hysterosonogram

Also called a sonohysterography, a saline hysterosonogram procedure may be ordered to evaluate the shape of the uterine cavity. The process is like a gynecologic exam involving the insertion of a transducer into the vagina after you’ve emptied your bladder. Through a small tube, which is also inserted into the vagina, a small amount of sterile saline is injected into the cavity of the uterus to study, so the doctor can study the lining using an ultrasound transducer. This procedure can determine if there are any polyps, fibroids, or other uterine abnormalities; and provides a clear picture of the soft tissues, which are clearly visible in x-ray images.

The alternative to evaluate the cavity is there is a suspicion of a uterine abnormality on regular vaginal ultrasound is to perform a short day surgical procedure called a hysteroscopy, dilation and curettage with polypectomy to remove a polyp or fibroid that is obstructing the cavity. It allows for an immediate therapeutic removal of the source of the problem while fully evaluating the cavity. 

Blood Tests

4. Follicle Stimulating Hormone (FSH) Screening 

FSH is produced by the brain to help regulate the menstrual cycle and egg production. FSH levels fluctuate throughout the cycle and as such, these are tested early in the cycle, usually around the second or third day. It can help the doctor gauge a woman’s ovarian function and evaluate the egg quantity. If results show elevated FSH levels, it means that a woman has lower ovarian reserve as the brain is trying to compensate for the poorer number of follicles by producing more FSH to stimulate their growth.

FSH screening may be used with other hormone tests for luteinizing hormone (LH), and/or progesterone levels are useful in:

  • determining the cause of infertility ( eg checking for successful ovulation)
  • diagnosing pituitary or hypothalamic disorders of the brain that can affect FSH production.

Often thyroid, prolactin levels and certain vitamins and minerals will also be tested to exclude hormonal imbalances and certain nutritional deficiencies that can affect fertility.

5. Anti-Mullerian Hormone (AMH) Testing

AMH is a protein made by the granulosa cells, which surround the follicle. Each follicle has thousands of granulosa cells completely engulfing and nourishing the egg. Having more eggs means more follicles, which consequently results in higher AMH levels. As you age, you will experience a natural decline in AMH levels, until it totally runs out when you hit menopause.

AMH  is considered a strong indicator of the ovarian reserve because the levels stay fairly consistent throughout the menstrual cycle, and can be tested on any day. AMH levels can also be a dependable guide in choosing the ideal fertility therapy. 

However, it is important to know that AMH does not predict pregnancy success but, rather, the ovaries responsiveness to an egg-freezing cycle or in-vitro fertilization (IVF) cycle. In general, women with higher AMH levels require less medication for stimulation and often generate a larger quantity of eggs ( and hence embryos).

Overall, the key intent in checking ovarian reserve is for fertility doctors to counsel women on the chances of success with fertility treatment. But know that screening doesn’t stop there. To pin down the root cause of infertility, your partner needs to undergo testing for you to get the full picture. 

Read: 6 Ways to Improve Your Chances of Getting Pregnant Fast

Infertility diagnosis in men 

Since one third of subfertilitiy is due to male factor and another one third due to combined male and female factors, it is important to check the male partner.

Semen analysis is an important test to check for sperm concentration, shape, movement, quality, infections, colour, or the presence of blood. This can also determine any infection in the reproductive system, such as Chlamydia, which can affect fertility. If semen analysis results are abnormal, a repeat test and additional blood tests may be ordered to identify the potential problem. 

If the results are poor, further blood tests can help point to the causes of male infertility because it can check the levels of testosterone and other hormones. Imaging can also check for any anatomical issues such as a blockage. For this, a scrotal ultrasound can be done to reveal issues such as varicocele, ejaculatory duct obstruction or retrograde ejaculation. 

So, if you have been trying to get pregnant for a year and remain unsuccessful, it’s time to take the next step and consider fertility testing. Know what’s holding you or your partner from conceiving. Get professional help and submit to necessary tests to find a suitable treatment for infertility.

If you have any questions, you may call +65 6254 2878 or drop us a line, here.

10 Common Causes of Infertility in Women

Struggling with infertility is not uncommon. Singapore has one of the lowest total fertility rates in the world at 1.2 per female in 2011. Women are starting families later due to education, work, family commitments or inability to find a suitable spouse earlier in life. The average age of first time mothers is now 30 years old. Subfertility can be very stressful and may come as a surprise since many women have no complaints until they try to conceive. Even when it ends with a healthy baby, the journey can exact a toll. 

Singapore has one of the lowest total fertility rates in the world at 1.2 per female in 2011. Click To Tweet

Most of us grow up believing that we can start a family when we are ready, but this is not often the case. A recent poll of 1000 respondents in Singapore found that more than half knew someone struggling for a first or second child.

Among the usual obstacles couples face are long work hours and job stress, which leave them too tired or not in the mood to have sex. However, apart from infrequent intimacy, there are also physiological factors that may negatively affect female fertility.

Infertility-rate

Medically, a woman is considered subfertile if she is unable to conceive after 12 months of trying naturally. If the woman is over the age of 35, she would be regarded as subfertile if she has not conceived after 6 months of trying. In about a third of subfertility, the cause is primarily female, in another third, the cause is male factor ( sperm abnormalities) while the remainder is a combination of both. 

To understand this struggle, here are 10 of the common reasons for infertility in women. 

1. Endometriosis

This is a condition in which tissues similar to your uterine lining grow elsewhere in the body. It can develop outside the uterus, tubes, ovaries, and even in the bladder or intestines. It may significantly lower the chance of getting pregnant in those who have the condition. Patients classically complain of painful periods, painful intercourse or painful bowel movements and urination. 

Endometriosis can trigger fertility issues in several ways such as scarred fallopian tubes, adhesions, distorted pelvic anatomy, inflamed pelvic structures, and impaired implantation. It can even alter your egg quality and ovulation. 

Through laparoscopy, the doctor can assess the amount, location, and depth of endometriosis then treat it. From these laparoscopic findings, your condition can be graded according to severity. This scoring system correlates to your chances of getting pregnant. Women who fall under severe (stage 4) have the most difficulty conceiving and will require extensive fertility treatment. If there are endometriotic cysts or deposits, these can be removed during laparoscopy and an assessment for fallopian tube patency (hydrotubation) can be performed concurrently.

2. Failure to Ovulate

Ovulation is when your ovaries release an egg—a process that is essential for pregnancy to be achieved naturally. However, there are cases where a woman does not ovulate (anovulation), or ovulation occurs irregularly (oligo-ovulation). If this seems familiar to you, know that ovulatory disorders are one of the common reasons women find it hard to conceive. 

A woman may fail to ovulate due to hormonal problems which are linked to malfunctions in the hypothalamus or pituitary gland or diminishing ovarian reserve as a result of ageing. In other cases, it is also linked to ovarian or gynaecological conditions such as polycystic ovarian syndrome (PCOS) or primary ovarian insufficiency (POI). Furthermore, scarred ovaries from previous surgeries, premature menopause, lifestyle, and environmental factors are also potential causes. 

An indicator of ovulatory dysfunction is when your menstrual cycles are shorter than 21 days, or longer than 36 days. It’s still possible for those whose cycle falls within the normal range of 21 to 36 days, but the length may vary every month. 

Common-Causes-of-Anovulation-and-ovulatory-Dysfunction

3. Primary Ovarian Insufficiency (POI)

It is expected that women in their 40s have a lower fertility rate. It is usually around this age where your body starts transitioning to menopause, often characterised by irregular menstrual periods. However, for women with POI, the process starts even before they reach 40, sometimes as early as their teenage years.

This is slightly different from premature menopause when periods stop before you hit 40. In such a case, you can no longer get pregnant. But, with POI, some women can still have occasional periods, giving them a 5 percent to 10 percent chance of getting pregnant even without medical intervention. 

In most cases, the cause of POI is unknown. But it has been linked to chromosomal abnormalities like Turner’s syndrome, autoimmune conditions and previous chemoradiation therapy.

4. Polycystic Ovarian Syndrome (PCOS)

PCOS is one of the most common causes of infertility among women of reproductive age. But having it doesn’t mean you can never conceive because PCOS is treatable. This condition is associated with hormonal imbalance due to the overproduction of androgens. Excess levels of these interfere with the development of ovarian follicles, which results in the formation of fluid-filled sacs or cysts. Hormonal fluctuations also interfere with the growth and release of eggs from the ovaries. Patients have abundant egg follicles but they do not mature and ovulate hence pregnancy chance is reduced.

Normally, a woman releases an egg (ovulate) 14 days before her menstrual period. But, if you have irregular cycles, it may be difficult to predict ovulation and time the intercourse. 

5. Malfunction of the usual hormonal (hypothalamo-pituitary-gonadal) axis

In the brain, the hypothalamus sends hormonal signals (Gnrh) to the pituitary gland to release the hormones FSH and LH that control the stimulation and maturation for eggs to develop in the follicles of the ovary. If there is a failure of the brain to control this process, the egg will also fail to mature and will be unable to get released. Stress is one common reason for delayed periods because of non-ovulation during the cycle. Increase in cortisol (stress hormone) suppresses the reproductive hormonal axis in favour of survival ( flight or fight response). It is evolutionary that the body will reduce reproductive potential when experiencing stresses like illness, malnutrition, chronic fatigue, excessive physical toll like heavy exercise, or emotional turmoil like anxiety or depression as it will be perceived as an incompatible time to carry a fetus. 

6. Reproductive Tract Infection

Reproductive tract infections are among the causes of subfertility in women, especially those that manifest no symptoms. 

Untreated infections like gonorrhoea and chlamydia can cause scarring that can block the fallopian tubes. Bacterial vaginosis is an infection that causes a bacterial imbalance in a woman’s vagina, and may even affect IVF results. Furthermore, if you get pregnant with untreated syphilis, you have a 50 percent chance of a miscarriage or stillbirth. 

Meanwhile, chronic vaginal infections can also reduce the amount or quality of mucus and natural lubrication making intercourse uncomfortable and patients unkeen for intimacy.. 

7. Structural Abnormalities of the Reproductive System

In some instances, structural issues to your reproductive system can also be a contributing factor to infertility. For example, a blocked fallopian tube due to endometriosis can impede fertilisation. In the same way, scarring or adhesions on the uterus caused by injuries, infection, or surgery can obstruct implantation, which can also lead to infertility. 

Uterine fibroids, which are growths that can potentially distort the uterine cavity, also play a significant role in infertility depending on their size and location. Polyps, which are also non cancerous growths in the uterine lining, may prevent the successful implantation of a fertilised egg. 

Sometimes, the uterus and fallopian tubes may not form as they should, and an unusually shaped uterus (congenital malformation) can also be a problem. While this usually goes unnoticed, it can affect implantation or a woman’s ability to carry a pregnancy to term. Some types of congenital abnormalities like septums can be resected with surgery.

8. Uterine Fibroids

Types-of-uterine-fibroids

Uterine fibroids are noncancerous growths that form inside the uterus, which can reduce fertility in a variety of ways. First, fibroids can potentially change the shape and size of the uterus. Consequently, it may affect the cervix and the number of sperm that enters the uterus. This structural change can also interfere with the movement of the sperm or embryo. Second, fibroids may block Fallopian tubes or impair implantation. Third, these growths can also interfere with blood flow to the uterus, which can hamper the implantation of the embryo. 

Fibroids located in the uterine cavity (submucosal) or push into the cavity (intramural type III) are more likely to cause fertility issues and miscarriages. This is particularly true for growths that are larger than five centimetres. 

Scientists do not know what triggers fibroid formation but it is believed that genetics, hormones, and environmental factors all play a role. 

Read: A Beginner’s Guide on Fibroid Treatments in Singapore

9. Impaired implantation

Apart from anatomical causes preventing implantation, there may also be impaired functioning of the endometrium. A thin endometrium at the time of implantation and poor receptivity may affect the ability to conceive. There are some studies linking immunological factors or antibodies (thrombophilias) to poor receptivity but interventions like IV Ig, steroids, or aspirin are still controversial. 

10. Autoimmune Disorders

Autoimmune disorders occur when your body’s immune system malfunctions, setting off an inflammatory response aimed at healthy tissues. Women with an existing autoimmune disease, including rheumatoid arthritis, diabetes, systemic lupus erythematosus (SLE), or Crohn’s disease, may be at higher risk of infertility. The reason is not fully understood and may differ between diseases, but it is believed that inflammation in the uterus and placenta, or medications used to treat the disease, may have a hand in this. 

Investigating Possible Causes of Female Subfertility

A subfertility evaluation may be prescribed to a woman who, by definition, has subfertility or has a high risk. This process involves a comprehensive medical history, a targeted physical examination (e.g vital signs, thyroid, breast, pelvic examination), ovarian tests  (e.g. ovarian reserve, ovulatory function, structural abnormalities), and imaging of reproductive organs. 

A subfertility evaluation may be prescribed to a woman who, by definition, has subfertility or has a high risk. Click To Tweet

In women, tests may be conducted to check blood and urine. One can tell from a urine LH kit analysis when and if you have ovulated. Meanwhile, blood tests that may be ordered will measure: 

  • ovarian reserve (egg supply) 
  • progesterone levels (to check if you have ovulated) 
  • thyroid function (thyroid issues may cause infertility)
  • your levels of prolactin (high levels disrupt ovulation)

To check structural issues, these are the usual imaging tests and surgical procedures involved in female infertility: 

  • Ultrasound – It can view changes to the follicles and help predict when ovulation will occur as well as rule out polyps, fibroids and congenital malformations.
  • Hysterosalpingography – It is an x-ray procedure that investigates the shape of the uterine cavity, as well as the shape and patency of the fallopian tubes.
  • Laparoscopy – It involves the use of a device called a laparoscope, which comes with a camera and a thin light source. It is inserted through the umbilicus and into the abdominal cavity to view internal structures such as the fallopian tubes, ovaries, and the outside of the uterus. 
  • Hysteroscopy – It involves a device with a camera and a thin light source, inserted through the vagina into the cervix and into the uterus. It can explore the internal structures and show any abnormal intrauterine structures. 

How is Female Infertility Treated? 

Medication is among the common interventions for female infertility. Often, medication is prescribed to correct ovulation problems. Some are formulated to trigger ovulation while others stimulate the ovaries to release multiple eggs. There are also drugs that can help those who struggle with unexplained infertility and serve as a therapeutic option for those who didn’t find success in other treatments. 

Laparoscopy is a minimally invasive procedure that can remove fibroids or endometriotic lesions and scar tissue, unblock a fallopian tube, or reverse tubal ligation—all of which can help increase the chances of conceiving. 

Hysteroscopy. In this procedure, your doctor places a hysteroscope into your uterus through your cervix. It is used to remove polyps and fibroid tumours, divide scar tissue, remove congenital septums and open up blocked tubes.

Intrauterine insemination (IUI) is a procedure where the semen is prepared and inserted into your uterus around the time you’re ovulating. It is occasionally done along with pharmacologic interventions that help stimulate the release of an egg (SO-IUI).  

In vitro fertilisation (IVF) is a form of treatment that uses assisted reproduction technology (ART) to help couples struggling with conceiving. It is a combination of medications and surgical procedures where the ovaries are stimulated to produce a large number of mature eggs that are extracted under sedation. Sperm and an egg are put together in a petri dish and fertilised in the lab. The grown embryo is then implanted into your uterus 3-5 days later. If both partners agree, extra embryos can be frozen and saved for future use. 

An IVF is considered for the following reasons:

  • A woman’s fallopian tubes are blocked or missing
  • A woman has severe endometriosis
  • There is unexplained infertility for a long time 
  • Intrauterine insemination has not been successful 
  • A man has a low sperm count, poor sperm quality, and low sperm quantity

Another ART option is ICSI (intracytoplasmic sperm injection) which is similar but specifically caters to sperm-related infertility problems. In this procedure, the lab technician injects a chosen sperm directly into the egg instead of allowing natural fertilisation of the sperm and egg placed in a dish and this improves the rate of fertilisation of the egg and development into an embryo. 

Egg donation is also another option when your ovaries fail or you are above 40 yr with poor ovarian reserve but you have a normal uterus. The process involves retrieving eggs from a consenting donor with normally functioning ovaries. After in vitro fertilisation, your doctor transfers the fertilised eggs into your uterus.

Surrogacy to overcome uterine factors for subfertility is illegal in Singapore. Many patients opt to seek commercial surrogacy services overseas eg USA. 

With all that, now you realise that while there are several reasons behind female infertility, there is also a gamut of treatments to address it. What’s important is that you take the first step as soon as possible because when it comes to fertility, age is a critical factor and time is of the essence.

So, seek the right help. With what you know now, ask the right questions during a consultation. If you have any concerns, Dr Pamela Tan provides customised care for all your obstetric and gynecologic needs. Send us a message if you wish to schedule an appointment today!