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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.

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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. 


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.


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. 


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


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!

13 Things You Don’t Want to Happen During Your Pregnancy

Pregnancy can be an exciting journey. However, beyond the themed baby showers, gender reveals, and carefully curated nursery designs it’s also important to look at the ugly side of getting pregnant. It’s important to be aware that as you cross milestones for the next nine months, there are also factors that can complicate this journey. Get to know 13 of them, below.

1. Preeclampsia

Hypertension, or high blood pressure, is fairly common in Singapore where it affects less than 1 in 4 between the ages 30-69. This is well within the age of conception in a lot of women in the country. If uncontrolled, this can result in a number of complications for you and your baby

Preeclampsia is one of the complications of hypertension, and it is described as a sudden increase in blood pressure after the 20th week of pregnancy. Initially, it will not show any symptoms, but early signs include high blood pressure and the presence of protein in your urine (proteinuria). If the condition progresses, the woman may experience fluid retention evidenced by swelling in the face, hands, ankle, and feet. The baby will also be smaller than expected (growth retarded) with low amniotic fluid levels.

Experts are not sure why preeclampsia occurs, but it was surmised that this may be linked to problems with the development of the placenta. The blood vessels that supply it are narrower than normal, which means blood flow is limited and it may also respond differently to hormones. 

If left untreated, preeclampsia can develop into eclampsia which bears serious consequences like seizures, severe bleeding, stroke, coma, placental separation from the uterus, or even death. There can also be abnormal kidney, liver and platelet function that affects the ability to clot. Although uncommon, complications from preeclampsia can be prevented if blood pressure levels are controlled and a mother commits to her scheduled prenatal appointments.

Preeclampsia can be cured if the baby is delivered, but in rare occasions where it starts early in pregnancy, delivery will not be a suitable solution. How the treatment proceeds will depend on the severity of your case. 

So if you’ve experienced this in the past, you must take your doctor visits seriously because it can reoccur in a succeeding pregnancy. In such cases, medications like antihypertensives, anticonvulsants, and steroids for fetal lung maturation will be recommended.

With good management, you can recover well from preeclampsia. Most women improve within a day or two after delivery, and blood pressure levels revert to its pre-pregnancy rate around 1-6 weeks postpartum. 

Check your symptoms!

  • Swelling of the face or hands 
  • A headache that will not go away 
  • Seeing spots or changes in eyesight 
  • Pain in the upper abdomen
  • Nausea and vomiting (in the second half of pregnancy) 
  • Sudden weight gain 
  • Difficulty breathing

Read: Preeclampsia: The Hidden Dangers of Pregnancy

2. Gestational Diabetes

Another condition you don’t want complicating your pregnancy is Gestational Diabetes Mellitus (GDM). It’s a category of diabetes that develops in the middle or towards the end of pregnancy and then resolves after giving birth. This is common in Singapore affecting about one in five women.

Those with persisting diabetes even after pregnancy probably had underlying diabetes, to begin with. Furthermore, even in women whose condition resolve after giving birth are at an increased risk of developing diabetes later in life. 

Since it’s so common and some women who develop GDM don’t show any symptoms, it became necessary that an Oral Glucose Tolerance Test (OGTT) is done between the 24th to 28th week of pregnancy. The blood tests are conducted at fasting, 1 hour and 2 hours after a pregnant woman has consumed a specific sugar load or a drink with high sugar content.

Proper diagnosis and treatment can help women with gestational diabetes have healthy pregnancies and babies. But when it is poorly managed, it can result in complications that can affect you and your baby.

GDM can be controlled with diet and exercise. If you are diagnosed with GDM, you will be taught how to monitor your blood sugar levels at home using a glucometer. However, if it’s unresponsive to lifestyle changes and an ultrasound scan revealed that the baby is larger than expected, you may be prescribed oral tablets or hormonal injections. 

Check your symptoms!

  • Being unusually thirsty all the time.
  • Frequent urination in large amounts.
  • Feeling tired or nauseous (which can be confused with early pregnancy symptoms).
  • Sugar detected in urine tests (conducted during a prenatal visit with the gynaecologist).
  • Blurred vision

Read: The Real Impact of Gestational Diabetes on Mom & Baby

3. Preterm Labor

A typical pregnancy is 40 weeks and its conclusion is marked by labour where the uterus regularly tightens and the cervix thin and open. But, when your body starts getting ready for birth too early in your pregnancy (usually around 37 weeks) it is considered preterm labour. However, preterm delivery doesn’t always follow. Regardless, this requires immediate medical attention to ensure that you and your baby are safe. 

While no one knows for certain what the main cause is behind preterm labour, there are known factors that raise a woman’s risk. These include:

  • Stress
  • Smoking
  • Infections
  • Being under 20 years or over 35 years old
  • Long-term illness such as heart or kidney disease
  • The use of illegal drugs such as cocaine
  • Abnormally shaped uterus
  • Cervix unable to stay closed
  • Having a preterm birth in the past
  • A placenta that separates from the uterus early
  • The placenta is in an abnormal position
  • A placenta that does not work as well as it should
  • Early breaking of the sac around the baby (premature rupture of membranes)
  • Birth defects in the baby
  • Problems with fetal growth
  • Having more than one baby in the womb

To check if you’re indeed going into premature labour, cervical exam or a transvaginal ultrasound scan will be done by your OB to check. Tests may also be ordered to check the amniotic fluid or fetal fibronectin or  phIGFBP-1 (proteins found between the amniotic membrane and uterine lining). 

The management of preterm labour will be based on your OB’s assessment of your case. If your baby will benefit from a delay in delivery, medications can be given to reduce the risk of complications, help the organs mature, prevent infection, and stall the delivery. A cervical cerclage, which is a procedure where the cervix is stitched closed, may also be done especially if it is weak and unable to stay closed. Bed rest may also be advised. However, if these treatments are unsuccessful at preventing preterm labour or the safety of your baby is compromised, delivery may ensue.

Check your symptoms!

  • Painful abdominal cramps, with or without diarrhoea
  • A change in the type of vaginal discharge (watery, bloody, or with mucus)
  • An increase in the amount of discharge
  • Regular or frequent contractions or uterine tightening
  • Your water breaks with a gush or a trickle of fluid (indicates ruptured membranes)

4. Premature Rupture of Membranes (PROM)

Sometimes, the membranes that surround the growing fetus breaks before a woman goes into labour, this is called premature rupture of membranes (PROM). But, if the sac ruptures earlier than 37 weeks of pregnancy, it is referred to as preterm premature rupture of membranes (PPROM), and it comes with a higher risk of complications for you and the baby. 

Rupture of membranes occurs naturally in the process of labour as the amniotic sac weakens with the force of the contractions. However, the cause is not known with PROM, but triggering factors include:

  • Infection of the vagina, cervix, or uterus
  • Cigarette smoking during pregnancy
  • Too much stretching of the amniotic sac due to having too much fluid or more than one baby putting pressure on the membranes
  • Having been pregnant before and had PROM or PPROM
  • Surgeries or biopsies of the cervix

PROM can be detrimental because it exposes placental tissues to infection, which puts you and your baby in danger. It is also linked to other complications such as compression of the umbilical cord, early detachment of the placenta from the uterus (placental abruption), a cesarean birth, and postpartum infection. PPROM, on the other hand, poses a significant risk because the baby can be born within a few days after membrane rupture. This is why you must alert your OB right away once you notice any symptom.

The treatment for PPROM will involve hospitalisation, monitoring and treatment of infection, medications to help the baby’s organs develop, and drugs to prevent premature labour. If the baby is more than 34 weeks, labour can be induced. Meanwhile, expectant management is done if the baby is below 34 weeks. 

Check your symptoms! 

  • Leaking of fluid from your vagina
  • A feeling of wetness in your vagina or underwear

5. Pregnancy Loss or Miscarriage

Also called a spontaneous abortion or miscarriage, this is a non-viable pregnancy up to 20 weeks gestation. It occurs in up to 1 in every 4-5 pregnancies, where most happen during the first trimester and is referred to as early pregnancy loss. This type of miscarriage happens so early on that some women may not even be aware that they are pregnant. However, it may also occur between 12-24 weeks which is called a late miscarriage. 

About half of early pregnancy losses are due to genetic or chromosomal defects. Smoking, alcohol, and caffeine have also been identified as possible causes. Maternal age is also a factor as the likelihood of a miscarriage increases in older women.

Pregnancy loss beyond the first trimester of pregnancy may be caused by factors like underlying health conditions in the mother or infections that can lead to the bag of water breaking prematurely before any pain or bleeding.  Miscarriages can also occur when the neck of the womb opens too soon.

Losing a baby at any time in pregnancy can be physically and emotionally hard for a mother, and even for other members of the family. Counselling and support can help the family cope through this difficult time. For those who are still planning to start a family, it’s important that you seek professional care especially if you think you are among those high-risk women. 

Check your symptoms!

  • Vaginal bleeding 
  • Cramping
  • Mild to severe back pain
  • Sudden decrease in the signs of pregnancy
  • White or pink mucus discharge from the vagina
  • Weight loss

Read: A Mother’s Guide to Miscarriage and Moving On

6. Stillbirth

Globally, stillbirth is among the most common adverse pregnancy outcomes. It is defined as fetal death or pregnancy loss that occurs after 20 weeks of pregnancy, either before or during delivery. In Singapore, it affects two in every one thousand births. While these numbers are among the lowest in the world, it’s not reason enough to keep your guard down from potential risk factors.

Identified factors that increase the likelihood of stillbirths include, birth defects, problems with the placenta, a mother’s medical condition (obesity, preexisting diabetes, chronic hypertension), or her lifestyle choices (e.g. smoking, alcohol). Adding to that, advanced maternal age, twin pregnancies, and pregnancy that used assisted reproductive technology also heightens the risk. 

Not all causes of stillbirth are currently known, but if you know aggravating factors, the signs to look out for, and when to seek help, you can reduce the chances of this happening.

Check the symptoms!

  • Spotting or heavy bleeding
  • Fever
  • Chills
  • Pain
  • Stopping of fetal movement and kicks
  • Absence of fetal heartbeat when you check through a stethoscope or doppler

7. Ectopic Pregnancy

In our efforts to get pregnant, we assume that the embryo that develops will soon burrow into the uterus. However, there are cases where the egg that is fertilised by the sperm in the Fallopian tube grows outside the uterus, especially if the tube is scarred, damaged, or distorted. In 1% of pregnancies, these fertilised eggs end their journey in the fallopian tube, This is called a tubal ectopic pregnancy, which is a non-viable, high-risk condition because fallopian tubes are not designed to hold a growing baby. 

There is no measure that can help save an ectopic pregnancy, and it can never turn into a normal one. If the fertilised egg continues to grow in the fallopian tube, it can damage or burst resulting in heavy bleeding. Hence, this requires urgent medical attention.

To diagnose an ectopic pregnancy, your OB will perform a pelvic exam, and a transvaginal ultrasound scan will confirm it. A blood test may also be done to check for pregnancy hormones.

After an ectopic pregnancy diagnosis is confirmed, treatment options may include medical, surgical, and expectant management. The surgical approach is advised for patients who are medically unstable or are experiencing life-threatening haemorrhage. It is also preferable if the bhcg levels are very high or the ectopic is large especially if there is positive fetal heart activity. For others, management can be based on the patient’s preference after the risks, benefits, and monitoring requirements of other treatment approaches have been discussed.

Medicine can be used if the pregnancy is found early and the tube has not been damaged. To spare the removal of the fallopian tube, a chemotherapeutic drug used to treat it can also end the pregnancy. It may let you steer clear from surgery, but it also comes with side effects. You may also have to undergo blood tests to make sure that the treatment worked. 

Check your symptoms!

  • Abnormal vaginal bleeding
  • Low back pain
  • Mild pain in the abdomen or pelvis
  • Mild cramping on one side of the pelvis

8. Placental Abruption

Placental abruption is a relatively rare complication of pregnancy due to the partial or complete separation of the placenta from the lining of the uterus before the baby is delivered. It may cause you to bleed and it also heightens the odds of stillbirth. 

This complication occurs when the blood vessels that run between the uterus and the maternal side of the placenta are torn and the placenta shears off. This can be dangerous because these structures deliver oxygen and nutrients to the baby. 

Factors like hypertension or substance abuse can stretch the uterus which is an elastic muscle. In the event that the uterine tissue suddenly stretches the placenta remains stable and the vascular structure that connects the two gets torn away. This damage causes bleeding, and when blood accumulates, it further separates the placenta from the uterine wall.

If you show symptoms of placental abruption, the doctor usually does a physical exam, an ultrasound and a CTG that monitors the fetal heart rate pattern. If the doctor finds that this is a severe case, treatment would be to deliver the baby, usually through an emergency C-section. Unfortunately, delivery doesn’t always guarantee that the baby can survive. For those that do, they often face complications associated with prematurity and oxygen deprivation. 

While it’s impossible to prevent placental abruption, the risks can be reduced. It mostly has something to do with lifestyle changes where you should avoid smoking, never use illegal drugs, and have your high blood pressure under control. 

Check your symptoms!

  • Vaginal bleeding (although there might not be any in some cases)
  • Sudden Abdominal pain
  • Reduced fetal movements 
  • Uterine tenderness or rigidity
  • Uterine contractions, often coming one right after another
  • Blood stained amniotic fluid (if membranes are ruptured)

9. Cervical Insufficiency

Also referred to as an incompetent cervix, this means that your cervix is unable to retain a pregnancy by opening up too early even in the absence of pain and uterine contractions. While the reason behind it is not well-understood, it is believed to involve a combination of structural abnormalities and biochemical factors (e.g. infection, inflammation) which are either acquired or genetic.

The tricky part about cervical insufficiency is that it can only be identified until a woman delivers a baby too early. This can be confirmed through a transvaginal ultrasound. 

To keep the cervix from opening, doctors place stitches around or through the cervix which is called a cervical cerclage. It is done during the 12-14 th week if the risk of cervical insufficiency is high eg previous history of incompetence, previous cervical surgery or early delivery less than 32 weeks and a shortened cervical length is detected on ultrasound. It can also be done during the second trimester if the cervix is shortening on ultrasound surveillance or as a ‘rescue’ attempt if the patient presents with a dilated cervix before 24 weeks. 

Check your symptoms!

  • Mild abdominal cramps
  • A sensation of pelvic pressure
  • A change in vaginal discharge (volume, color, consistency)
  • Light vaginal bleeding
  • Braxton-Hicks-like contractions

10. Placenta Previa

This is an obstetric complication where the placenta lies low in the uterus and partially or completely covers the cervix. The placenta may separate from the uterine wall as the cervix begins to open up during labor. This classically presents as painless vaginal bleeding in the third trimester. 

Like most of the complications in this list, the cause behind placenta previa is unknown. However, the risk is higher in women over the age of 35, in those who have a history of uterine surgery, women pregnant with multiples, or those who had more than four pregnancies.

Without proper intervention, placenta previa can lead to:

  • Major bleeding on the maternal end
  • Shock from blood loss
  • Fetal distress due to lack of oxygen
  • Blood loss for the baby
  • Health risks to the baby, if born prematurely
  • Premature labour or delivery
  • Emergency caesarean delivery
  • Hysterectomy, (removal of the womb) if the placenta fails to separate from the uterus (placenta accreta)
  • Death

A diagnosis of placenta previa can dampen the anticipation of a healthy delivery. You can expect bed rest and activity restrictions. Medication, intravenous fluids, and blood transfusions may also be needed depending on the severity of your condition. While this can make the journey challenging, there is hope in knowing that some women go on to deliver healthy babies. 

Check your symptoms!

  • Light to severe bleeding after the 20th week of pregnancy
  • Painless vaginal bleeding during the third trimester
  • Premature contractions

11. Molar Pregnancy

This type of pregnancy is also known as a hydatidiform mole. Receiving this diagnosis can be distressing and it crushes expectations when you learn that the growing baby is actually just a fluid-filled mass of cells. These cells are called trophoblasts which is why a molar pregnancy is also called trophoblastic disease

Developing a molar pregnancy is a chance event. But the possibility of mole formation is higher in older women and in those who had a previous molar pregnancy. While there are usually no signs of a molar pregnancy, it can be spotted during a routine ultrasound scan at 8-14 weeks, or through tests carried out after a miscarriage.

This type of pregnancy can be treated with a simple procedure to remove the growth of cells from the womb. In cases where some get left behind, further treatment will be needed to remove it. 

Check your symptoms!

  • Dark brown to bright red spotting or bleeding
  • Severe nausea and vomiting
  • Early preeclampsia
  • Pelvic pressure or pain
  • Rapid uterine growth
  • Vaginal passage of grape-like cysts

Read: The Empty Belly: Truth Behind Molar Pregnancies

12. Infections

Infections cover a wide scope, and you are more vulnerable to certain infections when you’re pregnant and it may even complicate your pregnancy if left untreated.

Intrauterine infections occur when the environment where the baby develops  (womb and amniotic fluid) become infected. The usual suspects are the natural bacteria that many women carry on the skin or vagina, which are normally harmless, but have migrated to other parts of the body where they shouldn’t be. The vagina and cervix have been tagged as common sites of infection, but it can also find its way to the placenta via the fallopian tubes or through an invasive procedure such as an amniocentesis

Infections can be treated without leaving complications at its wake, but in some cases, it can also lead to preterm labor, birth defects, or a miscarriage. It poses serious risks to a point where it can be life-threatening to you and your baby. Therefore, no matter how small, these must be taken seriously. 

Some infections pose problems mainly for moms, such as vaginitis, urinary tract infections, or postpartum infection. Meanwhile, some are troublesome for your little bun in the oven, such as toxoplasmosis, cytomegalovirus, and parvovirus. 

To ensure that you avoid the potential dangers of an infection, make sure to reach out to your doctor whenever you feel ill. As preventive measures, you may also get the necessary immunisations which will be advised to you during your prenatal check-ups. 

Read: 5 Common Maternal Infections During Pregnancy

13. SGA Babies

Small for gestational age (SGA) is used to describe babies who are smaller than the usual number  of weeks of pregnancy. Their weight lies below the 10th percentile, which means they are smaller than other babies for their age. 

Some babies are small simply because of genetics, or their parents are small. However, most SGA babies are the way they are due to fetal growth problems that occur during pregnancy. If ultrasound shows poor fetal growth while in the womb, the baby may also be described to have “IUGR” or intrauterine growth restriction. This condition means that the baby is small because it’s not growing at a normal rate inside the womb. It occurs when the fetus isn’t getting enough oxygen and the key nutrients for proper growth and development. 

Infants who are small for gestational age are at an increased risk for morbidity and mortality. It is a concern because not only does this involve their size, but their overall body and organ growth. It also follows that their tissues and organ cells may also be compromised.

Except for those factors that are uncontrollable, expectant moms can minimise the chance of having SGA babies by making lifestyle changes. For instance, you should avoid recreational drugs and smoking especially once you are aware that you are pregnant. It also helps that antenatal care is started early on in pregnancy. Improved management for those who fall under high-risk pregnancies can also prevent IUGR. 

We all want a healthy pregnancy, but we can’t brush potential dangers aside. By knowing what may complicate a pregnancy is a step in the right direction. So, when you plan to start a family, or if  you have a little one on the way, you must learn to take the good with the bad. Enjoy the exciting milestones for the next nine months, while keeping an eye out for red flags. 

You may have some questions brewing after reading this. If you wish to discuss them more in detail, you may schedule a consultation with Dr Pamela Tan today. Work on a healthy pregnancy with the right help.