Category: For Her

WORDS LIM TECK CHOON

It can be great to be a woman living in 2019. We have our first female Deputy Prime Minister and more women in our government than before. Women have more access to education, career and social rights than before. Things can be better, of course, hence this year, for International Women’s Day, we are calling for #BalanceforBetter.

However, making great strides require iron in both fortitude and health. No matter how strong one’s fortitude can be, one also requires iron – the mineral– as it is an essential component of health. Unfortunately, iron deficiency in women is far more common than it should be.

Hence, HealthToday is pleased to invite you to join us this month as two experienced experts have kindly shared with us their insight on this subject.

Iron Deficiency: It’s More Than Just Anaemia

Oxygen is essential to convert the calories in the food we eat into energy, which then powers many essential functions of the body. It is transported in red blood cells, and iron is needed to make these cells. Hence, if our body is a factory, then that of someone with iron deficiency (ID) is comparable to a factory that is running on low efficiency due to shortage of power.

Most people usually equate  ID to anaemia, a condition in which the red blood cells do not carry enough oxygen from the  lungs to the rest of the body. However, Dr Jameela Sathar explains that ID doesn’t spring up abruptly overnight – anaemia is actually the manifestation of advanced ID.

“You can go on for many years before developing anaemia,” she says about people who have ID.

We Need A Change In How We Usually Detect Id

In the blood, iron is stored in a protein called ferritin. Healthcare professionals measure the levels of ferritin in the blood as an indication of the levels of iron in the body, and someone with ID typically has less than 30 nanograms (ng) of ferritin for each millilitre (mL) of blood.

However, most hospital laboratories tend to diagnose someone with ID only when there is less than 13 ng of ferritin in 1 mL of blood. Dr Jameela feels that this value is too low as by that stage, the person already has developed anaemia.

Additionally, taking absolute numbers at their face value  may not give an accurate picture. For uncomplicated cases, the serum ferritin value of less than 30 ng/mL indicates ID, but Dr Jameela points out that for patients with inflammatory diseases (chronic heart failure, chronic kidney disease, rheumatoid arthritis, etc), serum ferritin below 100 ng/mL may also indicate ID.

Therefore, Dr Jameela advocates for a nationwide policy to adjust  the cut-off point in diagnosing someone with ID.

For members of the public, however, the take-home message is that we don’t necessarily have to develop anaemia if we have ID. Measures can be taken to improve ID before it reaches the anaemia stage.

The Hidden Consequences Of Anaemia

Aside from having to deal with the symptoms of ID listed previously, there are other downsides to having anaemia:

• Patients with anaemia undergoing surgery have a higher incidence of needing blood transfusions. This increases the overall treatment cost and the risk of possible side effects of blood transfusions (infections, lung injuries, etc).
• Higher risk of developing infections of the urinary and respiratory tracts.

Therefore, We Should See A Doctor If We Suspect That We Have Id

How do we know if we may have ID?

• Hair loss
• Brittle nails
• Headaches
• Pica (an appetite for substances with little nutritive value like ice)
• Fatigue
• Frequent infections
• Depression
• Concentration impairment
• Taste disturbance
• Anaemia/pallor.

The doctor will typically order a blood test that specifically measures our ferritin levels. If the test shows low ferritin levels, we will receive appropriate treatment.

Iron & The Pregnant Woman

During pregnancy, a woman needs even more iron than normal, as her body needs to increase red blood cell production in order to nourish the child she is carrying. Hence, iron intake is an important consideration, as it now potentially affects the well-being of both the mother and child.

How much iron does a pregnant woman need?

According to Assoc Prof Dr Ina Ismiarti Shariffuddin:

• A 55 kg woman requires about 1,000 mg of iron throughout her pregnancy.
• During the second and third trimester, she needs about 500 mg of iron for red cell expansion. 300-350 mg of iron needs to be transferred to the foetus through the placenta for foetal development, while the remaining 100-200 mg is stored as standby in case of blood loss during delivery.

Mothers-to-be should consult their gynaecologist on how much iron they should take in their diet.

ID symptoms that pregnant women should watch out for

These include:

• Breathing difficulties.
• Fainting.
• Tiredness.
• Heart palpitations (rapid heartbeat).
• Sleep difficulties.

Assoc Prof Dr Ina cautions that severe ID can lead to heart failure and further complications to the delivery at a later date. It can also increase the risk of developing perinatal infections, pre-eclampsia and bleeding. The baby can also be affected by severe ID, as he or she faces an increased risk of being prematurely born, halted growth while still in the womb, and low birth weight.

How ID in pregnant women is treated

Assoc Prof Dr Ina shares that iron pills and supplements containing iron, vitamin B12 and folic acid specially formulated for pregnant women can be offered to overcome ID.

Intravenous iron – which is given through a drip – is considered for those whose pregnancy has entered the second trimester onwards, as well as for those who do not respond well to iron pills.

Therefore, expecting mothers should see a gynaecologist if they suspect that they may be suffering from ID. Prompt measures to manage ID would go a long way to ensure the safe delivery of a healthy baby. HT

WORDS LIM TECK CHOON

Infertility cuts deep into the heart. It hurts for a couple who long for a child, but can’t conceive despite trying so hard, and the hurt is made more intense by the fact that the joy of pregnancy and childbirth is all around them. Other couples share stories, photos, and Facebook posts of their parenthood experiences, making a couple’s inability to conceive seem even more unfair.

Yet, the door to parenthood may not be closed permanently. As fertility treatments become more advanced, we are starting to have more control over our chances of conceiving a child. There are still many things that are up to chance, but we also have more options than before to address difficulties in conceiving. This month, fertility specialist Dr Agilan Arjunan takes a look at some of the main causes of infertility among Malaysian women.

AGE: IT’S MORE THAN JUST A NUMBER

Dr Agilan had touched on this in recent articles but it’s worth bringing up again because a woman’s advancing age remains the most common cause of her difficulties in conceiving a child.

• A woman’s most fertile period is usually during her mid-20s.
• Her fertility begins to decline after the age of 30.

However, starting a family in the early twenties is not an option for every woman. A woman these days is more likely to be able to commit to starting a family in her thirties or even forties, a time when her fertility is on a decline.

What can we do about this? A fertility specialist can run a test called the anti- Müllerian test to estimate how many primordial follicles remain in a woman’s ovaries. For this test, the woman only needs to provide a sample of her blood. Once the test result is in, the fertility specialist can advise on the next best step.

In-vitro fertilization (IVF) may be helpful when it comes to selecting the highest quality egg cell for fertilization, therefore overcoming the issue of lower quality eggs produced at a later age.

Another option is for the woman to have her eggs frozen when she is at a more fertile age. These eggs can be thawed and used when she is ready to start a family at a later age.

To understand why fertility drops with age, we first need to understand how the ovaries work.

Dr Agilan shares that a woman only has approximately 10% of her egg reserve remaining by the time she turns 30, and the reserve continues to deplete until she reaches menopause and, hence, the end of her childbearing days.

1. The ovaries release a mature egg cell during a woman’s menstrual cycle (typically around day 14), and new life is formed when a sperm cell fertilizes this egg during sexual intercourse.
2. The egg cell develops from a pre- existing cell in the ovary called the primordial follicle. This process occurs under the infuence of hormones such as the follicle stimulating hormone (FSH).
3. Now, the woman is born with a set number of primordial follicles. No new primordial follicles will be made after she is born. Therefore, once all her primordial follicles are used up, she will no longer be able to produce any more egg cells.
4. Another issue that arises is that the quality of the egg cell produced tends to decrease with the woman’s age. This may occur even when a woman still has a good number of primordial follicles. This is because the good quality eggs tend to be released during the woman’s most fertile period. Egg cells produced at a later age tend to have a higher risk of being abnormal.

ISSUES WITH THE FALLOPIAN TUBES

Figure A. Blockage in the fallopian tube can prevent a mature egg cell from being fertilized by a sperm cell.

As indicated in Figure A, the fallopian tube is a tube-like structure that provides passage for the mature egg cell to travel from the ovary to the uterus. During sexual intercourse, it will encounter a sperm cell during its journey, and the subsequent fertilization will give rise to new life.

These days, fallopian tube issues are increasingly common. These issues include blockage and damage which prevent the egg cell from ever meeting the sperm cell.

Dr Agilan explains that these issues arise because more women are becoming sexually active at a younger age. This increases their risk of developing pelvic inflammatory disease (PID), especially if they do not practice safe sex. Some women may not realize that they have PID because its symptoms can be either absent or very mild.

Other possible causes of fallopian tube issues include ruptured appendix and a previous ectopic pregnancy (which happens when an embryo attaches itself into the fallopian tube instead of the endometrium in the uterus).

What can we do about this?

If fallopian tube issues are suspected to be the cause of a woman’s difficulty in conceiving, a type of X-ray test called hysterosalpingography can be performed to confirm that this is indeed the case. Once this is confirmed, there are a few options depending on the nature and location of the damage or blockage.

• laparoscopic surgery can be done to repair fallopian tube damage.
• If the fallopian tube damage isn’t too close to the uterus, surgery may be able to repair the damage. However, there is risk of scar tissues forming at the site of surgery during the healing process, causing the fallopian tube to be blocked.
• In-vitro fertilization is most likely the best option for couples wishing to have a child despite the presence of damaged or blocked fallopian tubes. The fertility specialist can extract eggs directly from the ovaries, bypassing the fallopian tube altogether.

ENDOMETRIOSIS

The innermost layer of a woman’s uterus is called the endometrium. It is here that  the embryo, which develops from a mature egg cell that has been fertilized by a sperm cell, implants itself to develop into a baby. If no fertilization occurs, the lining tissue thickens and breaks down before exiting the body as menstrual flow.

“Endometriosis arises when tissues from the endometrium grow outside of their usual place in the endometrium,” says Dr Agilan. “They may grow in the fallopian tubes, ovaries and even in the pelvis.”

These cells thicken, break down and bleed during the menstrual cycle, and this becomes a problem as the blood and broken-down tissue cannot exit the body. This leads to irritation in the surrounding tissue as well as formation of scars and cysts.

“ENDOMETRIOSIS, UNFAIRLY CALLED THE CAREER WOMAN’S DISEASE, WAS ONCE THOUGHT TO BE CAUSED BY DELAYED CHILDBEARING. WE NOW KNOW THAT’S NOT TRUE AT ALL.”

Consequently, someone with endometriosis can experience great pain. Her fertility is very likely to be affected as well, as endometriosis can reduce both the number of eggs as well as quality of these eggs.

What can we do about this? Treatment of endometriosis, which typically involves hormone therapy, makes it harder for a woman with endometriosis to conceive, as it prevents ovulation. Therefore, if the woman wants to have a child, the fertility specialist will recommend temporarily stopping treatment.

If necessary, laparoscopy can be performed to reduce the severity of endometriosis and improve the chances of pregnancy. Intrauterine insemination (IUI) may also be useful as this procedure allows the injection of sperm cells directly into the uterus, therefore improving the chances of a successful fertilization.

POLYCYSTIC OVARY SYNDROME (PCOS)

Polycystic ovary syndrome (PCOS) is a lifelong condition that give rise to several bothersome, uncomfortable and even painful symptoms, as seen in Figure B. According to Dr Agilan, it affects about 20% of women worldwide, and in Malaysia, it is especially common among Indian women.

Depending on the severity of her PCOS, the affected woman’s ovaries may fail to regularly release eggs. Dr Agilan shares that it is not unheard of for women with PCOS to not have their period for up to six months, perhaps even a year. This naturally affects their ability to have children.

What can we do about PCOS? Dr Agilan notes that more than 50% of women with PCOS have higher than normal levels of the hormone insulin, even though they are not diabetic.

“The higher the insulin levels, the harder it is for the woman to form a mature egg cell and ovulate,” he says.

Therefore, a way to increase the woman’s chances of conceiving a child is by reducing the insulin level. This is done by prescribing metformin, the staple medication for people with diabetes.

PROBLEMS AFFECTING THE UTERUS

“These problems include the presence of fibroids, which can affect the ability of a fertilized egg to implant into the endometrium or displace the fallopian tube and make it difficult for the sperm cell to meet the egg cell,” Dr Agilan says.

Another, rarer condition is adenomyosis, which is a type of endometriosis. In this case, endometrial tissues are found in the wall of the uterus, giving rise to an enlarged uterus, heavy and/or prolonged bleeding during menses and pain.

What can we do about it? Because problems with the uterus usually affect the ability of the woman to stay

pregnant – which is to say, it may prevent an embryo from being implanted or staying implanted in the endometrium – there is no simple “one size fits all” solution. The fertility specialist evaluates the patient and considers the best options on a case by case basis. HT

Guys aren’t left out! Dr Agilan will turn the spotlight on the main reasons why men have a hard time making babies in the next Woman’s Health and Fertility column. Watch out for it!

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WORDS LIM TECK CHOON

WOMEN’S HEALTH AND FERTILITY WITH

Dr Agilan Arjunan Consultant Gynaecologist & Fertility Specialist

KL Fertility Centre

This month, Dr Agilan Arjunan gives us a closer glimpse of a method that allows a woman to stop worrying about becoming pregnant. It’s a relatively simple and safe method but be warned: the result is practically irreversible!

WHAT’S LAPAROSCOPIC TUBAL LIGATION?

Pregnancy is the result of a sperm cell meeting and fertilizing an egg cell after sexual intercourse. The egg cell is released by the ovary and travels outwards towards the uterus (see Figure A), and along the way, it may encounter sperm cells.

Cutting and tying, cauterizing, or banding the fallopian tube prevents the egg cell and the sperm cell from ever meeting. Hence, there is no worry about pregnancy.

Such a procedure is called tubal ligation. ‘Ligate’ means ‘tie up’, hence this procedure is sometimes also called ‘getting the tubes tied.’

WHAT HAPPENS DURING A LAPAROSCOPIC TUBAL LIGATION?

Dr Agilan Arjunan explains that this is currently the most widely used method of tubal ligation. The surgery involves making small cuts or incisions through the skin.

1. The patient is given anaesthesia and a drip in the vein of an arm or hand.
2. A device will be gently inserted into the vagina to move the uterus.
3. The surgeon makes a small incision near the navel.
4. A thin, flexible pencil-wide tube with a camera and light source at the end (laparoscope) is inserted through the incision.
5. The abdomen is inflated with gas (don’t worry, it’s safe) to make it easier for the surgeon to view tissues and organs via the laparoscope.
6. A second small incision is made at the pubic hairline.
7. Through this second incision, the surgeon uses a special device to hold the fallopian tubes in place.
8. The fallopian tubes are then sealed either by cutting them, passing an electric current that causes blood to clot in the tube opening (electrocoagulation) or by using a band or clip over the tubes.
9. The laparoscope and other devices are removed, and the incisions are stitched up.

The entire procedure takes about 30 minutes, provided there are no complications.

WHAT HAPPENS AFTER THE SURGERY?

The patient will rest awhile in the hospital for observation. If all is well, she usually will be allowed to leave on the same day.

The patient can resume working a few days after the surgery, but it’s best to resume daily activities gradually as one heals.

Normally, sexual activity can resume a week after coming back from the hospital, but it’s best to get clearance from the doctor first.

WHAT ELSE CAN A WOMAN EXPECT AFTER THE SURGERY?

There may be some vaginal bleeding for a few days after the procedure, and this is usually normal.

Menses may resume 4 to 6 weeks later, and during the first two or three cycles, one may experience heavier bleeding and slightly more discomfort than usual.

The surgery does not affect one’s ability to enjoy sexual activities.

IS THIS PROCEDURE EFFECTIVE? WHAT ARE POSSIBLE RISKS INVOLVED IN GOING FOR THE SURGERY?

Laparoscopic tubal ligation has a chance to fail, although statistically it’s a small chance—fewer than 1-in-100 women.

Dr Agilan adds that there is also a risk of ectopic pregnancy, which sees an egg cell still being fertilized by a sperm cell and developing into a foetus in an abnormal location—usually in the fallopian tube itself. According to some studies, this risk is very low, lower in fact than the risk of ectopic pregnancy in women whose fallopian tubes are not ligated.

Other risks are those usually associated with any form of surgery: bleeding, infection and anaesthesia-related side effects.

Don’t worry too much about the risks for now, as a good surgeon will explain the risks before one agrees to go for the surgery. Dr Agilan recommends taking this opportunity to have any doubts and concerns cleared by the surgeon.

WHAT ARE THE ADVANTAGES OF THIS PROCEDURE OVER OTHER FORMS OF TUBAL LIGATION?

Dr Agilan shares that the chief advantage is that one recovers more quickly from surgery due to only a few small incisions being made on the body.

Some studies suggest that this procedure can also reduce one’s risk of ovarian cancer and pelvic inflammatory disease, although we still don’t know the exact reasons for this.

The biggest advantage of this procedure, perhaps, is that it is the best contraception available for a woman. “If the woman is absolutely sure that she doesn’t want to have children,” says Dr Agilan, “then this is the best method available. It’s effective and, unlike other female contraception methods such as the Pill, doesn’t affect the woman’s hormone levels.”

If the woman is 100% sure, that is, which is important as once it is performed, laparoscopic tubal ligation is practically irreversible.

While this surgery prevents pregnancy, it offers no protection against sexually transmitted diseases—other precautions such as the use of condoms will still be needed to avoid catching these diseases.

IT’S REALLY IRREVERSIBLE?

Reversing a tubal ligation is a very complicated procedure with a small chance of success.

“Once the fallopian tube is clipped, banded, or cauterized,” explains Dr Agilan, “scar tissues can form around the affected area. These scar tissues can grow over time until they eventually obstruct the tubes permanently.”

Even if the reversal is a success, there is still no guarantee that the woman can successfully conceive.

Therefore, Dr Agilan reiterates that a woman should be absolutely, positively sure that she doesn’t want children for the rest of her life before she undergoes this surgery.

CONSIDER OTHER OPTIONS IF ONE IS UNSURE

“This surgery is not the only option available,” Dr Agilan says. “For women who believe that they may want children some time in the future, there are other forms of contraception that can be considered.”

This includes the Pill, contraceptive patch and more. Alternatively, her partner can opt for vasectomy, which can be more easily reversed should the couple change their mind about having children in the future. Dr Agilan recommends discussing this matter further with one’s doctor to explore options that best suit one’s needs. HT

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