How Much Do You Know About PCOS?

How Much Do You Know About PCOS?

April 28, 2022   Return

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Dr Kim Wong   Consultant Obstetrician & Gynaecologist

They say to understand a woman, you have to go to the root of the problem to know what is really troubling her. And, this is very true of PCOS.

The number of women diagnosed with PCOS is on the rise globally. According to Dr. Kim, the prevalence of polycystic ovarian syndrome or PCOS is about 1 in 10- 20 women, which makes up about 5-10% of women of the reproductive age group. It seems that urbanization and stress may play a role in this.

So, what exactly is polycystic ovarian syndrome (PCOS)?

PCOS is a hormonal disorder which can affect women of the reproductive age.

And, there are 2 plausible reasoning for its occurrence:

  • Your genes. It could potentially be hereditary that this occurs, where the genes are passed down directly. On the other hand, it could be your genetic makeup that is the culprit. For instance, if someone in your family has PCOS, the chances of you having it are increased.
  • Lifestyle. The way you live your life could also trigger PCOS. For example, a poor diet, a sedentary lifestyle and stress may affect your chances in having PCOS. 

How do I know if I have it?

According to Dr. Kim, the 4 signs to look out for are:

  1. Irregular menses. Although factors such as pregnancy should not be excluded, visit a doctor if your menses are not as regular as they should be or if you experience heavy bleeding for days – especially if you have passed adolescence.  
  2. Abnormal hair growth. If you notice that you are having a moustache, pubic hairs that grow up to your navel, hairy legs and arms, bushy eyebrows, or receding hair lines similar to those of a male’s baldness, then visit a doctor.
  3. Obesity. Most women with PCOS are obese with weight gain observed around the waistline. They also tend to have a BMI of above 30.
  4. Have oily skin and acne

“PCOS can, in fact, happen to any woman of the reproductive age and when they are meant to menstruate on a regular basis,” says Dr. Kim.

The kind of tests required…

  • A transvaginal ultrasound. The ovaries usually appear enlarged with small cysts in it when a scan is done. Each cyst is measured to be around 8mm in size.
  • Diagnosis based on clinical history.  Your doctor will look out for common symptoms such as abnormal hair growth, irregular menses and acne or hair problems. A transvaginal ultrasound usually follows once the symptoms are identified. A blood test may also be necessary to support diagnosis.

Can it be treated..?

“Treatment varies according to symptoms,” says Dr Kim.

For weight and acne problems: Exercise and eat a well-balanced diet that contains the right proportion of carbohydrates, proteins, fibres and vitamins. Speak to a nutritionist if you are having trouble following the diet.

For abnormal health growths: Permanent removal of excess hair is possible through laser therapy or you can opt to for medications to control hair growth.

For acne problems:  Birth control pills are usually prescribed to resolve acne problems as they can reduce testosterone levels, which in turn reduce both acne and excessive hair growth.

For menstruation problems: A progesterone therapy is usually prescribed to those with irregular menses or experiencing prolonged heavy bleeding. Birth control pills can also be used for those with irregular menses.

For infertility problems:  Fertility drugs such as clomiphene or FSH injections may be given to treat infertility.

And the complications are…?

  • Infertility
  • Difficulty to conceive
  • Womb cancer
  • High risk of developing type 2 diabetes at a later age, stroke and heart attack
  • Prolonged periods of no menses (known as amenorrhoea) if left untreated or not treated properly.

And if you do get pregnant, you may experience one or more of the following complications:

  • Gestational diabetes
  • Hypertension
  • Premature delivery
  • Miscarriage

Is there a way to minimise risks..?

You can minimise your risk simply by living a healthy lifestyle:

  • Eat a balanced diet. A diet that follows the food pyramid and contains the right balance of carbohydrates, proteins, fibres and vitamins will do the trick. Best to avoid fine sugar, processed food, canned or sugary drinks.
  • Exercise at least once a day for 30 minutes.
  • Have enough rest and sleep daily. 8 hours of sleep should be enough for women of reproductive age while 6-7hours of sleep for those in menopause and older.

Don’t be shy, just come forward

 “It is okay to come forward and have a chat with a doctor should you face any of these difficulties. Don’t just sit on the problem and wait. Get it treated before it becomes worse,” Dr. Kim advices.

The most obvious symptom that could indicate PCOS is when you are not menstruating on time. Visit a gynaecologist if this happens.

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Screening for Hope

Screening for Hope

April 28, 2022   Return

In Fertility Specialist Dr Wong Pak Seng’s line of work, he is always up to date on the constantly evolving genetic screening technology. These days, there are machines that can help detect any number of mutated or abnormal genes present in one’s DNA, even the very rare ones.

Dr Wong believes that pre-conception genetic screening should be recommended for people with a family history of inheritable. “These are the high-risk groups, so they should go for screening,” he says. For other couples hoping to conceive and have no family history of such conditions, he recommends going for pre-implantation genetic screening and prenatal screening instead.

The following are couples who may benefit from pre-conception genetic screening:

  • With a family history of an inheritable conditions, birth defect, mental handicap as well as cancer.
  • Has a previous child with genetic condition, birth defect or mental handicap.
  • Have a history of two or more pregnancy losses, stillbirth or babies who died unexpectedly.

Accurate? While the list of conditions that can be screened for grows longer as technology evolves rapidly with time, not every condition can be tested, and the results of testing may not always be clear either. This is because there are still limitations to what current genetic testing methods can do. Therefore, a result indicating that everything is normal may not guarantee that the child will be healthy.

Why should you get screened? According to Dr Wong, many couples who have a family history of a condition that may be passed on to a child will find the results useful to help them decide whether they want to proceed with fertility treatments. And if they decide to go ahead, they can also look up options and plan in advance as to what they should do if their child is found to have an inheritable disorder.

What is the process like? Before fertility treatment such as in-vitro fertilization (IVF) can begin, the fertility specialist will review the couple’s family history thoroughly. Dr Wong explains that, should the specialist believe that there is a need for pre-conception genetic screening, the specialist will discuss this with the couple. The couple can also be referred to a genetic counsellor for advice as well as emotional support.

Once the couple agree to the screening, a blood sample will be extracted and sent to the laboratory for further analysis. How soon the results will be available depends on the specific gene mutation being analysed – rarer ones may require the sample to be sent to specialized labs out of Malaysia, for example, as their analysis may require special chemicals and/or equipment.

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The ‘Holy Grail’ of IVF

The ‘Holy Grail’ of IVF

April 28, 2022   Return

Aaron and Lisa Christy was a happily married couple with a young son and another on the way. But unlike their firstborn who was born healthy, their second son, Ben was diagnosed with Wilms’ tumour (a rare inherited form of kidney cancer) when he was merely 18 months old. “When Aaron was a child, the doctors had diagnosed him with the very same kind of tumour. Thankfully, chemotherapy and surgery saved his life. But we never expected our child to have this cancer as we were told that it couldn’t be passed on to the next generation,” Lisa explains in an interview with Perth Now. While Aaron survived, the same couldn’t be said for Ben. After two years of anti-cancer therapy, he finally succumbed to the aggressive cancer.

Despite their loss, Aaron and Lisa were still adamant to have more kids, as they had always wanted a large family. But they now knew that it would come with risks. “If we decided to get pregnant naturally, there was a significant risk that our baby would have Wilms’ tumour. We didn’t want to put ourselves through that painful experience ever again,” Lisa says.

With this in mind, they turned to genetic experts at a Sydney hospital who referred them for a procedure known as pre-implantation genetic testing whereby Lisa’s embryos were screened for genes carrying the Wilms’ tumour to determine which ones were healthy and which weren’t. Five of the embryos were found to carry the cancer gene, only three were unaffected. “The results just drove home the fact that if we had gotten pregnant naturally, we would have been playing Russian roulette.” One of the three unaffected embryos was then implanted in her womb – to great success. “Now, we have a totally healthy baby girl and couldn’t be happier. I wasn’t prepared to gamble with my child’s life so I underwent the procedure – and I’m glad I did.”

Maximising your chances

The Christy couple is not the only one who has to deal with the fear of passing on flawed genes to their offspring. Many couples share the same predicament. Fortunately, thanks to advances in fertility treatments such as pre-implantation genetic testing (PGT), their dreams of having a healthy baby can now become a reality.

But it isn’t just couples with a history of inherited disorders who are seeking out PGT, healthy couples are also opting for this screening method according to Pre-implantation Genetic Testing Scientist Mr Aaron Chen. “These couples have no history of inherited illnesses. They just want to increase their chances of having a baby via IVF. By choosing only healthy embryos for implantation, the higher the success rate of the pregnancy,” he explains. “Therefore, PGT can be for everyone.”

Lifting the curtain on…

Pre-implantation genetic testing

“Basically, PGT refers to the technique used for identifying genetic defects in embryos via IVF. It acts as an alternative to post-conception diagnostic procedures like chorionic villus sampling and amniocentesis (amniotic fluid test). For some couples, these tests yield unfavourable results which can put them in the difficult predicament of deciding whether to keep their baby or not.”

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Elaborating further, he explains, “We can break PGT down into a number of steps.”

  • Step 1: The woman undergoes IVF so we can collect and fertilise her eggs.
  • Step 2: The embryos (fertilised eggs) are grown in the lab for 2-3 days. By now, the cells would have divided and each embryo should consist of eight cells.
  • Step 3: One of the cells (a blastomere) is removed from the embryo.
  • Step 4: This cell is tested to see if the embryo from which it originated has a genetic or chromosomal anomaly.
  • Step 5: An embryo, which is found to be healthy, is implanted in the womb while unhealthy embryos are discarded.
  • Step 6: The remaining healthy embryos can be stored for future use. 

Pre-implantation genetic diagnosis

“PGT is actually divided into two types,” Mr Chen continues. “Firstly, we have pre-implantation genetic diagnosis (PGD) which is used to determine practically any inheritable disorder where a particular gene is known to cause that disorder. When one or both parents have a genetic abnormality, the embryos are subjected to PGD to see if they carry that same abnormality. Only genetically normal embryos are chosen.”

As of now, PGD is capable of testing for more than 250 inheritable disorders including:

  • Sex-linked diseases like haemophilia, which are usually inherited by the son from the mother who is a carrier.
  • Single-gene defects like thalassaemia, which results from a single gene abnormality.

Chromosomal disorders like Fragile X syndrome.

Mr Chen strongly recommends PGD to couples who are at risk of passing on inheritable disorders to their future children. Aside from couples with the aforementioned genetic conditions, potential PGD candidates are:

  • Couples with affected children.
  • Women who have had more than one failed fertility treatment.
  • Women aged 35 and above.
  • Women with a history of recurrent miscarriages.

Pre-genetic implantation genetic screening

“On the other hand, pre-implantation genetic screening (PGS) is where embryos from parents who are presumed to have chromosomally normal genes are tested for aneuploidy (chromosomal abnormalities). Aneuploidy occurs when a cell has an abnormal number of chromosomes such as 45 or 47 chromosomes, instead of the normal 46. Aneuploidy can result in disorders such as Down syndrome,” Mr Chen says.

Delving into the benefits which PGS offers, Mr Chen says, “Aneuploidy is the most common factor in IVF failure. By choosing chromosomally normal embryos, PGS helps to:

  • reduce the risk of spontaneous miscarriage
  • enhance implantation, pregnancy and live birth rates
  • allow single- or double-embryo transfers (subsequently, reducing the number of high-risk multiple pregnancies).

He recommends PGS to couples with:

  • A female partner who is advanced in age
  • A male partner who has severe male factor infertility
  • recurrent pregnancy losses (both naturally and via IVF).

“A decreasing live birth rate is a growing issue for couples who decide to wait till later in life to have kids. This is because late maternal age embryos are more likely to be chromosomally abnormal. This is why we suggest older couples to undergo PGS,” he stresses. “To sum it up, PGS is an effective tool in fertility treatment as it significantly lowers the risk of transferring chromosomally abnormal embryos into the mother.”

“Couples can rest assured, PGS has evolved over the years. In 2007, PGS used the Fluorescence In-situ Hybridization (FISH) technology which could only test 5-12 chromosomes and had a 9.1% error rate. Now, we have Next Generation Sequencing (NGS) which enables us to comprehensively screen all 24 chromosomes and has only a 1.9% error rate. It’s a great breakthrough.”

There’s always hope

Mr Chen concludes, “While genetic testing doesn’t guarantee that all clinical failures are eliminated, it delivers what it promises to do: significantly increases your chances of having a smooth pregnancy, a healthy baby and finally, a happy family. We like to call it the ‘Holy Grail’ of IVF.”

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References:

1. American Pregnancy Association. Available at http://americanpregnancy.org/infertility/preimplantation-genetic-diagnosis/

2. Fertility Centers of New England. Available at www.fertilitycenter.com/fertility_cares_blog/the-difference-between-pgd-and-pgs/

3. Genesis Genetics. Available at http://genesisgenetics.org/pgs/ngs/

4. Human Fertilisation & Embryology Authority. Available at www.hfea.gov.uk/preimplantation-genetic-diagnosis.html

5. Medscape. Available at http://emedicine.medscape.com/article/273415-overview#a4

6. Penn Medicine. Available at www.pennmedicine.org/fertility/patient/clinical-services/pgd-preimplantation-genetic-diagnosis/

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Pregnancy & Genetic Screening

Pregnancy & Genetic Screening

April 28, 2022   Return

After the anxious and often stressful weeks of undergoing fertility tests and in-vitro fertilization (IVF), it must surely be a joyous moment when the fertilized egg is successfully implanted and both husband and wife are now proud parents-to-be.

However, for couples who are considered to be of high risk when it comes to passing down genetic disorders to their children, it may be worth considering one more round of genetic screening to make sure that their baby is fine.

Dr Wong Pak Seng, a fertility specialist with years of experience and success stories under his belt, says that prenatal genetic screening is still worth considering because no genetic screening is 100% accurate.

Prenatal genetic screening can offer the parents-to-be more peace of mind. Even if the test comes back with unhappy news, the parents-to-be may appreciate having the opportunity to make special arrangements in advance. The parents-to-be also have time to prepare themselves emotionally and make necessary research on how to best provide a special needs child with tender loving care. 

Such screening is recommended for:

  • Parents-to-be with a family history of genetic disorders and birth defects.
  • Parents-to-be who are aged 40 years or older, especially the mother-to-be, as the risk of having a child with Down syndrome  and other conditions caused by chromosomal disorders is higher.
  • Mothers-to-be with abnormal ultrasound findings.
  • Mothers-to-be with a history of miscarriages or previous children with birth defects, mental handicap or genetic disorders.

The ‘Old school’ invasive ways

In the past, prenatal genetic screening was done through either amniocentesis or chorionic villi sampling (CVS). Both methods involve the use of needles or other devices to extract samples from the mothers-to-be – hence, the description of these methods as ‘invasive’!

Both methods can cause a certain degree of discomfort and even pain in some mothers-to-be. Furthermore, there is a very small risk of miscarriage, infection and other undesirable complications associated with these procedures. While such complications occur only very rarely, the fact that they can happen drives the medical industry to look for better, less invasive ways to perform prenatal genetic screening.

Fortunately, in the recent years we have developed the technology and method for a less invasive method for prenatal genetic screening. This method is called, appropriately enough, non-invasive prenatal screening test, or NIPST for short.

NIPST – A less invasive solution

Dr Wong explains that, during a NIPST, the doctor only needs to obtain blood sample from the mother-to-be. There are two NIPST services commonly offered by fertility centres in Malaysia.

Non-invasive prenatal diagnosis (NIPD)

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When a woman is pregnant, some of her child’s DNA finds its way into her bloodstream. NIPD analyse this DNA for birth defects and genetic disorders such as Down syndrome, Edwards syndrome and Patau syndrome, as well as chromosomal disorders such as Turner syndrome, Klinefelter syndrome and Triple X syndrome.

  • When to do it? NIPD can be done from as early as week 9 of one’s pregnancy, but please consult a gynaecologist or fertility specialist for the best time to take this test.
  • Accuracy. NIPD is considered to be more accurate than the other available prenatal genetic screening methods available at the moment.
  • Risks. Because NIPD only requires a small amount of blood from the mother-to-be, usually extracted from the arm, there is no risk to the mother or the baby she is carrying.
  • Expensive? NIPD costs a bit more than many other available methods, as it requires specialised equipment and chemicals to perform the analysis. Currently, fertility centres in Malaysia that offer this service send the blood samples to laboratories abroad for analysis.

First trimester screening (FTS)

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FTS is actually a combination of several tests that include ultrasound and blood analysis. It can screen for Down syndrome and heart defects.

  • When to take it? FTS is usually performed between week 11 and 14.   
  • The procedure. An ultrasound exam will be performed to check the size of the clear space in the tissue found at the back of the baby’s neck (nuchal translucency). Blood tests will be taken and analysed for the levels of two substances: pregnancy-associated plasma protein-A (PAPPA) and human chorionic gonadotropin (HCG).
  • Getting the results. The results of the above procedures, along with the age of the mother-to-be, will be used to determine the risk of the child having Down syndrome.
  • Risks. There is no known risk associated with FTS.
  • Expensive? FTS costs less than NIPD, but its scope of detection is narrower and is slightly less accurate than NIPD. However, it is still a powerful genetic screening procedure worth considering for couples who find NIPD above their budget.

Dr Wong reminds us that these screening tests are not 100% accurate. A low-risk result will not guarantee that the baby will be free from genetic disorders, just like how a high-risk result does not necessarily mean that the child will have a genetic disorder. In some cases, the gynaecologist or fertility specialist may recommend follow-up screening tests to verify the results of these tests.

At the end of the day, the choice to go for genetic screening lies ultimately in the hands of the couple, says Dr Wong. If the couple does not wish to proceed with genetic screening, they are certainly free to do so. The genetic counsellor is always available to offer advice and support if the couple encounter difficulties in making a decision.

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Why is My Period Late?

Why is My Period Late?

April 28, 2022   Return

Although a woman’s average menstrual cycle is 28 days, it is normal to have a cycle that is between 21 and 35 days. A cycle can also change due to hormonal changes caused by age, certain medical conditions and lifestyle factors. This does not necessarily mean there is an underlying serious problem. Even so, changes and irregularities in a woman’s menstrual cycle needs to be observed, especially when her period suddenly stops.

Maybe baby?

The most common cause for missing periods is pregnancy. Sexually active women who experience delays in their period can do a home pregnancy test to find out, using a pregnancy test kit that can be purchased at a pharmacy. The most common type of pregnancy test kit is one which uses a test strip or dipstick to detect the presence of a pregnancy hormone, called the human chorionic gonadotropin (hCG) in urine samples. When the kit is used exactly as instructed, a home pregnancy test has more than 99% accuracy, similar to results of a urine test in a doctor’s office. However, if done too early into the pregnancy, there may be insufficient hCG in the urine to be detected. Check the details on the package of the pregnancy kit for the best time to take a test.   

Should you be worried?

If you have been on birth control, changes in your menstrual cycle, and even skipping a period or two, is normal. But if you are not pregnant and on taking contraceptives, there may be other factors that could be responsible for your period stopping, including:

  • Prolonged emotional stress
  • Physical stress from extreme exercising or crash dieting
  • Unexplained drastic weight loss or weight gain Polycystic ovary syndrome (PCOS); a common endocrine system disorder among women of reproductive age, characterised by enlarged ovaries that contain small collections of fluids.
  • Medical problems that causes hormonal imbalances, such as thyroid problems and celiac disease
  • Recently stopped use of birth control
  • Early menopause

Changes to your cycle can be a harmless short-term condition, or it can be a sign of a more serious health issue. Whatever the case may be, missed periods are not to be taken lightly. So, consider making an appointment with a gynaecologist to set your mind at ease.

References:

Mayo Clinic. Available at www.mayoclinic.org

WebMD. Available at www.webmd.com

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Women in Action for Better Health Coverage

Women in Action for Better Health Coverage

April 28, 2022   Return

Kuala Lumpur, November 5 – The Women’s Health Summit has always been one of the highlights of the year ever since its conception in 2013. Organised by Pantai Hospital Kuala Lumpur, the summit brings together over 300 participants from diverse backgrounds, and enjoys the participation and support from the Ministry of Women, Family and Community Development (LPPKN), Ministry of Health, NGOs, various medical associations and civil societies.

The high point of the day is the Consensus Roundtable, which sees various key opinion leaders, experts and advocates coming together to deliberate on important issues in women’s healthcare, as well as to recommend policy innovations that will enhance healthcare coverage for women in this country.

This year, the 3rd Women’s Health Summit Consensus Roundtable is chaired by YBhg Tan Sri Rafidah Aziz, Patron of the 3rd Women’s Health Summit. Dr Azlina Firzah, consultant breast surgeon, serves as co-chair while Dr Patricia Gomez, also a consultant breast surgeon, acts as moderator.

The issues

Breast reconstruction should be seen as a medical right for breast cancer patients.

Ms Ranjit Kaur, Chairman of Together against Cancer Malaysia and Non-Communicable Disease (NCD) Alliance Malaysia explains that treatment of breast cancer is holistic in nature. It is not solely about surgeries or chemotherapy; the patient needs to receive care for her psychological and emotional well-being too. Breast reconstruction plays a significant role in the healing process, as it allows her to regain her self-esteem and confidence, leading to better adherence to treatment and improved chances of survival.

However, breast reconstruction is currently considered a cosmetic procedure by nearly all Malaysian insurance companies and the Employee Providence Fund (EPF). As a result, breast cancer patients who undergo mastectomy do not have the ability to withdraw funds from their EPF account to cover the costs of breast reconstruction, and only three out of 60 insurance companies in Malaysia provide coverage for this medical procedure.

The Consensus Roundtable brings up the fact that there are already precedents such as in the United States, where the Women’s Health and Cancer Rights Act (also known as Janet’s Law) made it compulsory by law for all sponsored group health plans, insurance companies, individual policies and health maintenance organisations offering medical and surgical benefits with respect to a mastectomy to also offer coverage for reconstructive surgery (including costs of implants and treatment for physical complications at all stages of the mastectomy).

Breast cancer survivors or women carrying breast cancer genes are discriminated by insurance companies as well as employers.

Professor Dr Teo Soo Hwang, Chief Executive of the Cancer Research Malaysia, brings up the Genetic Information Nondiscrimination Act of 2008 (GINA), implemented in the United States to prohibit the use of genetic information by employers and insurance companies to deny a woman her right to employment and insurance coverage, respectively.

In Malaysia, however, there is no similar law, and consequently, she points out that there are many instances when breast cancer survivors find themselves denied further insurance coverage and employment. Those with breast cancer genes are either denied insurance or they have to pay very high insurance premiums.

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The call for action

It is time for the government to act. Tan Sri Rafidah Aziz calls for the Malaysian government to make the right provisions for the women in this country. Dr Patricia adds that the government needs to look at Janet’s Law and GINA to see how countries such as the United States handle this matter.

The Consensus Roundtable also urges the Ministry of Health to consider abolishing the need for ex-government servants and pensioners to pay upfront for the prosthetics (implants) needed for breast reconstruction in government hospitals.

The insurance companies can play a role. Dr Myralini S Thesan (Chairman of the Joint Technical Medical Committee of LIAM and Medical Advisor and Head of Care Management of AHS, AIA Berhad) says that she will send a representative to talk to Prof Dr Teo and other parties on the types of changes that we need to see in local insurance policies, as well as to clear the air on any wrong perceptions or misunderstanding on how the local insurance companies operate.

EPF can step up. Mr Azrulzimar Aminuddin, the Deputy Manager of the Withdrawal Operations Department of EPF, states that he will propose allowing women to withdraw from their EPF accounts for breast reconstruction in an upcoming meeting, and Tan Sri states that she will personally write to the EPF to support Mr Azrulzimar.

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Delaying Menses for Hajj

Delaying Menses for Hajj

April 28, 2022   Return

Professor Dr Jamiyah Hassan  Senior Consultant OBGYN, Feto-Maternal Specialist, University Malaya Medical Centre

Each year, millions of Muslims undertake the pilgrimage to Mecca during a 5-day period, from the 9th to the 13th of Dhu Al-Hijjah, the 12th month of the Muslim lunar calendar. This pilgrimage is both a religious goal and the high point of a Muslim’s life. For Muslim women preparing for the Hajj, however, there is always a question lurking at the back of their minds: what if they were to menstruate during those precious days?

“Muslim women are not allowed to perform religious activities such as fasting and praying when they have their menses,” explains Prof Dr Jamiyah Hassan. “This extends to performing the Hajj.”

Dr Jamiyah, speaking at the Women’s & Men’s Health Intertwined seminar conducted by the Obstetrical and Gynaecological Society of Malaysia (OGSM) recently, said that combined oral contraceptive pills (COC, sometimes better known as “the pill”) can be used to delay menses during pilgrimage.

Religious decisions

The use of COC involves manipulating the female hormones. Is such a method allowed?

There is no fatwa on delayed menses by the National Fatwa Council, according to Dr Jamiyah. She however points out to specific fatwa in the states. For example in 1985, the Penang Fatwa Council stated that Muslim women are allowed (harus) to delay their menses for the purpose of Hajj, due to the distance travelled for the pilgrimage as well as the difficulty of performing the Hajj ritual. She has also spoken to many religious figures who agreed with this fatwa.

Delaying the period

According to Dr Jamiyah, any COC would work for this purpose, but she recommends choosing the newer brands of COCs. This is because in newer COCs, the active ingredient progestogen is designed to have a longer half-life and therefore, these COCs are more effective.

She offers the following general tips:

  • Start a month earlier, as your body needs time to acclimatise to the changes to your menstrual cycle.
  • A traditional pill pack contains 28 pills, but only 21 are active. The other seven pills are inactive. Discard the nonactive pills, and continue taking the active pills until you have returned to Malaysia.
  • If you bleed during the Hajj, you can still perform your religious duties, provided you clean up first. Dr Jamiyah explains that, according to the fatwa, such bleeding is not considered normal menses as it is the result of hormonal manipulation.

These are only general guidelines. Dr Jamiyah advises women hoping to delay their menses to first consult their doctor, for appropriate dosage and other important information.

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Rescheduling Motherhood?

Rescheduling Motherhood?

April 28, 2022   Return

sperm_egg_Dr Eeson S...

Dr Eeson Sinthamoney Consultant Obstetrician, Gynaecologist and Fertility Specialist

A sad fact of life is that biology is not feminist in nature. Women may have come a long way when it comes to attaining equal rights and becoming more independent, but human biology remains primordial. A woman’s peak fertility period is still in her late teens to her twenties – a time when she may not be ready to become a mother. By the time she is 35 (ironically the age when she may be ready to settle down), a woman’s chance of conceiving per month decreases by half. By age 45, natural fertility is reduced to only one percent.

Ah, but just imagine never having to worry about ‘baby panic’ or the biological clock counting down after hitting the big three-oh: being able to focus on establishing a career, working toward financial stability or emotional readiness. What’s more, if Mr Right is taking his time to show up, it’s no big deal – a lady can wait and not have to settle for less.

If that sounds great, well, these choices are now increasingly possible, thanks to advances in a procedure called egg freezing.

A woman may still have it all

Just like its name states, the procedure involves storing extracted eggs in a very cold environment. The very low temperature keeps the eggs in suspended animation, so that when they are thawed (even years down the road), they can be used to conceive a baby.

Fertility specialist Dr Eeson Sinthamoney explains that, traditionally, egg freezing is viewed as a method to preserve the fertility of women who are about to undergo chemotherapy or other forms of treatment that would affect their ability to produce healthy eggs in the future.

This is still true today, but egg freezing has evolved to become a solution for every woman who wishes to preserve her fertility.

The evolution is made possible because recent improvements made to egg-freezing technology have improved its chances of success.

Dr Eeson explains that, in the past, the freezing process could cause ice crystals to form in the eggs, damaging their structure and making them unusable when thawed.

This changed when a technique called vitrification was developed recently. The technique freezes the eggs very rapidly in order to prevent ice crystal formation. “The eggs can survive better because there is less damage,” Dr Eeson says. As a result, the success rate of egg freezing has improved tremendously. Dr Eeson describes this development as a ‘game-changer’ when it comes to preserving a woman’s fertility.

 

There’s still a catch

Unfortunately, there’s never a foolproof solution. Dr Eeson notes that there are many other factors determining the odds of success.

For example, the eggs that were harvested may already have some abnormalities in them that prevent a successful pregnancy. “The best time for egg freezing to take place is when the woman is in her late twenties to early thirties,” Dr Eeson says. Any later and it may be harder for the fertility specialist to extract enough healthy eggs for future use. This is because a woman is born with only a fixed number of eggs, which decreases as she grows older, and the eggs may also contain more abnormalities as time goes by.

Also, some eggs may be more susceptible to damage compared to others. Fertility specialists do not have a reliable way to ensure that all harvested and frozen eggs are normal or will be able to withstand the freezing process. Hence, there is no guarantee of a healthy pregnancy. 

 

Freezing embryos? Dr Eeson points out that a frozen embryo has a higher chance of resulting in a successful pregnancy compared to a frozen egg. However, the freezing of embryos raises a few issues. One, this may not be an option for an unmarried woman. Two, the freezing of an embryo raises ethical concerns as not all frozen embryos will eventually be used and the unused ones would have to be discarded as a result.

 

What is the procedure like?

  1. The first step is always a consultation, during which the fertility specialist will review the procedure thoroughly with the client. The specialist will also discuss the risks and address any concerns the client may have.
  2. The fertility specialist will then conduct a pre-screening test, called the ovarian reserve testing. This is a simple blood test, usually taken on day three of the menstrual cycle, in which the blood sample is used to measure the levels of anti-Müllerian hormone present. The results will give the fertility specialist a good idea of the woman’s ovarian reserve, which is the number of eggs remaining in her ovaries.
  3. Once all is in order, the client will receive fertility injections to stimulate the production of a large number of eggs.
  4. When the time is right, the fertility specialist would retrieve the eggs while the woman is under deep sedation. This is done using a needle under the guidance of an ultrasound.
  5. The eggs will then be frozen. Special chemicals called cryoprotectants may be used to prevent ice crystal formation.

The entire procedure would take about 10 to 14 days, and would not disrupt the woman’s normal routine much, says Dr Eeson.

For a reasonable annual fee, the fertility centre will store the eggs until they are needed.

 

Frequently asked questions

  • How long can the eggs keep?
    They can keep for a long time, Dr Eeson says. In fact, the actual limiting issue is the age of the woman when she wants to be a mother. Most fertility specialists would prefer that the woman uses her frozen eggs before she turns 50, as pregnancy at age 50 and above has its share of potential complications.
     
  • What happens if the frozen specimens end up missing or damaged?
    Consent forms will have to be signed before any procedure takes place to define what the fertility centre will and will not be held accountable for. Generally, the fertility centre will not be held accountable for any damages that are caused by what’s known as ‘acts of God’: natural disasters and other events that cannot be avoided by any amount of foresight or precautionary measures. If you suspect that the fertility centre has been negligent, you should consult a lawyer for further action.

What happens if the fertility centre goes out of business? What will happen to the frozen eggs?
To the best of Dr Eeson’s knowledge, there are currently no laws or regulations in Malaysia that set out the course of action required when a fertility centre closes shop. To date, no one in Malaysia has had to face such a situation.

Normally, an ethical fertility centre will make arrangements for another fertility centre to take custody of its frozen specimens. Perhaps the best course of action is to ask the fertility centre about this beforehand, as each centre may have its own contingency plan for such a situation.

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Cervical Cancer Elimination Receives a Boost with ROSE

Cervical Cancer Elimination Receives a Boost with ROSE

 April 27, 2022   Return

WORDS PANK JIT SIN

A multinational effort by stakeholders from University of Malaya (UM) and VCS Foundation Australia has resulted in an innovative approach to reduce and eliminate cervical cancer in Malaysia. Known as Removing Obstacles to cervical ScrEening (ROSE), the pilot programme integrates self-sampling, human papillomavirus (HPV) testing and e-health technology to improve cervical cancer screening uptake among Malaysian women.

According to Professor Woo Yin Ling, consultant obstetrician and gynaecologist at UM, who helmed the pilot programme, ROSE integrates “self-sampling, HPV testing and e-health technology to enhance every woman’s personal journey of maintaining good cervical health.”

“At its heart, ROSE is driven by empathy for the screening experience of women. ROSE embodies safety, privacy and dignity through self-sampling, encouraging more women to willingly participate in screening in a timely manner,” says Prof Woo. 

The HPV test accompanying ROSE is evidence-based and highly accurate, thus providing greater reassurance to the women tested. The diagnostic accuracy also allows for less frequent testing over a woman’s lifetime. Prof Woo reveals that it was the e-health component of ROSE that makes it unique and powerful. The programme utilizes mobile technology and VCS Foundation’s canSCREEN®, a population health management platform that enables healthcare professionals to track the progress of every woman screened through their lifetime regardless of whether they did it in a government or private setting.

The programme provides a welcome safety net to ensure women are screened at recommended intervals and followed up accordingly.

“It also allows optimization of health resources by preventing duplication of services while establishing a powerful resource to monitor our progress towards eliminating cervical cancer as a nation,” says Prof Woo.

Evidence for ROSE comes from a multi-sectoral collaborative effort, which was established to conduct the screening study. The pilot project took place in five MOH clinics in 2018 and involved 4,188 women. It was supported by academia, government, corporate, non-profit organizations, as well as private sponsors.

The pilot project found that 99% of the participants preferred the self-sampling method of ROSE, suggesting that Malaysian women would generally find this new approach to screening more acceptable.  Abnormal test results were detected in 5% of the women screened, and three cases of cancer were diagnosed and had the appropriate follow up. The mobile technology and e-health facilitated comprehensive follow through of the ‘screening to treatment’ pathway in the women.

 “The studies also found a high level of engagement with the ROSE model among participating healthcare professionals. They were very encouraged by its potential to increase the uptake of cervical cancer screening by women attending the clinics while not burdening the healthcare staff with additional administrative workload,” says Prof Woo.

Thus, the findings suggest that ROSE is the right way ahead in strengthening the national cervical cancer screening programme.

ROSE’s potential to change the landscape of cervical cancer has been recognized by WHO, Union for International Cancer Control, International Papillomavirus Society, U.S. National Cancer Institute and International Federation of Gynecology and Obstetrics. Dr Tedros Adhanom, Director-General of WHO, wrote in to endorse the women-centred approach of ROSE and said Malaysia is well on its way of meeting WHO’s target of screening and managing 80% of women aged between 35 and 45 by 2030.

Malaysia is the first country in the world to implement a programme such as ROSE, which incorporates self-sampling, HPV DNA-testing, and a digital platform that securely monitors the entire screening journey of women through an integrated platform.

The launch of ROSE and signing of Memorandum of Understanding between UM and VCS Foundation was also attended by Professor Dato’ Dr Adeeba Kamarulzaman, Dean of the Faculty of Medicine, UM, Dato’ Seri Dr Wan Azizah Wan Ismail, Deputy Prime Minister of Malaysia, Datuk Seri Dr Dzulkefly Ahmad, Minister of Health and Hannah Yeoh, Deputy Minister of Women, Family and Community Development. HT

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Taking Control Of Our Fertility

Taking Control Of Our Fertility

 April 27, 2022   Return

WORDS LIM TECK CHOON

Imagine being able to focus on building our career and achieving financial stability without having to worry that time may be running out when it comes to having a family. Perhaps life can be like a romantic movie or novel, and maybe we can wait until we can find that special someone without hearing the biological clock ticking away in our head.

Thanks to advances in fertility methods and technology, we now have options to gain some semblance of control over our fertility (within realistic limits, of course). This month, fertility specialist Dr Agilan Arjunan invites us to take a closer look at these options.

How Long Can A Woman Wait To Have A Baby?

WOMAN’S HEALTH AND FERTILITY WITH

Dr Agilan Arjunan

Consultant Gynaecologist & Fertility Specialist

KL Fertility & Gynaecology Centre

 

When it comes to fertility, the biological clock is quite real. Dr Agilan shares that:

  • A woman’s most fertile period is usually between the ages of 20-25.
  • Her fertility begins to decline after the age of 25 (more steeply after the age of 35), often when she is finally ready to settle down and start a family.

 

Why Is There Even A Biological Clock In The First Place?

While a man’s testicles continuously produce sperm over time, a woman is born with all her eggs already produced, to be released over time during each menstrual cycle.

This means that she has a limited number of eggs that can be used to conceive a child throughout her reproductive years. As we can see from Figure A, a woman has 100% of her eggs at birth,but the number decreases over time. By the time she is 30, she has approximately 10% of her eggs remaining, and the number continues to decline until she experiences menopause, after which she is no longer able to conceive a child.

It’s Not Just The Number That Counts, It’s Also The Quality.

Dr Agilan explains that age doesn’t just affect the number of eggs available for a successful conception. The quality of the eggs is affected too.

“The good quality eggs are often released during a woman’s most fertile age,” he elaborates. As the years pass, there is a higher risk for an egg to contain abnormal genetic material or develop into an abnormal embryo. This is why the risk of having a child with genetic disorders such as Down’s syndrome increases when a woman has a child at a later age (especially after 40).

There Are Other Factors That Also Affect A Woman’s Fertility.

Some of these include:

  • Being obese or overweight has been linked to abnormal periods and ovulation as well as reduced chances of successful pregnancy.
  • Diet and lifestyle may also contribute to reduced chances of conception.
  • Other possible factors that can affect fertility include the presence of pollutants and/or toxins in the environment and stress.

In-Vitro Fertilization Or IVF Can Solve All These Issues, Right?

Sadly, no. No matter how advanced IVF technology may be, it still requires the woman’s eggs. If she has low numbers of eggs, and there are few good quality eggs available, the chances of a successful IVF will be impacted significantly.

Fortunately, there is a way to freeze a woman’s eggs, obtained when she is younger and hence more fertile, which can then be used for IVF when she is at a later, less fertile age.

The Deep Freeze

Dr Agilan shares that, in the past, egg freezing was an option offered to women who were about to undergo cancer treatment. It still is, but with recent improvements being made to the technology, egg freezing is now also an option for women who wish to preserve their younger eggs for later use.

What Has Been Improved About Egg Freezing?

Dr Agilan shares that egg freezing experienced a surge in use after the development of a technique called vitrification. This process allows the egg to be very rapidly frozen in liquid nitrogen. This method greatly reduces the formation of ice crystals that can damage the eggs – a problem that plagued egg freezing prior to the development of the vitrification technique.

Dr Agilan further elaborates that the entire process may take about two weeks, which shouldn’t be too much of a disruption to a busy woman’s routine. He adds that the fertility specialist will try to accommodate the client’s schedule as much as possible.

So, How Much Is It?

The cost may vary from one fertility centre to another. Aside from the usual fees for consultation, injections, medications and the egg harvesting procedure, the fertility centre will charge a fee for the storage of the eggs. If the client has any concerns about the cost, the matter can be discussed with the fertility specialist.

Technology Has Allowed The Freezing Process To Have A Lower Risk Of Egg Spoilage. Hence, Egg Freezing Is Now A More Viable Option To Preserve A Woman’s Fertility.

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What Is The Procedure Like?

  1. Let’s talk about it first. Like most consultations, the fertility specialist will explain the procedure clearly and thoroughly to the client first. Dr Agilan adds that this is a good opportunity for the client to voice any concerns she may have.
  2. Let’s find out how many eggs are there. The fertility specialist may frst conduct a pre-screening test to obtain an idea of how many eggs the client has left (or her ovarian reserve). The knowledge will allow the fertility specialist to determine whether egg freezing is suitable for the client and, if yes, how many eggs would likely be harvested per cycle. Dr Agilan shares that the fertility specialist usually aims to collect about 10 to 12 eggs.

  3. Let’s get the ovaries to work. Once the client is ready, the fertility specialist will offer some injections to stimulate her ovaries into producing a large number of eggs.

  4. Let’s collect the eggs. When the time is right, the fertility specialist will put the client under deep sedation and harvest the eggs using a needle. An ultrasound will be used to help guide the fertility specialist.

  5. Let’s freeze the eggs. The harvested eggs will then be frozen in liquid nitrogen using the vitrifcation process.They will be stored in a safe and clean temperature-regulated area within the fertility centre.

Still Have Concerns? Dr Agilan Dishes Further About Egg Freezing.

How Long Can The Eggs Keep?

The eggs can keep for a considerable length of time so long as they are stored under the right conditions. According to Dr Agilan, the fertility centre typically agree to store a batch of eggs for 5 years.

Can The Fertility Specialist Guarantee The Success Rate When The Eggs Are Used In IVF?

No. Egg freezing serves to preserve a woman’s eggs at a younger age for future use. It doesn’t improve the quality of the eggs or increase the odds of success when these eggs are used in IVF.

What Happens If The Frozen Eggs Are Damaged Or Lost?

When a client agrees to have her eggs frozen at a fertility centre, she will be given a consent form to sign. Details such as accountability will be stated clearly on the form, and the client should read it carefully to make sure that the terms are agreeable before signing on the dotted line.

Details may vary from one fertility centre to another, but usually, the fertility centre cannot be held accountable if the eggs were damaged or missing due to unforeseeable or unpreventable incidents. These include events considered as ‘acts of God’, such as natural disasters. The fertility centre, however, can be held accountable for errors caused by carelessness or negligence.

What Happens If The Fertility Specialist Retires Or Transfers To Another Fertility Centre? Or, If The Fertility Centre Closes Down?

Ethical and responsible fertility centres have contingency plans for issues such as closure. Typically, clients will be notified in advance, and these fertility centres would have made arrangements with another one to take in the frozen eggs.

In the event of a transfer or retirement of a preferred fertility specialist, the fertility centre will be happy to continue the existing arrangement or, if the client prefers not to, help facilitate the efforts to transfer the frozen eggs to a fertility centre of the client’s choice. HT

Hey, how come only women need to plan their fertility? How about the men?

Don’t shoot the messenger, but biology isn’t big on equality of the sexes. Unlike women, men continue to produce sperm cells throughout their reproductive period, and hence there is usually no need to freeze their sperm. Dr Agilan says that sperm freezing is often an option to consider if the man is about to go for cancer treatment. Other than that, he believes that there isn’t any need for a man to freeze his sperm.

However, do note that male fertility has been decreasing on a global scale, although we have yet to fgure out the exact reasons for this phenomenon. Dr Agilan believes that some men may have fertility issues after the age of thirty, and as such, they should consider visiting a fertility specialist if they had been trying to have a child through regular sexual intercourse for a year or so, but have yet to be successful.

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