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Dr Peter Chew, Obstetrician and Gynaecologist at Gleneagles Hospital and Chairman of aLife Ltd, addresses fertility awareness issues.


Q: How can erectile dysfunction be treated?


A: Impotence or erectile dysfunction (ED) is the inability to obtain or maintain a penile erection sufficient for the male to satisfy his sexual needs or the needs of his spouse.


The conditions that must be present for an erection to take place are:
(1) Healthy male sexual organs, including testes and penis
(2) Normal circulating hormones including male sex hormone (testosterone) & milk-producing hormone (prolactin).
(3) Intact nerve supply and blood flow to the sex organs
(4) Healthy psychological response to sexual arousal, and
(5) Relaxed state of mind.


ED is a fairly common condition in Singapore, affecting about 50% in men aged 30 years and above according to a local survey. Many men with ED suffer in silence as they are too embarrassed to seek help.


The causes of ED can be due to psychological, physical, relationship and lifestyle problems.

~ Psychological:
• Performance anxiety
• Guilt about sex
• Fear of pregnancy or sexually transmitted diseases
• Resentment of women’s bodies
• Jealousy


~ Physical:
• Diabetes
• Drugs like antidepressants, tranquilisers, cholesterol-lowering medication
• Alcohol, smoking and drug abuse
• Diseases of the nervous system including injuries to the spine
• Diseases of the urinary system including prostate gland surgery
• Heart diseases
• Hormonal problems
• Chronic illnesses
• Depression


Loosing an erection occasionally during sexual intercourse is fairly common among men. However, it always leads a man to question his own masculinity. Difficulties with erections cause performance anxiety and the consequence is for the man to keep forcing an erection. The more he forces, the higher the chances he fails. This is because the anxiety will make him loose the sensations from sexual arousal. This vicious cycle will make the erectile problems recur and get worse with time.


When ED occurs, the couples must work together to get to the root of the problem. They must not be critical and point fingers at each other. Instead they should try to solve the problem in a cooperative and non-demanding manner.


If erection fails, it is important for the couple to stop trying. This will remove tension and performance anxiety. They should try to indulge in other intimate activities like kissing, hugging, cuddling, touching and messaging. Once the man is sufficiently aroused and the penis is rigid, he may be ready for the intimacy. The woman should then take the active role and try inserting the penis into her vagina in a female-on-top position or any other position the couple find comfortable.


If the problem persists, the couple should then seek medical help. The medical, surgical and sexual histories are reviewed and physical examination including examination of the sexual organs done. Blood tests including diabetes and hormonal tests are taken. Appropriate treatment will then be given.


Treatment options include:
• Sexual counselling and therapy.

• Oral medication – Viagra has been fairly successful in treating ED. However it is not suitable for everyone and there are side effects. Other medications (Cialis and Levitra) with longer duration of action and fewer side effects are also available. Some herbal products may also be helpful.

• Cock rings and vacuum erection devices – These mechanical devices help to maintain an erection by keeping the blood in the penis for a longer period of time.

• Self-injection of drug (prostaglandin) into the penis or urethra (urinary passage) has been used with good results. However, most men are hesitant to inject themselves even though the needle is quite small and the injection is generally painless.
• Surgical procedure – This is usually done as a last resort as it carries risks. Many procedures have been tried but the most popular is to implant a prosthesis into the penis and surrounding region. The implant is inflatable and connects to a fluid reservoir. When the man wants to have sexual intimacy, he uses the pump (hidden in the scrotum) to fill the implant with fluid and make the penis rigid.



Q: What food/health food is good for increased sperm in guys? Is Viagra/Tongkat Ali good and does it help?


A: Presuming this question is about low sperm count, Viagra and Tongkat Ali are meant for erectile dysfunction and not for improving sperm count.


To understand low sperm count, one should know the composition of normal semen. According to the WHO (World Health Organization), normal semen analysis should have the following values:
• Volume of the semen: 2 ml – 5 ml
• Concentration of sperm: at least 20 million/ml
• Motility of the sperm: 50% and above
• Normal morphology (shape of the sperm): 30% and above

What are the causes of low sperm count?
• Sauna, hot baths and tight underwear reduce the sperm count.
• Stress, drugs, alcohol and tobacco can affect sperm concentration and motility.
• Infection of testis and prostate gland: Sexually transmitted diseases like Chlamydia, Gonorrhea, Tuberculosis, Mumps
• Varicocoele: This is an abnormal collection of veins that surround the testis
• Testicular tumors
• Hernia or testis operation
• Patients on radiotherapy or chemotherapy treatment
• Genetic cause: some males are born with undescended testes or small and undeveloped testis
• Hormonal deficiency: Some males have low hormone production from the pituitary gland (a pea-size gland at the base of the brain) causing low testosterone production and sperm
• Patients with long standing diseases of liver and kidney may have low sperm count


About 50% of patients have unexplained causes.


How to improve low sperm count?

• Change the lifestyle such as smoking, excessive drinking and drug abuse
• Avoid sexually transmitted diseases and treat the sexually transmitted diseases early, if present
• Avoid sauna, hot baths, and exposure to hot environment or toxic chemicals (e.g. pesticides)
• Wear loose undergarments and trousers
• Take cold showers
• De-stress program with psychological support and counselling help
• Take supplements containing Vitamins A, B complex, C and E and trace elements Zinc and Selenium
• Food rich in these vitamins and trace elements include brightly coloured fruits and vegetables, such as carrots, tomatoes, spinach, broccoli, green beans, oranges berries and nuts like almond and walnuts
• Male hormones (testosterone) have been prescribed empirically with occasional success
• Remove the varicocoeles if they are present



Q: What are some tips to maintain sexual interest after a child comes along?


A: A new baby demands time and energy. Hormonal changes and soreness from stitches after delivery cause about 50% of women to have a decline in the interest or little desire for sex. Besides, breast-feeding reduces oestrogen which causes vaginal dryness, discomfort and painful sex.


Some tips for maintenance of sexual interest:
• Accept that things have changed since the baby arrived
• Be patient: Wait till the wound heals. Normally, perineal wound from vaginal delivery and abdominal wound for caesarean section will take at least 4-6 weeks to heal.
• For the husband, please help out with the household chores. Share the night feeds with your spouse so that she can have some rest especially if she is breastfeeding.
• Ask the gynaecologist when you can resume sex.
• Get advice from the gynaecologist as to what is the most suitable method of contraception. Fear of getting pregnant may inhibit your sexual desire. Use of contraceptive pills/hormonal injections/implants can cause a decline in sexual interest in the female by altering the hormonal balances.
• Use the water based lubricant if the vagina is dry
• Have couple time together and ask each other for sex
• Talk about what feels good sexually and how to make sexual intimacy better
• Continue with non-sexual affection especially physical touch such as cuddling and hugging
• Share and discuss your innermost feelings and don’t avoid conflicts
• Build up your “emotional tank of love” with your spouse by understanding his/her feelings through communication and quality time together. Understand your spouse’s and your own “languages of love” (book recommendation: The 5 Languages of Love by Dr Gary Chapman) is an important tool in building relationship.
• Remember “A good relationship leads to a good sexual life.”



Q: When are the most fertile days in a woman’s menstrual cycle for conception?


A: If a woman’s menstrual cycle is regular at 28 days, then the fertile day is between Day 12 to Day 16. If the cycle is irregular, then the fertile period cannot be predicted. Other methods like cervical mucus examination and ovulation prediction kit may have to be used.



Q: I was diagnosed with high nuchal translucency on the 2nd month of pregnancy and CPC was detected also during the 5th month. But after I delivered, my baby’s completely normal. How accurate are the NT tests and detailed scans? How can we be sure that the baby will be ok in the years to come?


A: Screening test using ultrasound for the back of baby’s neck was reported in the 1990s. This was based on the fact that the skin of Down’s syndrome babies appears to be excessive for their bodies, especially over the back of the neck. The ultrasound scan could identify and measure the skin fold over the back of the neck in the first trimester (at 11-14 weeks). This is known as “nuchal (neck) translucency” If this is thick, the baby is at a higher risk of suffering from Down’s Syndrome or some other genetic abnormalities.



Like all screening tests, it cannot diagnose the disease. Therefore, if your baby is born completely normal, he or she should be OK. Please follow the advice of the paediatrician regarding the child’s development.


Q: My wife has been dizzy for the last 2 weeks, the last DIY pregnancy test done a week before, was negative. Her menstruation is expected to come next week. What should we do next? How many times a week should we have sex if we’re planning to have a kid as soon as possible, given that we are both very busy career people.


A: Presuming your wife has delayed period as the pregnancy test is negative. It may be a result of:

• Polycystic Ovarian Syndrome (PCOS): In this condition, there is hormonal imbalance between oestrogen (female hormone) and androgen (male hormone). As a result, there is no ovulation and the menstrual cycle becomes irregular and/or prolonged. It is associated with obesity, acne, high blood pressure and sometimes excessive facial hair.
• Anxiety and emotional stress: Mental stress can temporarily alter the functions of hypothalamus — an area of the brain that controls the hormones regulating the menstrual cycle. Ovulation and menstruation stop as a result.
• BMI: Excessive weight gain and loss can interfere with hormonal functions in the body causing menstrual periods to stop.
• Vigorous and excessive exercise: This may interfere with ovulation and cause hormonal imbalance.
• Medications: medications such as tranquilizers and antidepressants can cause menstrual periods to stop.
• Thyroid malfunction: An underactive thyroid gland (hypothyroidism) or overactive thyroid gland (hyperthyroidism) can cause menstrual irregularities.
• Pituitary tumour. A noncancerous growth in the pituitary gland (a pea-sized gland at the base of the brain) can cause an overproduction of prolactin (milk hormone) which in turn interferes with menstruation.


What are the other symptoms of delayed period?
Delayed period is a symptom, not a disease. Other symptoms present would depend on the cause. For example, if you have the hormonal imbalance, you may feel bloated, have acne, breast milk secretions, weight gain or loss.


How is it diagnosed?
In order to find out the cause, the gynaecologist will take a detailed medical history. A general and a vaginal examination will be done together with other investigations such as blood hormone tests, x-rays and ultrasound scans.


How is it treated?
The treatment would depend on the cause. Returning to normal body weight and reducing stress may help solve the problem. Medications to induce ovulation may be prescribed and surgery may be necessary if there are tumours or cysts in your ovary.


Chances of conception are best during the most fertile days in a woman’s menstrual cycle. If the menses cycle is regular at 28 days then the fertile day is between Day 12 to Day 16. If the cycle is irregular, other methods like cervical mucus examination and ovulation prediction kit may have to be used to predict the fertile period.



Q: Can women get pregnant while still breast feeding?


A: Yes, ovulation may occur depending on whether the mother breastfeeds completely or partially. The high level of prolactin produced due to suckling can inhibit ovulation but pregnancy is still possible as the inhibition is not 100% complete. The mother can continue to breastfeed while pregnant.



Q: Would my wife’s thyroid affect fertility?


A: The thyroid gland is a butterfly-shaped organ situated at the lower part of the neck, below the Adam’s apple and in front of the windpipe. It manufactures thyroid hormones which help regulate the growth and the metabolism of every cell in the body.


When the thyroid gland is underactive (hypothyroidism), the body’s metabolism is slowed down .This is associated with symptoms such as constipation, weight gain, lethargy, fatigue and heavy periods. The ovulation is usually defective and this results in increased risk of miscarriage and infertility.


Hypothyroidism can also cause an increased production of prolactin, the milk hormone released by the pituitary gland. Excessive prolactin prevents ovulation causing irregular periods and infertility.


There is also an association between hypothyroidism and polycystic ovarian syndrome (PCOS), where ovulation is hampered and fertility impaired.


When the thyroid gland becomes overactive (hyperthyroidism), the body’s metabolism increases, resulting in frequent bowel movements, weight loss, increased appetite, insomnia, nervousness, hand tremors, heart palpitations and irregular, scanty periods.


Ovulation is usually inhibited resulting in fertility problems. Even when a woman with hyperthyroidism does conceive, risk of miscarriage or foetal death is high.


It should be noted that in both men and women with untreated thyroid disease, the sexual desire (libido) is often decreased. Hyper- or hypothyroidism can also cause male infertility since sperm development requires normal thyroid hormone levels.



Q: What dietary method/s can aid male SD?


A: Sexual Dysfunctions encompass a wide range of disorders. No dietary treatment can be prescribed. However, if the person maintains a healthy lifestyle and a balanced diet, the chances of SD will be less.



Q: If the percentage of normal shaped sperm is only 1 percent, is it possible to get pregnant naturally?


A: Pregnancy does not depend solely on normal shaped sperm. It also depends on the density of the sperm and the motility of the sperm. It is still possible to get pregnant as the number of normal shaped sperm can fluctuate with time, duration of abstinence, stress and other factors.



Q: Does sleep position after sex affect the pregnancy rate?


A: Sleep position after sex does not affect pregnancy rate. However, certain positions during sex may increase the chances of conception.


Although there is no strong evidence to suggest that sexual position affects chances of conception, it is thought that the nearer the sperm are deposited at the cervix, the better the chances.


MRI imaging techniques have shown that missionary and doggy (rear entry) styles allow deepest penile penetration and the sperm are deposited nearest to the cervix. Missionary position also allows the semen to stay inside the vagina rather than leaking out thus facilitating interaction between sperm and cervical mucus, an important step in the process of conception. Some experts advise the woman to lie down for a while after sex and place a pillow underneath the hips to elevate the pelvis. This allows sperm more time to move up the genital tract.





For more information, you may contact aLife Ltd at (65) 6258 8816 or email us at alife@singnet.com.sg.


The answers to the above feature questions have been contributed by Dr Peter Chew, Senior Consultant Obstetrician and Gynaecologist at Gleneagles Hospital and Chairman of aLife Ltd. Please visit www.alife.org.sg to read more.


NOTICE: Any information or materials posted on this web site are intended for general informational purposes only, and should not be construed as diagnosis or treatment. Any information posted on the web site is NOT a substitute for medical attention. See your health-care professional for medical advice and treatment.





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