Category: 2017

Relactation: Can you breastfeed your weaned baby again?

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Just how easy is it to stimulate milk supply after stopping or induce lactation as an adoptive mother? Charlene Yared West explores the topic of relactation and induced lactation to find out more.

Firstly, what is relactation?

According to Leana Habeck, La Leche League Leader (llli.org/southafrica), there is a difference between relactation and induced lactation. “Relactation is about re-establishing of milk secretion after weaning baby from the breast,” says Leana. “Adoptive breastfeeding, also called induced lactation in a woman who was not pregnant with the current baby, may involve hormonal preparation (oestrogen and/or progesterone – simulating a pregnancy) followed by sudden cessation of the hormones (simulating a birth) and then the commencement of pumping or suckling and a galactagogue that increases prolactin secretion.” Internationally Board Certified Lactation Consultant, childbirth educator and midwife Emma Numanoglu explains the protocols for inducing lactation, developed by Dr. Jack Newman and Lenore Goldbarb, as involving a regime of taking the contraceptive pill together with domperidone. “A few weeks before the expected arrival of the baby the mother stops taking the pill, continues with domperidone and starts expressing milk (this mimics the process of pregnancy and lactogenesis after birth). This method has been used successfully and safely for three decades by many women who induced lactation,” she says. “A mother who is planning to apply one of the protocols will need to find a doctor who is supportive of breastfeeding, can explain risks and benefits of taking the medication, and is willing to take responsibility for prescribing domperidone in doses that exceed  guidelines for licensed use.”

Commitment to breastfeeding is key to success

Relactation, explains Emma, is also an option for those mothers who have have decided to bottlefeed and have then changed their minds and wish to go back to breastfeeding, or even for those mothers whose babies are not tolerating formula well. “In my practise, this is the most common reason for relactation and the reasons are important as it requires quite a commitment from the mother. For example, if the baby is intolerant to the breast milk substitutes being given, the mother may be more committed to resuming breastfeeding,” she says. “It is important not to place emphasis only on her milk as evidence of success, as this can cause anxiety and thereby inhibit her milk production and ejection reflex. For these reasons it is important to discuss with the mother the benefits, the concerns and problematic elements of relactation.” Emma sees the most success in relactation with babies under three months, but older than that is not impossible, it may just take more effort. “Induced or adoptive lactation is becoming more popular. Mostly adopting couples and lesbian couples seek assistance in breastfeeding their adoptive baby.”

The aim is bonding and creating a milk supply

“For both adoptive breastfeeding and relactation, the aim is to bring about (or back) a milk supply and bring the baby back to the breast. These two are interconnected endeavours, as the best thing for a milk supply is to have a baby breastfeeding frequently and a baby is more likely to breastfeed or return to the breast if there is plenty of milk there,” says Leana. “The difference between the two is such that with a natural pregnancy the milk making tissues are built, whereas with adoptive breastfeeding (if a mother has never been pregnant) she may need hormonal preparation. For many adoptive mothers it may be more about connecting deeply with the new baby through breastfeeding, than producing large volumes of breastmilk.” Emma adds that relactation can fail if mothers are not given the correct support and professional advice preferably from an IBCLC or SACLC trained consultant and La Leche League leader. “Success also depends on quite a few other factors, such as the determination of the mother, no underlying medical conditions and the baby’s age.” 

How the breasts work

Leana describes the anatomy of the breast as 10 to 20 branches (milk ducts), heavy with clusters of grapes all intimately bound together by interweaving vines and vegetation. Each single grape an alveoli or milk sack where milk is made and each alveoli is surrounded by a basket of muscle cells that squeezes the milk out into the ducts when it contracts. The 10 to 20 branches are all rooted in the nipple, though each nipple has only between four to nine openings through which the milk is excreted. “Baby’s suckling acts as a stimulus to mom’s body – sending a message to the brain to release the milk producing hormones, prolactin and oxytocin into bloodstream,” she says. “Prolactin, released with the Milk Ejection Reflex (MER), acts on the alveoli to produce milk and Oxytocin, released with the MER, acts on the muscle cells around the alveoli causing them to contract and squeeze out the milk towards the nipple.” It is important to note that large amounts of milk are not stored in the ducts before the MER and that the rapid sucking action of the baby stimulates the let down of milk. The most important thing is to ensure a good latch to help the MER during breastfeeding as well as a good breast pump to stimulate the production of milk too. 

Methods of relactation

Emma recommends holding your baby skin to skin as often as you can, in a calm relaxed environment such as lying in your bed, in a comfy chair or even carrying them around in a sling at home. Directly feeding your baby from the breast is the most effective way to increase your supply or relactate. Offer your breast to your baby frequently when they are happy! Do not try breastfeeding when your baby is upset or irritated as it will be nearly impossible to latch them on.  “This is an extremely important step. Although it sounds so simple, often this is how babies get interested in breastfeeding again.You can start pumping if you find your baby does not want to breastfeed for very long, or is not interested in taking the breast.  Since you are trying to build your supply back up or induce lactation again, it is important to pump frequently,” she says. “If you can pump every two to three hours, that would be ideal. At night you can go for longer between pumping but try to get at least one pumping session in per night.  When you start pumping you might not get any milk at all or just small amounts, just keep on going! Some women find it takes a couple of months to really get their supply going again, especially if their babies are not breastfeeding or are only occasionally breastfeeding.” She adds that women who have had an extended period of time since breastfeeding might find they do not build up enough of a supply to exclusively breastfeed, but most women will at least be able to partially breastfeed their babies and many women will eventually be able to exclusively breastfeed their babies. 

What is a supplemental nursing system?

A nursing supplementer is a device that allows a baby to receive extra milk at the breast rather than by bottle and teat. It consists of a container that is worn on a cord around the mother’s neck. Fine tubing carries expressed breastmilk or artificial baby milk from the container to the nipple. When the baby sucks at the breast, milk is drawn through the tubing into his mouth, along with any milk from the breast. “Most mothers who have problems getting breastfeeding started will solve them without using a breastfeeding supplementer. Often all some mothers need is information and support. Talking the problem over with someone who understands and supports your wish to breastfeed and who knows a lot about breastfeeding can help you work through any problems. Often they will be able to suggest new ideas to try,” says Emma. “Sometimes, you can solve your own problems by learning more about how breastfeeding works. It is important that the baby is able to suck well at the breast, even if he tires easily, in order for the breastfeeding supplementer to work. A baby with a poor or abnormal suck may not be able to get the milk through the tubing any better than from the breast itself.”

I breastfed my adopted babyDanielle Bischoff is a photographer and storyteller and lives and works in Cape Town with her husband comedian, Rob van Vuuren and their six-year-old adopted daughter, Bijou.
“Rob and I both have adoption in our families and when falling pregnant became increasingly difficult and a cause of huge distress for us, the doctors said the only option was to go the IVF route. We both felt like we needed to take a breather from the whole thing and put the baby plans aside for a few months. We didn’t want to rush into a whole IVF mission. We felt that we had been through enough of a wringer just trying to figure out what the problem was. So we left it for a while. After a couple of months we both felt that adoption was the best way forward. I can’t describe it in any other way than I just new our baby was coming to us through adoption. I felt a deep connection and I had even chosen her name before our first meeting with our social workers. There was just this indescribable knowing that baby was on the way and I had to get ready. I didn’t even know that inducing lactation was a thing, but I was so determined to make it happen. So you can imagine the relief I had when contacting Internationally Board Certified Lactation Consultant Jean Riddler, who immediately promised she could help me. It was important to me for two reasons, because  I didn’t get to experience a pregnancy I felt like I didn’t want to miss out on the experience of breastfeeding. I had also done some reading on all the amazing benefits. Strengthening the bond was a huge reason and because Bijou was adopted I felt like I had some catching up to do as I hadn’t carried her.I started on the birth control pill to mimic a pregnancy. I wasn’t really happy about going on the pill but as I mentioned before I was pretty determined about it. Once we got the news that a birth mother had chosen us and we had Bijou’s due date, we sped up the process by taking the vomidom (domperidone) and using a double breast pump to stimulate the breasts. This was honestly the hardest part of the whole business. There were moments while sitting there with pumps on my breasts with nothing happening where I really questioned my sanity. Anyway just over a week later the milk started coming out! I was totally amazed and in awe of the human body. I wasn’t able to produce enough milk to purely breastfeed which I was initially quite sad about, but after sometime I was just grateful for the opportunity. I soon realized that being able share the feeding duties with my husband was beneficial for all of us. So in the end we mainly bottle fed her and did top ups with breast milk. I breastfed Bijou until she was about two-years-old. It was a bit of a roller coaster ride to be honest. I felt emotions that I didn’t know I would have. The feelings of inadequacy I felt when I realized that I wasn’t able to purely breastfeed did overwhelm me. I felt like I had let her down and how could I be a mother if I couldn’t feed her. Obviously in retrospect I realize how irrational all that thinking was. Luckily my husband was there to help me through all that. It was totally worth every second on my mothering journey with my precious daughter.”
<Sidebar> PATIENCE AND PERSEVERANCE!Many women who keep persevering and gently encourage their babies to breastfeed while doing heaps of skin to skin with their babies do get results, says Emma. “Don’t give up. It just takes a lot of patience, perseverance and time. It will not happen overnight.  Support helps too and is very important. Ask for help with cleaning, laundry, cooking and other household chores, while you focus on just being with your baby.  Rest and just “hang out” with your baby.” 
<Sidebar>Amazing motherhood hormonesAt every stage of motherhood there are hormones present to facilitate the changes taking place. In addition to a very long list of natural ingredients, breastmilk also contains the following amazing hormones: Prolactin is the hormone of milk production. The suckling newborn increases prolactin levels which physically works in creating more milk, and emotionally, prolactin encourages the mothering instinct of nurturing and selfless devotion to the baby’s health and well being. Oxytocin is known as a shy hormone and is present in orgasm, labour, birth and breastfeeding and causes the Milk Ejection Reflex (MER). Emotionally it is a bonding hormone, also known as the love hormone because it occurs at intimate, private moments of family bonding and love. Physically it is a contracting hormone and as such contracts the uterus in orgasm, facilitates contractions in labour and birth and allows for the milk let down as the milk ducts are contracted and squeezed to allow for milk to flow. Endorphins are the body’s own natural painkiller and can create euphoria and are released during sex and breastfeeding. 
<Sidebar> A word on galactagoguesGalactogogues are medications or other substances believed to assist initiation, maintenance, or augmentation of the rate of maternal milk production. Human milk production is a complex physiologic process involving physical and emotional factors and the interaction of multiple hormones, the most important of which is believed to be prolactin, explains Leana. “One should caution against inappropriately recommended galactogogues prior to emphasizing the primary means of increasing the overall rate of milk synthesis, such as frequent feeding and regular draining of the breasts.”A galactagogue may be helpful to speed up the process but are not magic bullets, she adds. They provide building blocks for milk production but effective removal of milk is essential since milk supply seem to be calibrated based on how well the breasts are drained. “If baby is not breastfeeding (well) yet, it is advisable to double pump with a good quality electric pump using the hands-on method.” According to Leana, the currently available pharmaceutical galactogogues are all dopamine antagonists and will increase prolactin levels. Herbal remedies have been used throughout history to enhance milk supply. Some herbs mentioned as galactogogues include fenugreek, goat’s rue, milk thistle (Silybum marianum), oats, dandelion, millet, seaweed, anise, basil, blessed thistle, fennel seeds, marshmallow, and many others. “Although beer is used in some cultures, alcohol may actually reduce milk production. A barley component of beer (even non-alcoholic beer) can increase prolactin secretion, but there is no hard evidence supporting this,” she says. “Mothers wanting to make use of a galactogogues should contact their doctor for a prescription since La Leche League Leaders or International Board Certified Lactation Consultants are not allowed to prescribe any medication be it natural or pharmacological.”  Emma points out the most important thing to remember is that an herbal or prescribed galactogogue will only work if you take it while actively trying to build your supply at the same time.  “You will not see an increase if you do nothing but take a galactogogue.You should only take a galactogogue if your doctor is in agreement and all side effects and contraindications have been discussed,” she says. 

‘Surrogacy gave us the gift of twins’

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Tasha and Wayne McKenzie wanted a baby even before they said their vows on their wedding day. After four years of trying to fall pregnant naturally and after six unsuccessful rounds of IVF, their friend Lee-Ann Laufs said she would be their surrogate. Charlene Yared West sat down with Tasha, Wayne and Lee-Ann to learn more about their surrogacy journey. 

Surrogacy chose us

Wayne and Tasha felt that they had exhausted all their options to have a baby, save the adoption route. Their friend, Lee-Ann Laufs worked closely with with a safe house for abused and abandoned children called Miracle Kids in Cape Town. “I emailed her to get the details and she called me back saying that she had been telling my wife Tash for months that she would be our surrogate – and that she really meant it. I was blown away by what she said and wanted to laugh and cry simultaneously. I knew this could finally be it… We could have our baby!” 

Tasha recalls how she got to know Lee-Ann in her beauty salon; “When she came for treatments, we got to know each other and would start chatting about where I was in fertility treatment. She always mentioned wanting to be our surrogate, but sometimes people say things they don’t really mean and I wasn’t sure if this was one of those times, so I left it at that. She gave birth to her second son and after the caesarean messaged me from the hospital saying she would do this for us. She told us to be patient and wait a little while longer until she had healed and was ready to be pregnant again. We left it at that and I still didn’t believe her!” 

It was only after Lee-Ann and Wayne had spoken that the offer of surrogacy became real to Tasha. “Unless you have been through the process, you will never know the heartache of infertility and I was terrified to allow someone else to carry my baby.” adds Tasha. “It was the best news to hear that both eggs survived and we were expecting twins. Prof Thinus Kruger from the Aevitas Clinic dealt with the embryo transfer and making us pregnant.”

Lee-Ann recalls how during the pregnancy, Wayne started calling her “Smeg”, which was a code word for oven. “That was exactly how I viewed the pregnancy; I was an oven for their babies. Simply put; their sperm and eggs, my uterus. The babies don’t receive anything from the surrogate mom except food and a warm comfy womb.This is known as gestational surrogacy,” explains Lee-Ann. “There were no feelings afterwards of ‘I wish they were mine.’ The joy it gives others is so worth it and helps erase all the heartache they went through to finally have their babies.”

The medical side

“The surrogate and the commissioning mother need to sync their monthly cycle,” says Professor Thinus Kruger from Aevitas Fertility Clinic in Cape Town. “Hormone injections are administered to the surrogate to stop her from ovulating at this time. Her uterine lining also needs to be a certain thickness so that the embryo can be transferred into the lining to grow.” He explains how the commissioning mother’s eggs are stimulated to get as many as possible and are then grown until they are mature enough to be harvested and then fertilized by sperm from the father. “The laboratory scientist selected eight eggs based on quality and and then fertilized those. They are then grown and allowed to undergo cell-division outside of the body between three and five days. Not all the eggs will go through these stages of cell division and then another selection process takes place where only two embryos are transferred into the surrogate’s uterus at this time. After the transfer, there is a waiting period of ten days before seeing if the pregnancy is viable.” Prof Kruger explains that there are variations to this process and it is not successful at every stage.

Gynaecologist and obstetrician Dr Gary Groenewald was chosen by Lee-Ann to continue his care as her primary caregiver. “Lee-Ann is an extremely giving person and to do this for friends – to undergo pregnancy and surgery via caesarean section – is a major sacrifice. It really takes a special, very generous person to do this for someone else,” he says.

Since the McKenzies’ case, Life Healthcare developed a very practical and sensitive protocol to deal with future surrogacy cases. Wayne shared how special the caesarean was at Life Kingsbury and that he and Tasha were allowed to be there as well as Lee-Ann’s husband, Shaun. “It was the best day of our lives and we are forever grateful to Lee-Ann for what she did for us. We are adjusting to life with our baby girls, Lea and Madi and being parents,” says Tasha. “It has been an amazing journey and all the pain and disappointment of infertility is slowly fading, but it still feels like a dream sometimes… but then I see my daughters and I am so proud and happier than I could ever have imagined possible.” 

Surrogacy Quick Facts 

  • According to Surrogacy.co.za, women who want to be a surrogate need to have had experienced pregnancy and birth and have at least one living child of their own. 
  • A surrogate also needs to be in good physical, emotional and mental health. A thorough medical and psychological examination is carried out to ascertain suitability of the surrogate and the parents. 
  • Since 2010, new laws about surrogacy were passed and women wanting to be surrogates may no longer gain financially from the process. However, all medical bills for the pregnancy must be footed by the commissioning parents. You may only be a surrogate for altruistic reasons. 
  • Commissioning parents opt for surrogacy because they are unable to conceive their own child via fertility treatment or otherwise. Many gay couples who want a child of their own often look for a surrogate to help them achieve this. 
  • As a surrogate you have no rights to the child after birth. 
  • A contract is drawn up with the Surrogate Lawyer so that your surrogate does not run away with your unborn child. In the contract it also states how many IVF processes the surrogate is willing to do and how many IVF processes the parents to be are able to afford before cancelling the contract. 
  • Check out www.surrogacy.co.za for more info. 

Multiples: A dream come true through IVF

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If you have been trying for a baby for more than a year, but have been unsuccessful, you are one of at least 50-million couples who experience infertility worldwide. The number of children being born in South Africa is also on the decline and according to the Recorded Live Births 2013 to 2015 report, the number of birth registrations decreased by 6.8% from 1.6-million in 2013 to 1.08-million in 2015.  As a result, many couples are turning to infertility treatment to fulfil their hopes of having a baby. If you’re a good candidate for In Vitro Fertilisation, it may be the only way to help you grow your family unit from husband and wife to three… or even four… or more! 

Multiples and IVF

“IVF treatment can result in multiple births because, often, more than one embryo is transferred into the uterus of the mother,” says Dr Henk Burger, gynaecologist and obstetrician at Life Carstenhof in Gauteng. “The chance of having multiple births can be reduced considerably by only putting one embryo back into the womb.” The cost of IVF ranges from R30k to R50k per attempt, which explains why many couples opt for implanting more than one embryo to increase their chances of a successful pregnancy the first time around, explains Dr Burger. He notes that sometimes a termination of one of the embryos is requested after implantation, but this is very difficult and dangerous for the embryo that stays behind. 

Multiples and risk

We all know how adorable twins are – and they make for an instant family unit, but they also come with a certain level of high risk in pregnancy. “Around 30% of multiples are prone to prematurity – and born before their due date. There is also the risk of intrauterine growth retardation, birth defects and miscarriage. The mother is also five times more likely to get pre-eclampsia and six times more likely to have polyhydramnios and antepartum haemorrhage,” says Dr Burger. “Mothers carrying multiples must ensure they attend each and every antenatal consult; every four weeks up to 20 weeks, every two weeks up to 28 weeks and every week up to birth thereafter. The aim is to get the mother to carry her baby to at least 36 weeks, but this is often not the case.” He also advises mothers to eat a  balanced diet, not to smoke and to take antenatal supplements. “Simple things like positioning of the safety belt in the car when driving are also important to remember to reduce risk,” he adds. 

Natural or Caesarean birth for multiples

According to Dr Burger, birth by caesarean section is the safest for multiples, because of the risk, especially for the babies born after the first one. “There is positional risk such as breech or transverse positioning, especially for the second baby. There is also the risk of premature labour, placental abruptia, fetal distress and even early closure of the cervix,” he says. “There was a case reported where the cervix closed after the mother had naturally birthed the first of her twin babies. Her cervix remained closed for 56 days before she birthed the second one! It is the longest reported period between delivery of the two babies.” 

Breastfeeding your babies

Dr Rebecca Makate is a paediatrician at Life Carstenhof and is experienced in helping parents adjust to life with their new babies. “Breastfeeding for any baby offers major health advantages such as less infections and better neurodevelopment. The breast can make enough breastmilk for two or more babies as breastfeeding is based on supply and demand,” she says. “In other words, the more you breastfeed the more milk your breast produces. It is also possible to breastfeed twins at the same time on different breasts. Having said that, having more than two babies can come with huge challenges during feeding time.Even if you breastfeed, occasional supplementing your babies formula will give you some much needed freedom and sleep.”

<Sidebar> So what is life like with multiples?Despite some challenges and drawbacks, having multiples is a great joy, says Dr Makate. “There is a level of convenience and efficiency in parenting children simultaneously; some of the unpleasant aspects are sleepless nights, feeding times, potty training and teenage troubles which all have to be endured at once. Mostly though, there is a great pleasure and enjoyment in parenting multiples, every moment is multiplied and every simple joy is magnified,” she says. Dr Makate lists the following challenges couples should consider before IVF:-Pregnancy and birth risks when carrying multiples.-Fetal complications and time in the NNICU.-Lack of sleep.-Difficulty bonding.-Economic impact on the family unit.-Relationship with your spouse is put under pressure.-The need for extra help with caring for the babies. 
<Sidebar> What are Monozygotic and Dizygotic multiplesMonozygotic multiples: In monozygotic multiples, the embryo splits and the babies are born identical. In utero, they share one placenta and one amniotic sac. Dizygotic multiples: In dizygotic multiples, there are two separate embryos, each with their own placenta. Monozygotic multiples are higher risk for a few reasons: Placenta abruptia: where the placenta tears away from the uterus during birth and deprives one or more of the babies from it’s life source of oxygen and blood. Cord prolapse: where the umbilical cord of the second baby born prolapses out of the mother’s vagina. Twin-to-twin transfusion syndrome: where the babies share a joint blood circulation through the placenta, which contains abnormal blood vessels, where blood is transfused disproportionately from one twin (the donor) to the other twin (the recipient).
Lindy and Michael’s* story
We fell pregnant after many, many years of trying to conceive – almost ten years. Initially we tried naturally, then Artificial Insemination and then only In vitro Fertilisation. As I am an older mom it was necessary to go this route. It’s a very drawn out process with lots of steps and checks and balances. One needs to eliminate the options that are not viable first and the doctors are all very cautious and considered in how they approach IVF in South Africa. It is a very expensive process, but we were committed to being parents, and I was not willing to give up, so we just kept on trying until we had a positive outcome. We first attended the Cape Fertility Clinic but after no luck there, we moved to Aevitas which is based at Life Vincent Pallotti. Prof Kruger and Prof Siebert from Aevitas were absolutely amazing, as were all the sisters that worked with them in their team. A number of eggs were fertilised and the best quality eggs were implanted and we were very lucky that two fertilised eggs resulted in our gorgeous twins, Jacques and Stella. It was a very long and stressful process. We lost a baby at full term, Ruby Mae, who was stillborn at 41 weeks.  Soon after this loss, we tried again to conceive and with the help of Aevitas got pregnant with the twins who were born on 1 May 2015. It was amazing and unbelievable to find out we were pregnant with twins after losing our previous baby.  We were elated and also scared as twins are a major change in one’s life. On the 13th of January we felt our first big kick after steak strips with Szechuan pepper and salad for dinner, it was wonderful! We made it through to 38 weeks and delivered them with the help of Dr Marie Pienaar and her team and Panorama Mediclinic. We love them to bits and they entertain, inspire and motivate us each day to be better, kinder parents. Its tough with two but the highlights are by far in excess.  It is stressful and one learns how to cope. Support makes all the difference, whether it is grandparents, siblings, night nurses, nannies or friends. Also each baby is so unique and has their own personality and it’s such a joy to experience the gift of twins.*Names have been changed. 
Vanessa and Philipp’s storyWe had been trying to conceive for a long time, but I knew that with my pre-existing conditions of Polycystic ovarian syndrome and Hashimoto’s Thyroiditis, it would not be without some challenges. In 2015 I had a molar pregnancy – very rare – where a non-viable fertilised egg implants in the uterus and grows as abnormal tissue.In that time, we had been in touch with an adoption agency to come ‘kangaroo parents’, which are like safety parents for babies under 3 months old, where we would care for them for up to 90 days until they were transferred to their forever homes. When we started the paperwork, I found out I was pregnant and we felt it might be too much to go through with the adoption agency, but then later that year, I miscarried and this broke me on so many levels. After that I left for Europe and shortly after we received a call from the adoption agency to know if we were perhaps keen to foster twins who were 6.5 months old. We slept on it and the next morning we decided that we would do it and eight days later they arrived. We lost our hearts completely to the babies and decided to start the process of legally adopting them. We still kept our sights on having our own biological child one day, so we kept on trying naturally at first and then decided on IVF at the Aevitas Clinic at Life Vincent Pallotti. On the day of the transfer they implanted two eggs and at the 9 week scan we heard three heartbeats! The two boys shared one placenta, but each had their own sac and the girl had her own placenta and sac. I honestly felt as though I lost the ground under my feet and the world was spinning… we would be parents to five children now, the twins included! My pregnancy was easy until 26 weeks when I started having contractions and had to have bedrest at Life Vincent Pallotti until my caesarean birth on the 24th of April at 30 weeks pregnant with Dr Jacky Searle at Life Vincent Pallotti. My precious babies weighed 1290g, 1220g and 1540g at birth and now we are a beautiful family of seven. I am thankful for blessings in abundance and the good health of all my children. 

Dealing with infertility, when he has the problem

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It’s not just a women’s issue

Struggling to fall pregnant? Usually women are the first to seek help when trying to conceive. However, if the woman has been thoroughly examined and it is not due to her that she is unable to fall pregnant, it falls to the male partner to be tested. According to a study published in 2015, infertility affects about 15 per cent of couples globally, amounting to about 48.5-million couples. The study also found that males are found to be solely responsible for 20-30 per cent of infertility cases and contribute to about 50 per cent of cases overall. Furthermore, at least 30 million men worldwide are infertile with the highest rates in Africa and Eastern Europe. If a male factor is what’s making it tough for a woman and her partner to conceive, it’s important to understand what may be causing his infertility and what the couple’s options are. Charlene Yared West speaks to the experts to find out more… 

Infertility and feelings of inadequacy and impotence

“Research indicates that the male partner is not willing to seek medical advice about infertility. They feel embarrassment for not being able conceive naturally and suffer guilt, self-blame and shame,” says Dr Liezel Anguelova, Counselling Psychologist at Life Roseacres Hospital. “Many men do not feel comfortable with the testing procedure as it includes the examination of their testicles and penis and the production of a sperm sample. As such, men often associate infertility with impotence, when they are actually unrelated.” Dr Anguelova explains how infertility can be devastating to the man who experiences the failure of his procreative nature, as it is so intrinsically linked to his sexuality. “It is often an assault on the masculinity of the male partner and it is not uncommon for him to develop sexual problems such the loss of sexual desire or erectile dysfunction, which can leave him feeling that he is ‘less of a man’,” she says. 

What causes male infertility?According to Dr Sulaiman Heylen, Specialist in reproductive medicine at Life Kingsbury Hospital, male infertility is diagnosed by an abnormal semen analysis. “We always start at the beginning of the fertility testing with the semen analysis. We don’t want to do a lot of testing on the female without knowing what the male factor is. Semen analysis is very easy and inexpensive.”
There are three parameters important in the semen analysis according to 2010 WHO criteria:
1. sperm count: must be over 15 million sperm per milliliter.
2. sperm motility (how they move): 50% of sperms cells must be motile.
3. sperm morphology (their shape): at least 4% of the sperm cells must have a normal morphology.
“If one of these parameters is abnormal we speak of male infertility in combination with an inability to conceive,” he explains. Dr Heylen lists the following as possible causes of male infertility;Varicocele: These are varicose veins of the testis, they can contribute to up to 30% of all cases of male infertility. Trauma of the testicles; related to accidents or sports injuries.Sexual transmitted disease which can lead to infections of the testis and blockage of the epididymis (tubes of the testis)Mumps of the testis.Pollution and environmental factors (estrogen like factors in the environment): These are called xenoestrogens. Estrogen is the normal female hormone. Xenoestrogens are chemical compounds that mimic estrogen. There is more and more evidences that pollution and environmental factors can contribute to male infertility.Unhealthy lifestyle: Obesity, excessive alcohol, smoking and drugs. Anabolic drugs are well known to cause low sperm counts. Antibodies that attack sperm: Anti-sperm antibodies are immune system cells that mistakenly identify sperm as harmful invaders and attempt to destroy them.Undescended testes: During fetal development one or both testicles sometimes fail to descend from the abdomen into the scrotum. Genetic: there are genetic defects in the chromosomes or small defects of the Y-chromosome. Unknown: We not always can identify the cause of the low sperm count. 

How is male infertility uncovered?

Urologist, Dr Dap Louw from Life Beacon Bay Hospital explains how the physical examination entails a general exam, evaluation of the testes ( volume, masses, varicocele, infections, etc) and a prostate exam if needed. “The basis of the evaluation starts with taking  a thorough medical history. We normally do a pelvic and scrotal ultrasound as well, to evaluate the testicular tissue and to look for signs of sperm transport blockage. Other more invasive diagnostic methods can be used especially when there is little or no sperm seen in the ejaculate. This would then be aimed at distinguishing between abnormal sperm production or blockage of sperm transport,” he says. 

What treatment is available? 

Dr Louw explains that treatment is aimed at the underlying problem whether it is advice on a healthier lifestyle, surgical correction of a testicular abnormality or medically treating an underlying infection, sexual dysfunction or hormonal abnormality. “When there is no urological correctable contributing cause to the infertility, I then like take a multidisciplinary approach and get the infertility specialists and/or gynaecologists involved,” says Dr Louw. “Together we can then decide on further optimal treatment, according to their hormonal levels, semen analysis and then also female factors. These can then vary from medical treatment, sperm washing with artificial insemination, IVF (in-vitro fertilization) or ICSI (intracytoplasmic sperm injection).” Dr Louw always emphasises to his patients that 20-30% of sub-fertile couples end up falling pregnant without any further help, which is positive – as nature is on their side! “Anxiety about infertility also plays a significant role and it is important to explain the normal conceiving time of 6-12 ovulatory cycles,” he says. “It does unfortunately happen where our patient is not able to have children and the couple would need to discuss alternate options like sperm donation or adoption.” 

Can a couple survive infertility treatment?Infertility can be a relationship maker or breaker depending on how it is managed says Dr Anguelova. “It will put your relationship to the test, but if you focus on the importance of your relationship, it could be used as a opportunity to make your relationship stronger.” She shares some tips for surviving infertility;Stay in the moment, because it can be very overwhelming.  Wait for each doctor’s visit to gather information on the process before making decisions and planning ahead.  Communicate openly and honestly to address unmet expectations, fears, frustrations and  stress. Find professional assistance and counselling if you are not communicating effectively.  Do not get caught in a blame game of resentment, but rather become committed as a team. Remain positive about yourself and your partner.Keep your sexual relationship spontaneous and full of fun and nurture intimacy by touching, hugging and kissing outside of a sexual connotation.Do not let your entire life be merged into the fertility treatment process. Continue with other hobbies and keep other dreams alive.Build a support system. Support each other and include friends and family in the process.

Useful Resources

Working together to treat a tumour

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When it comes to cancer, patient care is a team effort and not the work of a single doctor. Life Healthcare doctors take a multidisciplinary approach and utilise good teamwork between the various specialists, which is crucial to the successful care of cancer patients from detection to treatment and follow-up.

Discovering the brain tumour

People with brain tumours present first to many different doctors due to the varied symptoms caused by brain tumours. These symptoms are mainly due either to raised pressure in the head or neurological symptoms that are caused by compression or invasion of brain tissue. “Headaches, seizures or stroke-like symptoms often cause patients to see a neurologist first, whilst blurred or double vision might prompt a visit to an ophthalmologist. For patients who are known to have other tumours that later spread to the brain the first contact is often the oncologist seeing them already. Some patients have the tumour picked up incidentally when having a scan for another reason, so see the radiologist first,” explains Dr Grant White, neurosurgeon at Life Vincent Pallotti Hospital. “Many patients will have been referred after starting with their General Practitioner for these and other symptoms.” Dr CF Kieck, neurosurgeon at Life Vincent Pallotti Hospital adds that not every headache is an indication of a brain tumour. “See your GP first if you are experiencing any problems or symptoms which are worrying and they will refer you on to the specialists.”

Referral to a neurologist
“Very often the neurologist is the first port of call after the patient has consulted a GP.  Patients might present with complaints of blurred vision, headaches, weakness, slurred speech, etc. The location and size of the tumour plays an important role in how the patient might present.  For instance, if the tumour is located in the left side of the brain, the patient might experience difficulty expressing themselves or might complain of right-sided weakness. If the tumour is located in the right side of the brain, their visuospatial ability might be affected and they might experience left-sided weakness. Should the tumour be located in the front part of the brain, the patient might present with behavioural disturbances or personality changes,” explains Dr A Rawoot, neurologist at Life Vincent Pallotti. Neurologists are clinical specialists who diagnose and manage neurological disorders. If a neurologist suspects a brain tumour based on the patient’s symptoms and examination, a scan of the brain would be requested to confirm the diagnosis. The patient will then be referred to a neurosurgeon for further management.”

Meeting the radiologist
When a tumour or an abnormality is detected, the first task of the radiologist is to identify the exact location of the tumour and the extent of the disease, says Dr Christian Stoyanov of Life Empangeni Private Hospital, “C Stoyanov Radiological Services Inc.” “After the detection of cancer, the radiologist interprets the cross-sectional images of the patient, makes the diagnosis and determines the stage and extent of the disease based on their findings,” he says. “Image interpretation is the most visible contribution of radiologists. Diagnosis by expert radiologists is based on the extensive knowledge of anatomy, normal variants, pathology and technical principles of the imaging modality.” In some cases, the radiologist may intervene and provide treatment using small catheters and needles under the guidance of the imaging equipment.  These techniques can assist in the treatment of many conditions, including cancer, with minimally invasive interventions, thus avoiding open surgery. “With the technological advances in the field of medical imaging, brain tumour imaging has become an essential component in diagnosis, treatment planning, and monitoring treatment response as well as patient prognosis,” adds Dr Stoyanov. 

Consulting the neurosurgeon

Once the tumour has been confirmed via high-tech imaging, the neurosurgeon would take on the role of decision-making regarding further treatment of the patient and this is where the collaboration with the radiologist and oncologist is essential. “Often, the specific diagnosis of the tumour may be made only after surgery when part of the tumour has been provided to the pathologist for microscopic and laboratory analysis.” says Dr White. “Distinguishing between benign and malignant tumours and between different types of tumours allows for the best treatment to be selected for a patient. The neurosurgeon’s most specific expertise is in the planning and performance of surgery for the brain tumour. This involves balancing the risks of various surgical approaches against their benefits, choosing the right tool for the job and deciding on the specific aim of the surgery and then doing the procedure as safely and effectively as possible.” Guiding and educating the patient and family is an essential preparation before any operation; brain tumour surgery is particularly challenging and everyone needs to understand the risks and limitations of surgery, adds Dr CF Kieck; “After surgery, the neurosurgeon will continue to look after the patient through their hospitalisation and will refer them for any rehabilitation needed and involve the oncologist where chemotherapy or radiotherapy is appropriate. The neurosurgeon will usually continue to check up on a patient who has had a brain tumour at intervals for the rest of their lives.” he says.

Seeing the oncologist

Once the diagnosis has been established, patients are then referred to an oncologist for treatment. “Secondary brain tumours are often diagnosed by oncologists, as we are following up patients with previously diagnosed cancers and when they present with brain associated symptoms we would proceed with a scan. We would then sometimes refer them to a neurosurgeon if we felt surgery was possible or necessary,” says Dr Jacqueline May Hall, clinical oncologist, Life Vincent Pallotti Hospital. “We also sometimes enlist a neurologist to help us with the management of associated seizures. An oncologist’s role is to perform treatment (obviously other than surgery) and would oversee, monitor and prescribe any radiotherapy or chemotherapy required.  We would also support the patient holistically with for example – symptom control that includes steroids, analgesia, anti-seizure medication; referral for physiotherapy, occupational therapy, rehabilitation and we would also counsel and refer for counselling as needed. We also refer to Hospice as appropriate.”

Less is more when it comes to salt

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Cutting out or reducing sugar intake has become very fashionable over the last few years, but what about salt? Charlene Yared-West makes a strong case for the latter.

The recommended daily salt allowance is one teaspoon, but many South Africans are consuming more than that; up to three teaspoons a day because most salt is hidden in everyday foods. The Heart and Stroke Foundation aim to reduce discretionary salt intake among the public by encouraging consumers to cook with less salt and salty ingredients. Salt Awareness Week kicks off on March 20 to March 26 to encourage South Africans everywhere to eat less salt, but why is salt so harmful?

Why should we eat less salt?

Excess salt intake can result in high blood pressure, thereby contributing to heart disease, strokes and kidney disease. “High blood pressure (otherwise known as hypertension) can be very dangerous since the disease has many secondary consequences. However, at the same time hypertension doesn’t always present with symptoms. As a result, you can have a very high blood pressure and not know it. Hence you should check your blood pressure regularly,” says Lila Bruk, registered Dietitian at Lila Bruk & Associates.

In a 2012 research paper entitled Reducing the sodium content of high-salt foods: Effect on cardiovascular disease in South Africa, researchers estimated that a reduction of salt from breads, margarine, soup and seasonings would amount to a 0.85 gram daily reduction per person. Using expected improvements in blood pressure and national statistics, they calculated the expected impact on the nation’s health. This level of salt reduction is estimated to result in 7 400 fewer cardiovascular deaths and 4 300 fewer non-fatal strokes every year. “If you do have high blood pressure, it is important to have less salt in your diet, but also to have more fresh fruit and vegetables, more calcium, exercise regularly and lose weight if necessary,” adds Bruk. 

Salt is hidden in everyday foods

A lot of foods that we consume already contain a generous amount of hidden salt, explains Margaret Lehobye, registered dietitian at Life Roseacres. “In general, processed foods are higher in sodium, so by reading the labels properly and by choosing fresh, unprocessed foods you can lower your salt consumption drastically.” On average, South Africans eat double the recommended limit per day and most of this salt comes from what is added during the manufacturing process. Lehobye points out that foods like biltong, stock powder, prepared sauces and marinades, soup mixes, commercially made cereals, biscuits and snack foods (e.g. crisps and pretzels, frozen and tinned foods, convenience meals, tinned meat or fish and salted nuts are examples of foods that contain a lot of hidden salt – and should be eaten in moderation or preferably; not at all.

Are there healthier alternatives?

Most people associate less salt with meals being less tasty, but flavour can come from a variety of different herbs, juices and fresh ingredients which do not contain salt. In truth, one’s pallet can be trained to require less salt. “Try eating raw, unsalted nuts, homemade sauces and marinades (for example, using more lemon juice, garlic, ginger, herbs and spices to add flavour), fresh fruit as a snack, low sodium soup mixes, oats rather than pre-packaged cereals, and fresh veggies rather than tinned wherever possible,” says Bruk. According to the Heart and Stroke Foundation, lemon is the new salt! Lemon flavours food fragrantly without the risk of pushing up your blood pressure. “Healthy food doesn’t need to be bland and boring, adds Lehobye. “Making dietary and lifestyle modifications does require an adjustment in one’s sense of taste, so gradually introduce low-sodium foods and alternatives and cut back on table salt until you reach your sodium goal. That’ll give your palate time to adjust. It also helps to try out different ways of flavouring your food, which will soon result in one appreciating the lighter, fresher taste of less salty food.” 

Get Food label savvy  

Ingredients are labelled in descending order. Consumers should avoid products which have salt high up in the ingredients list. “Avoid foods with a sodium content of > 600mg per 100g of that product,” says Lehobye. “Consumers should familiarise themselves with other names that are used for salt such as Monosodium Glutamate (MSG), Baking soda and baking powder.” HSFSA also encourages consumers to choose Heart Mark products as they are lower in salt as compared to other items on the shelf in grocery stores. 

Helping South Africans choose less salt

Legislation reducing the salt content of commonly consumed foods came into effect on 30 July 2016. This legislation is important, but it will take more to resolve our excessive salt intake. South African consumers add on average 4 grams of salt to food at home – and this does not account for the hidden salt in bought food. “I think it’s an excellent initiative. I feel that when it comes to behaviour change, much of the resistance to change comes from being afraid of the unknown. However, if changes have been made in this gradual way, it allows the public’s taste buds to change with minimal effort in a relatively “painless” way. In addition, the legislation also creates greater awareness with regard to changing salt consumption habits. So, all round a great campaign,” says Bruk. Lehobye adds that foods affected by the legislation like potato chips and processed meats will still be very salty, but that consumers should demand less salty products – and at home, add less salt to their cooking and at the table. “It is the only way to create change is to change what we eat. The big food corporations will then change the foods to suit the healthier marketplace. That hope can become reality – but as citizens, we have to spearhead that transformation by choosing healthier alternatives.”