There Is Always Something To Worry About - Part 3

How to Get Pregnant and Have a Healthy Pregnancy

Step 3 – Getting Pregnant

When I meet an infertility couple, the first things I want to know are the age of the woman, her past reproductive history and how long this couple has been having intercourse without contraception. I’m generally not as interested in how long they’ve been “trying” to get pregnant. The reason I say this is because if couple has been “trying” to get pregnant for 6 months but have not used any form of birth control in six years, then they have 6.5 years of infertility. Their prognosis is frequently much worse than another couple who quit birth control 12 months ago and is not pregnant.

If you have not used birth control in 1-2 years and are not pregnant, call and make an appointment today to be seen by your provider or by us at 423-876-2229. If you are still truly in the early stages of trying to get pregnant, please continue to read.

Areas of Concern
When we give talks about getting pregnant, we frequently discuss 6 areas of concern: duration of infertility, adequate intercourse, adequate ovulation, adequate sperm, anatomy and ovarian reserve.

Of the six areas of concern, three are essential to conception and these are: a woman must produce an egg (ovulation), the man must have sperm, and the sperm and the egg must be able to meet (adequate anatomy.

Adequate Intercourse
Many couples who are trying to conceive fixate on exact timing of intercourse, when in truth exact timing is not particularly important. What is essential is that a couple has intercourse on, or prior to, the day of ovulation. Sex on a single day of the month has virtually the same chance of pregnancy if the sex occurs on the day of ovulation, the day before ovulation or even the day before that. Sperm can live up to 5 or 6 days and still fertilize. This means, for most couples, intercourse every 2-3 days is adequate.

Intercourse 24 hours after ovulation has a very low chance of pregnancy. After ovulation, the egg lives only about 12-24 hours. So make sure you have sex prior to ovulation if you want to conceive.

Ideally, adequate intercourse would mean satisfactory intercourse for both partners. Unfortunately, for the purpose of getting pregnant, it really only has to be satisfactory for the male – as he must deposit sperm into his partner. Female orgasm has no significant role in fertility. I know, it’s not fair.


Adequate Ovulation
Ovulation (producing an egg) is essential to getting pregnant. Most women who have regular predictable menses are ovulating. Ovulation is even more likely in regularly cycling women who reliably predict their menses because of breast tenderness or bloating or mood changes that precede the menses by a few days. Ovulation can be confirmed various ways, with basal body temperatures, ovulation predictor kits, or even a blood test. Ovulation is generally deemed adequate when the luteal phase is 11 days or longer based on basal body temperature charts or 12 days or longer based on ovulation predictor kits. For more details, click Ovulation.

Normal menstrual cycles are between 24-35 days. Shorter cycles frequently mean a woman’s ovarian reserve is declining and should be evaluated. Longer cycles can mean a woman is not ovulating and also should be evaluated.

Adequate Sperm
If a man has any sperm, it is possible to get pregnant; however, once sperm counts go below 15 million per ml, the chances of pregnancy can plummet significantly. Of course, we don’t recommend home sperm testing, because there are many facets of sperm which may affect fertility. Because it is a painless test, this should be the first test sought by a couple.

If there is a history of frequent sauna or hot tubbing, significant testicular trauma, testicular surgery, undescended testicle, prior radiation or chemotherapy, low libido, erectile dysfunction or low volume ejaculations then a more immediate evaluation should be pursued.

Adequate Anatomy
The fallopian tubes serve as a transit system for sperm and eggs. When a woman ovulates, the tube picks up the egg and holds it there for sperm to fertilize. For their part, the sperm are deposited in the vagina and have to swim through the cervical mucus, up through the uterus and out to the tube. Only 1 in a million sperm will eventually make it to the egg with intercourse.

□ If the cervical opening is small or scarred due to prior surgery it may not produce the needed cervical mucus which assists in the transport of sperm.
□ If the tubes are blocked, the egg and the sperm cannot meet.
□ If sheets of adhesions (scar tissue) separate the ovary from the tubes, getting pregnant can be a real challenge.
□ If benign tumors such as fibroids are growing in the uterus, this may prevent a pregnancy from taking hold.

Women with infertility for more than 1 year should have an x-ray called a hysterosalpingogram performed. For more details, click on HSG.

Endometriosis, a condition in which uterine lining grows outside the uterus, can sometimes distort the anatomy. Even when it doesn’t distort the anatomy, endometriosis can make getting pregnant more difficult. If you are just starting to get pregnant and you have a history of endometriosis, ask your physician if yours is so severe that you should do something about it. We’ll talk more about endometriosis and fertility in a future post. For more information now, click Endometriosis.

Ovarian Reserve
This is the biologic clock. The best predictor of the biologic clock is a woman’s age. By age 35, nearly 30% of women will be sterile. By age 40, nearly 70% will be sterile. In a study of women who never used any birth control and stayed married their entire lives, the last average pregnancy occurred at age 42. Many of these pregnancies ended in miscarriage because the embryos have a higher rate of being abnormal the older women get.

The biologic clock, or ovarian reserve, is determined by several factors: how many eggs a woman had at birth, how much damage has occurred to her ovary or eggs throughout her life, and how quickly she has lost her eggs.

Smoking, ovarian surgery, radiation and chemotherapy can all lead to premature depletion of eggs. Genetics can also cause early loss of eggs. We find that many women with unexplained infertility and with endometriosis have findings consistent with diminished ovarian reserve.

A sign that ovarian reserve is decreasing is a shortening of the menstrual cycle. Women who were regularly menstruating every 28 days, may find themselves having cycles every 24 days. This can be evidence of diminished ovarian reserve. The same goes for women who had PCOS and who never or rarely ovulated on their own who suddenly find themselves having normal menses.

If you have any of the risk factors above, strongly consider having your physician, or us, evaluate your ovarian reserve.

For more information click on diminished ovarian reserve.

If you have questions on any of the topics listed above, call us and make an appointment, visit our website: http://www.trmbaby.com/.

There Is Always Something To Worry About - Part 2

How to Get Pregnant and Have a Healthy Pregnancy

Step 2: Preconception Counseling

Informing your obstetrician of your intention to get pregnant is advised. He or she can tell you what the risks of pregnancy are for you, given your past medical history. Prior to pregnancy, your pap smear and breast examination should be up to date.

Vaccines: Chicken pox can be devastating to a baby and fatal to a pregnant woman. If you have no history of chicken pox and never received the vaccine, your doctor should test you to see if you are immune. Prior to pregnancy, the chicken pox vaccine can be administered and very effectively reduce the chances of infection during pregnancy.

Rubella (which causes German Measles) can also harm a pregnancy. Just because you had a vaccine once (or twice) does not mean you are immune. Rubella testing can tell you if you are at increased risk for German Measles. If you are not immune, you may receive a two dose booster to induce immunity.

Neither the chicken pox or Rubella vaccine should be given during pregnancy, therefore, testing and vaccination prior to conception are advised.

Genetic testing: Your doctor should determine if your ethnicity or family history places you at increased risk for having a baby with a genetic disorder. If a known genetic disorder runs in your family, you may be at increased risk for having a baby with that disorder. Frequently, testing can be done to screen for that disorder in an individual patient.

Groups at high risk for genetic disorders include:
Women who are 35 years old when they deliver: While the risk of having a baby with Down Syndrome or other chromosomal abnormality is never zero, the risk does increase with age. At age 35, the risk of having a baby with a chromosomal abnormality is greater than the risk of losing a baby from amniocentesis (test for the abnormality), so counseling is advised.

African Americans: approximately 1 in 12 carry the trait for sickle cell disease.

Caucasians: approximately 1 in 25 carry the trait for Cystic Fibrosis.

Ashkenazi Jewish: are at increased risk for multiple diseases including Tay Sachs, Canavan, Neimann-Pick, Blood Syndrome, Fanconi’s Anemia, Familial Dystautononemia, BRCA mutations and many other diseases and syndromes.

Families with a history of Autism or mental retardation should consider testing for Fragile X Premutation.

For more information preconception testing, see: http://www.trmbaby.com/fertility/preconception_counseling.shtml

If you have questions on any of the topics listed above, call us and make an appointment, or visit our Facebook Page.



Coming next: How to Get Pregnant

There Is Always Something To Worry About - Part 1

How to Get Pregnant and Have a Healthy Pregnancy

For many people, how to NOT get pregnant is the most important question relating to fertility. Yet when the time comes to start a family, the anxiety can shift to the opposite camp and people begin to worry if they CAN get pregnant.

If you are in the early stages of trying to get pregnant or are thinking about getting pregnant in the near future, there are some things that you can do to optimize your chances of getting pregnant and of having a healthy pregnancy.

Step 1: Optimizing your health before you get pregnant

Fitness: Women with a normal body weight prior to pregnancy have lower rates of pregnancy complications including diabetes, pre-term delivery and preeclampsia. Women who are physically fit also have lower rates of cesarean section. Three hours of aerobic exercise per week should be the minimum goal of any woman trying to get pregnant.

If you are morbidly obese (BMI 40), you are at increased risk of many pregnancy complications including birth defects such as heart malformations and spina bifida. Alternatively, if you have been underweight and not ovulating or if you have been taking steroidal medications for a long time, you may be at increased risk of osteoporosis and of experiencing bone fractures during pregnancy.

Nutrition: Women who are deficient in folic acid or other B vitamins have an increased risk of neural tube defects (or spina bifida). At a minimum, a woman should supplement her diet with 400 mcg, ideally 800 mcg daily.

It is also becoming apparent that Vitamin D is important in many aspects of health and pregnancy. Vitamin D is also important for bone health. Fish and sunlight are good sources of Vitamin D. The daily recommended intake of Vit D is 600 IU daily, which means many people need to take a supplement.

In general, a healthy diet will contain the RDA recommended nutrients and consist of 1200-1500 calories per day (depending on the weight of a woman).
> See more regarding weight and fertility

Smoking: Smokers and women married to smokers have lower monthly pregnancy rates. Smokers more frequently have small for gestational age babies.

Alcohol: Even modest alcohol consumption has been shown to decrease pregnancy rates and increase miscarriage. In the IVF setting, 1 drink per day has been associated with both lower pregnancy rates and higher miscarriage rates. In natural populations heavy alcocohol consumption is associated with high estrogen levels in women and this can impair egg growth and has been shown to cause a woman to stop ovulating.


Caffeine: More than 300 mg of caffeine per day has been associated with miscarriage. Next time you're at Starbucks check out the caffeine dose in a Grande coffee - 330 mg.

Summary:

A bad lifestyle is not birth control. So if you don't want to get pregnant, I wouldn't count on drugs, alcohol and cigarettes to save you. On the otherhand, if you are young and fit, a non-smoker, who doesn’t drink or have any medical problems then you’re off to a good start, but this does not mean you will be fertile. It doesn't even mean you are nutritionally ready to conceive. In our next post we will discuss preconception counseling and the labs that are advised prior to conception.

If you have questions on any of the topics listed above, call us and make an appointment, or visit Tennessee Reproductive Medicine's Facebook Page.

Coming Next: Preconception Counseling, then How to Get Pregnant

Fertility Testing At Home - Ovarian Reserve Tests

Ovarian reserve is basically another phrase for the biologic clock.

Younger women generally have more eggs and more of those eggs are normal, compared to older women. Women who have gone through menopause generally have no normal eggs remaining and they cease to ovulate. Between normal ovarian function and menopause, there is a state called diminished ovarian reserve.

Women are born with 1 – 2 million eggs and every day of a woman’s life she is losing eggs. Some women are born with fewer eggs, some women lose them more quickly, and some women accumulate damage in their eggs more rapidly than others and they develop diminished ovarian reserve.

Women with diminished ovarian reserve frequently have a more difficult time getting pregnant.

Genetic predisposition is one cause of diminished ovarian reserve, so premature menopause in a relative should alert women to the possibility that this can occur in them. Other causes include smoking, ovarian surgery (such as the removal of a cyst).

A sign that ovarian reserve can be decreasing is if a woman's menstrual cycle begins to shorten betweeen periods. If a woman has always menstruated every 28-30 days and starts to menstruate every 24-26 days, this can be a sign of diminished ovarian reserve and should be evaluated.

Now women have the choice of testing ovarian reserve through their physician, or in the privacy of their own home through urine test kits that are used much like a home pregnancy test.

The kits range in price from under $4 to nearly $100, and they test for a hormone called follicle stimulating hormone (FSH) on or around menstrual cycle day 3. FSH is what makes eggs grow. It’s like the gas pedal to the ovary. Like a well tuned car does not require someone to mash hard on the gas pedal to get up to speed, the normal ovary only requires a little FSH to ovulate. If the FSH is high, then the ovary is not working well and the woman has diminished ovarian reserve.

The inexpensive kit costs around $4 per test and is available at http://www.early-pregnancy-tests.com/fsh-tests.html . This kit detects the equivalent of an FSH of 25 mIU/ml, which is consistent with infertility and possible menopause. A normal test is when the FSH is below 25 mIU/ml. The problem is, women are generally infertile when FSH exceeds 17 mIU/ml.

A more sensitive kit by Genosis Ltd, called Fertell, can detect FSH levels of 10 mIU/ml, which is consistent with diminished ovarian reserve. Fertell has recently become unavailable in the United States, but may be purchased on line. A normal test is when the FSH is below 10 mIU/ml

The problem with both tests is that they only measure 1 hormone, FSH, which by itself can be meaningless. To know if the FSH is valid, an estrogen level must accompany it.

If a woman has a normal test it can be falsely normal (because estrogen is elevated prematurely – as can be seen in women with diminished ovarian reserve. See Pitfalls of Day 3 FSH Testing at: http://www.trmbaby.com/welcome/WebPearlsDec08FSH.pdf .

So a normal test does not mean the woman has normal ovarian reserve.

An abnormal test can be falsely abnormal, too. During the midcycle, many women will bleed due to a temporary drop in estrogen associated with ovulation. If the woman thinks this is her period, she might measure FSH at an inappropriate time. If a woman measures her FSH during the midcycle, the FSH is normally high and might trigger a positive test.

So either way, these tests need to be confirmed by a doctor. This is the best way to avoid false alarms and false reassurances.

Fertility Testing At Home: Home Sperm Testing

Over the past few years more and more fertility tests have become available for home use. This month one of the leading journals in the fertility world, Fertility and Sterility, published a very nice review of many of these home tests. Coincidentally, I just gave a talk about many of these tests and thought I would share my thoughts about them.

For the sake of time and space, I’ll tackle these one at a time. Today, we’ll talk about home sperm testing.

Before we get there, let me give some background.

The idea of home testing fits a definite need among consumers. It’s nice to be able to learn that you’re pregnant without making a doctor’s appointment. It’s also nice to identify problems early, if that leads to evaluation and effective treatment.

The problem with a lot of tests on the market is that they can be falsely reassuring and may cause some people to delay proper evaluation. There is no good evidence that performing such tests actually improve a couple’s chance of conception. A patient without a history of infertility is most likely wasting their money. On the other hand, if a couple has not conceived within 1-2 years of unprotected intercourse, I’m not sure that any home test is particularly reassuring. A falsely reassured patient may delay treatment and therefore is at risk for not meeting their reproductive dreams.

Several years ago after hearing a story about home fertility testing on NPR’s All Things Considered, http://www.npr.org/templates/story/story.php?storyId=10712488 I wrote a letter describing some of the pitfalls to such testing. http://www.npr.org/templates/story/story.php?storyId=10819112

The two tests described where a semen test and a test to measure a woman’s FSH, marketed under the name Fertell (Genosis Ltd).

The Fertell sperm test can determine if a man has 10 million total motile sperm and is sold for close to $100. The advantage of this test is that many men are embarrassed to have a formal semen analysis performed. Also, the test determines the motile concentration, which is fairly predictive of normal fertility. Recently, the World Health Organization (WHO) published findings showing that 95% of fertile men had a sperm concentration of 15 million sperm/ml and 32% were progressively motile and 5% or more had a normal shape. A reassuring Fertell tests should correlate well with 2 of those 3 parameters. If abnormal, the test should lead a man to have further testing performed.

The drawback to the Fertell sperm test is that it does not test morphology, which can be very important. The cost is also a drawback. For an additional $50, a patient can have a full semen analysis at our clinic and have it interpreted by a physician who can interpret the results in the context of the couple.

Other home semen tests are also available. Embryotech has marketed several tests FertilMARQ, Start Male Infertility Test and PreConceive: A Male Fertility Sperm Test, all of which purport to evaluate sperm concentration. Because it tests only a single parameter (concentration), it tells nothing about motility or morphology. A man with few or no moving sperm may be falsely reassured. (As with the Fertell test, an abnormal result should be followed up with a visit to a physician’s office.)

There are also small microscopes available: http://www.amazon.com/Micra-Sperm-Test-Count-Motility/dp/B000SLM504. The disadvantage of this test is that interpretation is left up to the patient. As with all home testing, the disadvantage to the home microscope is that there is no one with clinical experience to interpret the test in the context of the couple.

One of the tenants of good medical practice is to treat the patient, not just the test.

As I said above, a normal test does not mean that all is well. A person without infertility may find this test reassuring; however, this person probably doesn’t need the test in the first place. A full semen analysis gives significantly more information than any of these tests. A couple with infertility is probably better off having a medical evaluation by a knowledgeable physician. However, if the only way to get a man to get tested is with at an at home test, I would pick Fertell since it gives the most information with the easiest interpretation.

It’s a Mother of a Day

This week some of our patients have had some good news about their pregnancies and this Mother’s Day may be like no other. For them, this will be a joyful occasion, a day many of them never expected to have.

However, some of our patients and friends have had crushing news and are not yet pregnant, or are grappling with the possibility of never having a child. I know of others who have recently lost a child or a parent. I can’t imagine the sorrow a day like Mother’s Day may bring for them.

I can count my blessings for now, as both my wife and I still have our parents and we have our children. We can still celebrate this day with all the people who have been a part of our lives.

It is my hope and my prayer for all of those who are suffering a loss…either loss of what never or has not come to pass, or the loss of a parent or a child…can find a path to peace.

I well remember those Mother’s Days, waking next to my wife, when we were childless. It is a certainty that I felt sadness and fear. But I can tell you this: the sadness I felt was shared. It seems strange to say, but sharing a burrowing sadness was somehow comforting to me. The fact that I shared it with the person whom I loved more than any other person on the planet somehow made the sorrow not only bearable, but good.

My wife and I shared a sorrow. It was a sorrow wrapped, enveloped in a deep love…which in the end felt like a form of gratitude.

So this weekend, this is my wish for all of us, in case anyone has forgotten…. May you all have peace in your hearts and be grateful for your shared sorrow, cherish the ones you love, whether they are here or not. Cherish the Mother you were, the Father you were, or the one you could have been.

If you have lost a child or a parent, honor them by living a life which pays tribute to them.

It’s the rarest elements in nature that are valued so dearly. The time we have together here on earth is so small, so fragile and so very precious. We never know exactly what we will be given, or how long we will have it. I think we should all be thankful for what we have been given, no matter how briefly. If we have been given less, or have suffered loss…it is my hope that we can all appreciate even the small gifts as what they are….precious and rare.

This world contains enough sorrow that no one will ever go wanting for it. May we all recognize joy, too, and let it overflow from us and into others around us. If you know someone who is in the depth of sorrow and can’t find a way out, may you help to bring them peace.

True Love May Last Forever, But Fertility Does Not

When it comes to fertility, we frequently find that our patients take their lead from celebrities. Too often, this has a negative impact on our patients. We see Hollywood starlets, senators’ wives, and TV personalities having children in their mid-to-late 40s or even early 50s, and we are left with the impression that fertility is lasts longer than it actually does. Sadly, as we have said before, many of these pregnancies are achieved through egg donation (using a younger woman’s egg to get pregnant), but the general public is not really aware of this.

Lately, we’ve had a new couple to watch, a couple to remind us about the choices that face all of us who are lucky to find our true love. The couple is Prince William and his bride, Kate Middleton. The choice is: when to start a family.

I came across a nice little article by Dr. Manny Alvarez, who had some advice for this couple. And by extension, it applies to many couples.

(See the article here: http://www.foxnews.com/health/2011/04/27/kate-middletons-pregnancy-plan/ )

Dr. Alvarez correctly points out that Kate’s fertility will be on the decline from this point on. He advises her to try to conceive soon, rather than wait. Of course, from a medical perspective, he’s correct.

But life is about balance and, for many of us, the trick is to know what decisions to make to maximize our chances of future happiness.

Most of us dream about finding true love. We dream of all that comes with it. We will be secure. We will be complete. We will have children and we will watch them grow. We will be happy.

But most newly married couples do not want to have children right away. They want to have time on their own to consolidate their married life together, to grow accustomed to the changes this brings. Adding a child immediately into the mix can place a couple under financial strain, time constraints and emotional fatigue that can interfere with the initial bonding between the couple.

In the case of Prince William and Kate Middleton, I’m not sure we could concoct a more story-book modern day romance. Kate, the commoner (a term we don’t use in the US), marries a prince and becomes a princess. The presumption is that she will also become a mother and chances are good that she will reach this goal without any assistance from me or any other infertility specialist.

I hope they do have a story book life.

But if I were in Kate and William’s shoes, would I follow Dr. Alvarez’s advice and try to have children right away?

That would depend on my goals, I guess. I frequently ask patients to project themselves into their early to mid 40s and picture themselves childless. From that vantage point I ask them to look back on their lives and reflect, to the best of their ability, what choices do they wish they had made when they were younger.

If the life they spent growing together fuels their happiness, perhaps that is more important. If not having children is a devastating thought, perhaps they should begin just as soon as they are ready.

Either way, this decision is to be considered carefully. Think about the pitfalls of each choice, about each direction. Think about how you will deal with those pitfalls ahead of time. Talk about them as a couple. Have a plan for what you will do if things don’t work out as planned. Agree with each other about how you will treat the other person if things don’t work out as planned. Agree to remain flexible as, sometimes, we can all change our minds.

As for Will and Kate? It’s the same as I have for any couple. I wish them a storybook ending no matter whether it was the ending they planned, or not.