What to Expect When You're Not Expecting ... Yet
some lessons in Fertility 101 for couples who are hoping to conceive
It’s time to have a baby and birth control gets left behind. Months go by and nothing has happened. One period after another and no pregnancy or even a positive pregnancy test. It’s a scenario that occurs more often these days as we have moved to delay growing our families until later in life.
When you are young and otherwise healthy, there is nothing more emotionally frustrating and draining than not being able to get pregnant when you want to be.
Our fertility, or “fecundity” as we refer to it in the world of medicine, is the highest shortly after women settle into a pattern of regular menstruation (median age is 12 for starting menses in the United States), and slowly declines each year until menopause (median age is 52 in the United States). On average, if you take 100 couples and send them on the mission to get pregnant, you would expect that at six months from when they start “trying” that 70 percent of them are pregnant; at 12 months, 85 percent are pregnant; and at 2 years, 92 percent are pregnant. The remaining couples will have very limited success in getting pregnant without some help. The “normal” couple has a 25 percent chance of getting pregnant in any given month, and if they are not successful in three to four months we know their percentage chance per month in the successive months will continually be dropping.
Infertility is defined as no pregnancy in 12 months of trying for those couples under the age of 36; and no pregnancy in six months for those 36 and over. We encourage couples who meet these definitions to seek help. If women are not having a regular cycle (defined as having menstrual periods that are 25-35 days from the first day of one period to the first day of the next), couples should seek help prior to trying to get pregnant and come in to the office for what we like to call a “preconceptual counseling” visit.
Speaking of “preconception,” there are a few things for all of us to make sure we are doing before we get pregnant to maximize our chances of getting pregnant and having a successful pregnancy and healthy baby. For women, take a vitamin that has extra iron, calcium, and – most importantly – 800 to 1,000 micrograms (0.8 to 1 mg) of folic acid. Both men and women are less fertile if they smoke more than 10 cigarettes a day or have more than 14 alcoholic beverages per week. Although we really recommend you quit the cancer sticks and cut down dramatically on the booze, at a bare minimum you should knock it down to less than five cigarettes a day and two to three alcoholic beverages per week.
Timing and frequency of your lovemaking should be two to three times a week in the two weeks after menses are over. And oh, by the way, make sure to have fun making love! We are not sure what the connection between our nervous system and our fertility is, but we know that it does not help to get our brains too wrapped up in the issue. When you are young and otherwise healthy, there is nothing more emotionally frustrating and draining than not being able to get pregnant when you want to be. Keep your relationship with one another at the center of your lives and enjoy one another as you always have.
Infertility evaluation in the office usually consists of taking a good medical history of the couple and using that history to guide what diagnostic testing makes the most sense for the couple to consider. Some common diagnostic tests for infertility are blood work assessing thyroid and pituitary function in women; semen analysis for the men (part of the problem as much as 40 percent of couples); assessment of ovulation for women (ovulation prediction [urine LH] tests, progesterone levels, and basal body temperature charts); hysterosalpingogram (dye study of the uterus and fallopian tubes) or pelvic ultrasound for women; and in select cases consideration of laparoscopy (looking into the abdomen and pelvis with a scope) or other more sophisticated lab testing.
Treatment can be as simple as giving the women who doesn’t ovulate on her own a medication to produce ovulation or as complicated as a couple working with a reproductive endocrinologist and Infertility specialist and pursuing the “test tube baby” (in vitro fertilization) technology. Treatment is tailored to overcoming what we think the problem is. What we see is when we make a treatment intervention, we know our treatments are not making the couple super fertile, but are hopefully getting them back to having that 25 percent chance of pregnancy in each month, and that if that is the case-they should likely have the treatment work in a three- to six-month window just like every other “normal” couple. If we don’t have success it is back to the drawing board where we reassess what we know and consider the next steps in diagnosis and treatment.
So … you finally have a positive pregnancy test when you are a day late. Something worked! These days you can buy a reliable urine pregnancy test for a buck at the dollar store that can tell you when you are just a whiff pregnant. Congratulations! This is always exciting, but it is important for us all to try and not get ahead of ourselves with unrealistic expectations. When we are a day late and have a positive urine pregnancy test only 50 percent of us are going to have a take-home baby. When you are two weeks late, starting to feel pregnant, and the ninth pregnancy test you have done is still positive, you have about a 70 percent chance of having a take-home baby. When you are a month late and you come into our office for a pregnancy confirmation visit and we look with the ultrasound machine and see a three-quarter-inch little blob with a heartbeat and a normal three-part gestational sac – it’s a 98 percent take-home baby rate! The statistics get a little better even yet, and when you are two months late and are in for your first prenatal care visit, we listen with our little Doppler stethoscope and when we hear a healthy heartbeat, you have a 99.8 percent take-home baby rate.
When you look at all the pregnancies lost in the first month, we see that nearly 75 percent of those pregnancies are chromosomally abnormal. The most common window for something to go wrong and a fetus to die is when you are between two to four weeks late – the window of organogenesis. When something does go awry and the fetus dies in early pregnancy the average time it takes for you to have any signs or symptoms that something is wrong is 30 days from when it happens. Miscarriage is a difficult and devastating thing to have to experience, and it is important to remember the above, and when we are excited about being pregnant temper our expectations until we get into a window where we know the process gives us more to rely on! Chemical pregnancies are great and can be exciting, but healthy newborn babies laying on our chest eight or nine months later are the real goal. Good luck!