Pregnant - At Last !
from the book How to Have a Baby:
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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For most infertile patients, getting pregnant is the ultimate dream which
keeps them going through tests, treatments and surgery. What happens when the
dream finally comes true?
Making the Diagnosis of Pregnancy
How do you find out if you are pregnant ? For most treatments, doctors will
wait till you miss your period before starting pregnancy testing. You should ask
your doctor when you should schedule a pregnancy test every time you take
treatment - after all, you never know when it's going to work ! A reasonable
choice would be to conduct the test 16 to 18 days after ovulation. For IVF and
GIFT cycles, in some clinics, testing may start as early as 10 to 12 days after
the embryo transfer or GIFT.
When the pregnancy test is positive, the first response is often one of
disbelief since it's hard to believe you are finally pregnant, especially if you
have been trying for many years. Some patients get emotional - it's over ! The
time and effort and money has paid off ! Infertility is a memory ! But you soon
realize that it's not all over. What you want is not a pregnancy but a baby !
There are still uncertainties, and things can still go wrong, which is why
careful monitoring is essential.
A pregnancy should be documented as early as possible. This is important,
because appropriate care and precautions can then be taken atan early stage .
The most sensitive pregnancy test is a blood test for the presence of beta HCG (human
chorionic gonadotropin) . The HCG is produced by the embryo, and as the embryo's
signal to the mother that pregnancy has occurred.
HCG can be measured in the blood by RIA (radioimmunoassay) or ELISA (enzyme
immunoassay) testing; and positive levels (more than 10 mIU/ml) in the blood can
be detected as early as 2 days before the period is missed. In the old days, the
only way of determining the presence of HCG was by testing the urine, i. e, by
using urine pregnancy test kits. Modern urine pregnancy kits (using monoclonal
antibody technology ) are now quite sensitive and can detect a pregnancy as
early as 1 to 2 days after missing a period (at a blood HCG level of about 50 to
100 mIU/ml). The benefit of urine pregnancy test kits is that they are less
expensive; and testing can be done at home by the patient herself. However,
instructions need to be followed carefully, and errors in interpreting the test
results are not uncommon. These errors could occur if the urine is too dilute;
or if the test is not done properly; or if there is a urinary tract infection
The major advantage of blood tests is the fact that they measure the actual
level of the HCG in the blood - and this factor can be very helpful in managing
pregnancy problems, if they occur. As the embryo grows rapidly, HCG levels
normally double every 2 to 3 days. Thus, one reliable sign of a healthy
pregnancy is the fact that the HCG levels are increasing rapidly, and often
doctors may need to do 2 HCG levels 3 days apart in order to determine the
viability of the pregnancy. A rising HCG level is reassuring.
Problems with HCG testing can occur if you have earlier been given HCG (human
chorionic gonadotropin) injections for inducing ovulation. Normally, this
exogenous HCG is excreted by the body in 10 days; but sometimes it can linger
on. This is why, if the HCG level is very low, the test may need to be repeated,
to confirm that the level is increasing.
What are "biochemical pregnancies" ? These are pregnancies in which
the HCG test is positive after the period has been missed; the levels increase,
but are still low; and no pregnancy is ever documented on ultrasound.
Biochemical pregnancies are often seen after IVF and GIFT. While they are not
clinical pregnancies, they are of useful prognostic information, because they
may mean that your chance of getting pregnant in a future cycle are good.
One drawback with the HCG test is that a positive HCG simply means a
pregnancy is present in the body - it does not provide any information about the
location of this pregnancy, which may be tubal or ectopic.
During the very early pregnancy, HCG levels are the only way of monitoring
the pregnancy . HCG levels which do not increase as rapidly as they should may
mean that there is a problem with the pregnancy - the embryo may miscarry
because it is unhealthy; or the pregnancy could be an ectopic pregnancy.
Differentiating between the two conditions is obviously important, and this is
where vaginal ultrasound plays a key role.
With vaginal ultrasound, it is possible to detect a pregnancy as early as 2
to 4 days after a missed period. An early pregnancy is observed as a pregnancy
sac or gestational sac in the uterine cavity. The uterine lining is thick and
bright white; and the sac (also called a gestational sac) in the uterine cavity.
The uterine lining is thick and bright white, and the sac appears as a black
bubble in this lining. The sac should grow (at the rate of about 1 mm per day )
and, if it does so, this is reassuring. The sac represents only the placental
tissue - the embryo is so tiny at this stage, that it cannot be seen on
ultrasound. At 6 weeks of pregnancy, an echo can be seen within the sac; this is
the embryo. This grows rapidly, so that on scans done by 8 weeks, one should be
able to see a beating fetal heart as well. This is very good evidence of a
healthy fetus and the chances of a problem occurring in pregnancy after this
point are small.
Ultrasound is useful because it provides information about the number of
pregnancies (multiple pregnancies are not uncommon after infertility treatment
and should be looked for !) ; as well as their location. If the sac is not seen
in the uterine cavity, then a tubal pregnancy should be suspected. The
ultrasound provides information which is complementary to that of the HCG level.
Often both need to be done simultaneously and interpreted together.
What about do’s and don'ts during pregnancy ? What precautions should you
take to minimise your risks ? Unfortunately, there is little anyone can do today
which is of much use. During pregnancy, most doctors may put you on supplemental
progesterone injections (to help support the endometrium); and perhaps
mutlivitamins; and low-dose aspirin. All this treatment is empiric - there is no
proof that it works ! Also, many patients will put themselves on bed-rest to
prevent disturbing the pregnancy and the value of this is doubtful as well . If
the pregnancy is going to have a problem, no matter what you do, it will. And if
it is going to be uneventful, then you don't really need medical attention in
any case . The trouble is we do not know which pregnancy is going to have
problems and which one is not ! Any bleeding, no matter how slight , should be
taken seriously - and usually calls for hospitalisation.
Unfortunately, it is a fact of life that 10 to 20% of all pregnancies will
end in a miscarriage - and the risk of an infertile woman's miscarrying is even
higher. This is because they are often older; their medical problems which
caused the infertility can also cause miscarriage; and sometimes the infertility
treatment also increases this risk. Of course, some of the increased risk is
only apparent, because the testing is so intensive and thorough.
Unfortunately, no treatment exists for preventing early miscarriages - and
all the doctor (and patient) can do is wait and watch. This can be shattering !
Nevertheless, the fact that you have got pregnant provides hope for the future.
If the pregnancy miscarries, then a curettage is needed. This tissue must be
sent for histopathologic examination, to provide documentation of the pregnancy.
This also helps to rule out an ectopic pregnancy.
Coping with miscarriage after infertility can be hell ! When you finally get
pregnant after so many years of trying, you feel it is cruel on God's part to
then snatch it away. In fact, perhaps the only trauma worse than not being able
to conceive, is to lose a pregnancy after trying so hard. Remember that nature
is not perfect and neither is medical care. The most painstaking attention to
detail cannot stop the unexpected from happening and no amount of obsession with
detail will guarantee a perfect outcome.
If you miscarry, you are going to blame yourself - that it was something you
did (or did not do ) which caused the miscarriage. However, remember that 70% of
miscarriages are because of a chromosomal abnormality at conception - something
over which you have no control.
We will never know the reason why they occur. This why most doctors would not
investigate you after just one miscarriage, since the chance of finding
something significantly abnormal is so small - and your chance of having a
healthy pregnancy the next time is better than 85% . Most would reassure you -
and the best option would be to try again (even though this can be emotionally
very taxing !). If you've had a previous miscarriage, it is very normal to be
frightened and worried - and starting infertility treatment again can be very
difficult . You have to start from scratch all over again - and you wonder if
and when you will again get pregnant. The lurking fear of losing the pregnancy
once more, if you do conceive again, could torment you as well.
Coping with pregnancy after infertility treatment can be difficult even if
the pregnancy is going well. So much time, energy, love and money have been
invested in the pregnancy, that you don't want to take the slightest chance that
something will go wrong. The anxiety can be overpowering - and even the minor
aches and pains of pregnancy can send you rushing to the doctor for reassurance
that all is well.
Your pregnancy will be monitored carefully, and this may involve frequent
visits to the doctor; as well as repeated ultrasound scans. You will be very
vulnerable and terrified, and will be bombarded by suggestions from well-meaning
friends and relatives as to what to do, and also what not to do.
If you are more than 35 years of age, your doctor may advise you have a
chorion biopsy or amniocentesis to screen for genetic defects in the newborn,
such as Down's syndrome. Also, if you have multiple pregnancies, frequent
hospitalisation and bed-rest may be needed.
Yours is a "premium pregnancy", and will be treated as such even
though your risk for complications is no more than any other woman's. However,
since the pregnancy is so precious , the hazard is greater than for someone has
no trouble conceiving , which is why an "at risk" approach to managing
your pregnancy is appropriate. This is why the chance of your requiring a
cesarean section for birth are greatly increased, because neither you nor your
doctor will want to take the slightest "chance" of something going
What about after the delivery ? Is this when the joy and happiness you have
been anticipating for so long and happiness you have been anticipating for so
long begin? Maybe ! Certainly life is never the same when the child you have
been looking forward to for so long finally arrives, especially if you have
twins ! Babies are demanding and not everyone can adjust adjusts easily to the
new situation. If couples are older then it may be harder for them to cope with
the changes, especially after spending years of being together without the
company of children.
The infertile woman who becomes pregnant expects perfection in every aspect
of motherhood, because that's the stuff dreams are made of. However, when the
reality of pregnancy, delivery and parenting actually takes hold, you may even
feel disappointed, because real life is often harsher and unkinder than you had
imagined. For example, you may have a hard time coping with 2 a.m. feedings and
you may even start to resent your having to get up to take care of your newborn.
This can make you feel guilty for not appreciating what you have-your child, for
which you worked so hard! Don't worry , this feeling is normal and will pass.
Your parenting also is going to be influenced by your experience of
infertility, because your child is extra special and it is natural for you to
want to dote on him or her. This can be wonderful for your child because he or
she will always know how much he or she was wanted and how much he or she is
loved - but watch out for the emotional traps of being overprotective and
unintentionally spoiling the child.
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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