Pregnancy

Q. What is infertility?

A. Infertility is a disease or condition of the reproductive system that interferes with the ability to conceive. It’s typically defined as not being able to get pregnant after having regular unprotected sex for one year. “Regular” is considered every few days when a woman is ovulating–the time of the month when one or more eggs are released from the ovaries. Couples may want to seek medical treatment sooner than the one-year mark if the woman is over 35 or if there is a history of irregular menstrual cycles or diseases of the reproductive system.Infertility also includes the inability to carry a pregnancy to term, as in the case of someone who’s had multiple miscarriages, says Diane Clapp, director of medical information at RESOLVE, a nonprofit advocacy organization for men and women facing infertility. “Some people think that infertility is all in the head and can be fixed with relaxation or a vacation,” says Clapp, who is a registered nurse. “But infertility is a medical disease that most people can be treated for.” About two-thirds of people who are treated for infertility will become pregnant, according to RESOLVE.

Q. What kinds of doctors evaluate and treat infertility?

A. Obstetrician-gynecologists (OB-GYNs) can evaluate and treat infertility in women. OB-GYNs specialize in general medical care of women, including care related to pregnancy and the reproductive tract. Urologists, who specialize in the urinary tract and the male reproductive organs, can evaluate and treat infertility in men.More resistant and complex problems are typically handled by “fertility specialists,” board-certified reproductive endocrinologists who have completed training in obstetrics and gynecology, followed by specialized training in hormonal problems and infertility. One example of a complex problem is a history of failure to conceive despite regular unprotected intercourse in a woman who has regular menstrual periods and whose male partner has normal sperm. Other examples of complex problems include a woman who has experienced multiple miscarriages or who has severely damaged fallopian tubes requiring the need for treatment with assisted reproductive technologies (ART)–the joining of eggs and sperm in a lab so that fertilization can occur.The decision about when to ask for a referral to a fertility specialist is a personal one. Experts say that couples should consider the age of the woman, the complexity of their problems, and how they are feeling about the progress of their treatment. Consumers should be proactive about asking their doctors for a referral to a specialist and about investigating the qualifications of the specialist. A certificate of special qualification in reproductive endocrinology and infertility from the American Board of Obstetrics and Gynecology ensures that the specialist has completed a rigorous course of training.

Q. What goes into a fertility evaluation?

A. A standard fertility evaluation includes physical exams and medical and sexual histories of both partners. Men undergo a semen analysis that evaluates sperm count and sperm movement. “We look at the percent that are moving and how they are moving–are the sperm sluggish? Are they wandering?” says Robert G. Brzyski, M.D., Ph.D., associate professor of obstetrics and gynecology at the University of Texas Health Science Center at San Antonio. “Often, it’s not possible to identify a specific reason for a sperm disorder,” he says. “But there is new recognition that very low sperm or no sperm may be related to genetics–an abnormality of the Y chromosome.”For women, doctors first check to see whether ovulation is occurring. This can be determined and monitored through blood tests that detect hormones, ultrasound examinations of the ovaries, or an ovulation home test kit. “An irregular menstrual pattern would make us suspicious of an ovulation problem, but it’s also possible for a woman with regular periods to have an ovulation disorder,” Brzyski says.If a woman is ovulating, doctors then move to a standard test called the hysterosalpingogram, a type of X-ray of the fallopian tubes and uterus. This test involves placing a radiographic dye solution into the uterine cavity. Multiple X-rays are taken. If the fallopian tubes are open, the dye will flow through the tubes and be visible in the abdominal cavity. If the fallopian tubes are blocked, the dye will be retained in the uterus or fallopian tubes, depending on the location of the blockage.

Doctors have begun to assess the ovarian reserve by measuring hormone levels and seeing how the ovaries respond to various fertility treatments. This helps evaluate the availability of eggs and the likelihood that a healthy pregnancy will result. “Some women who are 35 are fertile while others are not because their supply of eggs is depleted,” Brzyski says. “In the last decade, we’ve learned this can be investigated through a blood test on the third day of the menstrual cycle. If the numbers are normal, it doesn’t guarantee fertility. But if the numbers are abnormal, it points to a serious problem. Up to 20 percent of women who seek infertility care have an abnormal ovarian reserve test.”There are also tests that evaluate how sperm and eggs interact, as well as whether either party is developing antibodies to the sperm. This occurs when the man’s or the woman’s immune system recognizes the sperm as something foreign and attacks it.

Some of the same discomforts you had in your second trimester will continue. Plus, many women find breathing even more difficult and notice they have to go to the bathroom even more often. This is because the baby is getting bigger and it is putting more pressure on your organs. Don’t worry, your baby is fine and these problems will lessen once you give birth.

The following aches and pains often appear for the first time during the third trimester:

Heartburn

Swelling of the ankles, fingers, and face. If you notice any sudden or extreme swelling or if you gain a lot of weight really quickly, call your doctor right away. This could be a sign of preeclampsia or toxemia.

Hemorrhoids

Tender Breasts

Trouble Sleeping

As you near your due date, your cervix becomes thinner and softer (called effacing). This is a normal, natural process that helps the birth canal (vagina) to open during the birthing process. Your doctor can check your progress with a vaginal exam.

Weight Gain

Everyone gains weight at different rates. On average, it is normal to gain about one pound per week, or three to four pounds per month, during the third trimester. By the end of your pregnancy you should have gained, on average, about 25 to 30 pounds. About 7 1/2 pounds of that weight should be the baby.

Changes in Your Baby

Your baby is still growing and moving, but now it has less room in your uterus. Because of this, you might not feel the kicks and movements as much as you did in the second trimester. During this final stage of your pregnancy, your baby is continuing to grow. Even before your baby is born it will be able to open and close its eyes and might even suck its thumb.

As your body prepares for birth, the baby will start to move into its birth position. You might notice the baby “dropping,” or moving down lower in your abdomen. This can reduce the pressure on your lungs and rib cage, making it easier to breathe.

At birth, the average baby is 20 to 22 inches long and weighs 7 1/2 pounds. But newborns who weigh between 5 pounds, 11 1/2 ounces and 8 pounds, 5 3/4 ounces are considered healthy.

Sleeping in the 3rd Trimester

Your energy may lessen as you enter the ninth month. So you may begin to slow down. This is normal. It’s important to get enough rest now, even though it can be more difficult to sleep as you get larger. The baby’s movements, bathroom runs, and an increase in your body’s metabolism can make sleeping difficult.

As your due date approaches, ask questions and share concerns you have about labor and delivery. You and your doctor will discuss what kind of delivery you will have. Some women need to have a cesarean section (c-section). During a c-section a surgical cut is made in the abdomen and uterus to remove the baby.

If you plan on a non-surgical, vaginal birth, you should talk to your doctor about the pros and cons of pain relief. Some women opt for pain medicines and others want to deliver naturally, without medicine. Many women find childbirth classes very helpful, even if they have already had a baby. Women often bring their partners or a friend or relative to childbirth classes, particularly if this person will be with them during the birth of their baby.

When to Call Your Doctor

Before your due date, make sure to talk with your doctor about how to reach him or her if you go into labor. It’s also helpful to be familiar with the hospital or birthing center, where you should park, and where to check in ahead of time. Know that sometimes you can think you’re in labor, but really are not (called false labor). This happens to many women, so don’t feel embarrassed if you go to the hospital certain that you are in labor, only to be sent home! It’s always better to be seen by a doctor as soon as possible once labor has begun.

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Most women find the second trimester of pregnancy easier than the first. But it is just as important to stay informed about your pregnancy during these months.

You might notice that symptoms like nausea and fatigue are going away. But other new, more noticeable changes to your body are now happening. Your abdomen will expand as you gain weight and the baby continues to grow. And before this trimester is over, you will feel your baby beginning to move!

Many of the aches and pains you had in the first trimester may continue. So remember to follow the tips from Pregnancy Basics to help prevent and ease these discomforts.

Some of the following aches and pains may make their first appearance during the second trimester:

• Pain in the abdomen, groin, and thighs

• Backaches

• Shortness of breath

• Stretch Marks

• Skin Changes

• Tingling in hands and fingers

Itching on the abdomen, palms, and soles of the feet — Call your doctor if you have nausea, loss of appetite, vomiting, jaundice or fatigue combined with itching. These can be signs of a serious liver problem called cholestasis of pregnancy.

Weight Gain in the Second Trimester

Everyone gains weight at different rates. On average, it is normal to gain about one pound per week, or about three to four pounds per month during this trimester.

Changes in Your Baby

By the end of the second trimester your baby will weigh about 1 3/4 pounds and be about 13 inches long. With this growth comes the development of fingers, toes, eyelashes, and eyebrows. Around the fifth month, you might feel your baby move! By the end of this trimester, all of your baby’s essential organs like the heart, lungs, and kidneys are formed.

2nd Trimester Tests and Procedures

During the second trimester, you should continue to see your doctor for prenatal care. Most pregnant women have monthly office visits with their doctor or midwife until the end of this trimester.

During the second trimester your doctor can use an ultrasound to see if your baby is developing in a healthy way and to find out your baby’s sex. You will also be offered screening tests to look for genetic birth defects.

Birth defects result from problems with a baby’s genes, inherited factors that are passed down from the mother and the father at conception. Genetic birth defects sometimes occur in people with no family history of that disorder. Women over the age of 35 have the greatest chances of having a baby with birth defects.

Tests your doctor might suggest in the second trimester:

Amniocentesis

This test is performed in pregnancies of at least 16 weeks. It involves your doctor inserting a thin needle through your abdomen, into your uterus, and into the amniotic sac to take out a small amount of amniotic fluid for testing. The cells from the fluid are grown in a lab to look for problems with chromosomes. The fluid also can be tested for AFP. About 1 in 200 women have a miscarriage as a result of this test.

Chorionic villus sampling (CVS)

This test is performed between 10 and 12 weeks of pregnancy. The doctor inserts a needle through your abdomen or inserts a catheter through your cervix in order to reach the placenta. Your doctor then takes a sample of cells from the placenta. These cells are used in a lab to look for problems with chromosomes. This test cannot find out whether your baby has open neural tube defects. About 1 in 200 women have a miscarriage as a result of this test.

Maternal serum screening test

This blood test can be called by many different names including multiple marker screening test, triple test, quad screen, and others. This test is usually given between 15 and 20 weeks of pregnancy. It checks for birth defects such as Down syndrome, trisomy 18, or open neural tube defects. Doctors take a sample of your blood. They check the blood for 3 chemicals: alpha-fetoprotein (AFP) (made by the liver of the fetus), and two pregnancy hormones: estriol and human chorionic gonadotropin (hCG). Sometimes, doctors test for a fourth substance in the blood called inhibin-A. Testing for inhibin-A may improve the ability to detect fetuses with a high risk of Down syndrome.

Higher levels of AFP are linked with open neural tube defects. In women age 35 and over, this test finds about 80% of fetuses with Down syndrome, trisomy 18, or an open neural tube defect. In this age group, there is a false positive rate (having a positive result without actually having a fetus with one of these health problems) of 22%. In women under age 35, this test finds about 65% of fetuses with Down syndrome, and there is a false positive rate of about 5%.

Targeted ultrasound

The best time to get a targeted ultrasound is between 18 and 20 weeks of pregnancy. Most major problems with the way your baby is formed can be seen at this time. Some physical defects such as clubbed feet and heart defects may not be seen.

Your doctor can also use ultrasound to see if your baby has any neural tube defects, such as spina bifida. In most cases, if you want to find out the sex of your baby, you can ask your doctor during this test. This is not the most accurate test for Down syndrome. Only 1 in 3 babies with Down syndrome have an abnormal second trimester ultrasound