Pregnant - At Last !

from the book How to Have a Baby: Overcoming Infertility
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 exists.

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 wrong.

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.

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