My First Trimester

The onus of infertility rests equally between the female and male factoring about one-third of the time for each. The remaining one-third causation is either not known or a combination of both male and female factors. With age, there is a natural decrease in fertility spurring the investigation and management of infertility to be started sooner by some specialists in certain couples.

Identifying the cause of female infertility can be challenging but there are several treatments available once the cause is realized. Your possible treatment will depend on the primary problem. Treatment may not always be warranted as numerous infertile couples do go on to conceive a child naturally. It is estimated that approximately six percent of married women (15-44) are not able to become pregnant after one year of unprotected sex, and that roughly twelve percent of women (15-44) struggle with infertility or carrying a pregnancy forty weeks regardless of their marital status.

Male infertility data from the National Survey of Family Growth in 2002 that was analyzed by the CDC showed that 7.5% of all sexually experienced men younger than age 45 reported seeing a fertility doctor during their lifetime. This means that 3.3–4.7 million men sought help for infertility and of the men who wanted help, 18% were diagnosed with a male-related infertility problem, including sperm or semen problems (14%) and varicocele (6%).

Symptoms

The foremost symptom of infertility is the inability of a couple to become pregnant. Female infertility may be associated with a lack of ovulation arising from a menstrual cycle that is excessively long (35 days or more) or short (less than 21 days). An irregular or absent period can signal a lack of ovulation as being the cause of infertility. However, there may also be no other apparent signs or symptoms.

When you decide to see a doctor and seek medical help depends, to some extent, on your age, as a woman’s age is probably the most significant factor related to her ability to conceive. According to the Mayo Clinic:

• If you’re in your early 30s or younger, most doctors recommend trying to get pregnant for at least a year before having any testing or treatment.
• If you’re between 35 and 40, discuss your concerns with your doctor after six months of trying.
• If you’re older than 40, your doctor may want to begin testing or treatment right away.

Your doctor will most likely recommend a member of the American Society of Reproductive Medicine in your area to help you with your infertility.

Causes

Today, the trend of delayed marriage and childbirth are the main social causes of infertility. Physically, in order for you to become pregnant ovulation, sperm, regular intercourse, open fallopian tubes and a normal uterus must all co-exist working simultaneously together. However, there are several factors that can prevent this process from taking place and causing female infertility. Genetic testing will also help determine whether there’s a genetic defect may also be a source of infertility prompting the need for genetic testing.

Ovulation disorders

Ovulation disorders are responsible for roughly 25 percent of couples remaining infertile. This condition causes you to ovulate irregularly or perhaps not at all. Inconsistency in the reproductive hormonal regulation by either the hypothalamus or pituitary gland, or by difficulties within the ovary itself may be to blame for this problem. The Mayo Clinic defines ovulation disorders as:

• Polycystic ovary syndrome (PCOS). In PCOS, complex changes occur in the hypothalamus, pituitary gland and ovaries, resulting in a hormone imbalance, which affects ovulation. PCOS is associated with insulin resistance and obesity, abnormal hair growth on the face or body, and acne. It’s the most common cause of female infertility.
• Hypothalamic dysfunction. The two hormones responsible for stimulating ovulation each month — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — are produced by the pituitary gland in a specific pattern during the menstrual cycle. Excess physical or emotional stress, a very high or very low body weight, or a recent substantial weight gain or loss can disrupt this pattern and affect ovulation. The main sign of this problem is irregular or absent periods.
• Premature ovarian insufficiency. This disorder is usually caused by an autoimmune response where your body mistakenly attacks ovarian tissues or by premature loss of eggs from your ovary due to genetic problems or environmental insults such as chemotherapy. It results in the loss of the ability to produce eggs by the ovary, as well as a decreased estrogen production under the age of 40.
• Too much prolactin. Less commonly, the pituitary gland can cause excess production of prolactin (hyperprolactinemia), which reduces estrogen production and may cause infertility. Most commonly this is due to a problem in the pituitary gland, but it can also be related to medications you’re taking for another disease.

Damaged fallopian tubes (tubal infertility)

The inability of sperm to reach the egg or the failure of the fertilized egg to reach and implant in the uterus may be due to damaged or blocked fallopian tubes. The Mayo Clinic states tubal damage or blockage may be a result of:

• Pelvic inflammatory disease, an infection of the uterus and fallopian tubes due to chlamydia, gonorrhea or other sexually transmitted infections.
• Previous surgery in the abdomen or pelvis, including surgery for ectopic pregnancy, in which a fertilized egg becomes implanted and starts to develop in a fallopian tube instead of the uterus.
• Pelvic tuberculosis, a major cause of tubal infertility worldwide, although uncommon in the United States.

Endometriosis

Uterine tissue that implants and grows elsewhere is called endometriosis. This additional growth of uterine tissue when removed surgically may cause scarring obstructing the narrow fallopian tube. If this occurs, the egg and sperm will not unite. Equally, endometriosis may also affect the lining of the uterus jeopardizing the implantation of the fertilized egg. This condition may also be indirectly responsible for upsetting fertility by causing injury to the sperm or egg. It is estimated that 25-50 percent of women have this condition.

Uterine or cervical causes

There are a number of uterine or cervical conditions that may interfere with your egg becoming implanted in the uterus. This increases the risk of a miscarriage. The Mayo Clinic defines these conditions as:

• Benign polyps or tumors (fibroids or myomas) are common in the uterus, and some types can impair fertility by blocking the fallopian tubes or by disrupting implantation. However, many women who have fibroids or polyps can become pregnant.

• Endometriosis scarring or inflammation within the uterus can disrupt implantation.
• Uterine abnormalities present from birth, such as an abnormally shaped uterus, can cause problems becoming or remaining pregnant.
• Cervical stenosis, a cervical narrowing, can be caused by an inherited malformation or damage to the cervix.
• Sometimes the cervix can’t produce the best type of mucus to allow the sperm to travel through the cervix into the uterus.

Male infertility

This may be caused by various factors. It is usually diagnosed by two semen analyses taken at least one month apart. A specialist evaluates the number of sperm (concentration), motility (movement), and morphology (shape). If the result is slightly abnormal, a diagnosis of infertility is not necessary made. However, if the abnormal result is due to an illness such as a viral infection, it will take roughly two to three months before the sperm parameters change and the test can be repeated. This analysis will aid in deciding how male factors are possibly contributing to the couple’s infertility.

According to the CDC, the conditions that can contribute to an atypical semen analyses include:

• Varicoceles, a condition in which the veins on a man’s testicles are large and cause them to overheat. The heat may affect the number or shape of the sperm.
• Medical conditions or exposures such as diabetes, cystic fibrosis, trauma, infection, testicular failure, or treatment with chemotherapy or radiation.
• Unhealthy habits such as heavy alcohol use, testosterone supplementation, smoking, anabolic steroid use, and illicit drug use.
• Environmental toxins including exposure to pesticides and lead.

The National Institute of Health (NIH) state that other causes of male infertility may include:

• Physical problems with the testicles.
• Blockages in the ducts that carry sperm.
• Hormone problems.
• A history of high fevers or mumps.
• Genetic disorders.
• Lifestyle or environmental factors.

Unexplained infertility

Unfortunately, a source for your infertility may never be discovered. Unresolved fertility issues may result from a combination of various minor causes affecting the couple as a whole. It can be devastating to not know the reason for your infertility but the good news is that infertility can possibly be reversed in time.

Risk factors

According to the Mayo Clinic, there are definite risk factors that may increase your chances of infertility. They are:

• Age. With increasing age, the quality and quantity of a woman’s eggs begin to decline. In the mid-30s, the rate of follicle loss accelerates, resulting in fewer and poorer quality eggs, making conception more challenging and increasing the risk of miscarriage.
• Smoking. Besides damaging your cervix and fallopian tubes, smoking increases your risk of miscarriage and ectopic pregnancy. It’s also thought to age your ovaries and deplete your eggs prematurely, reducing your ability to get pregnant. Stop smoking before beginning fertility treatment.
• Weight. If you’re overweight or significantly underweight, it may hinder normal ovulation. Getting to a healthy body mass index (BMI) has been shown to increase the frequency of ovulation and likelihood of pregnancy.
• Sexual history. Sexually transmitted infections such as chlamydia and gonorrhea can cause fallopian tube damage. Having unprotected intercourse with multiple partners increases your chances of contracting a sexually transmitted disease (STD) that may cause fertility problems later.
• Alcohol. Heavy drinking is associated with an increased risk of ovulation disorders and endometriosis.

It must also be noted that passive smoking has also been established to have an effect on fertility and the heavy use of marijuana decreases fertility in both men and women.

Preparing for your appointment

If you decide to have your infertility evaluated, it’s important that you begin tracking your periods, your symptoms and dates of intercourse before your first visit. You will also want to make a list of medications and supplements — either vitamins or herbal remedies — with doses and frequency for your specialist. Any pertinent medical records with previous tests or treatments should accompany you.

Both you and your partner will have a medical and sexual history taken; any previous pregnancies with your current partner will be discussed. You will both be assessed for possible causes as well as potential treatments to correct this condition.

Don’t forget to bring a notebook or iPad with you for two reasons. First, beforehand you can prepare any questions that you would like answered, and second, you will be able to jot down any essential information given to you at this time.

Tests, diagnosis, treatments and drugs

Your specialist may possibly order any number of tests that he or she feels will help to evaluate, diagnose and treat your condition. Testing may range from a simple over-the-counter ovulation prediction kit to a laparoscopy which is a minimally invasive procedure visualizing your fallopian tubes, ovaries and uterus to genetic testing which will indicate if a genetic problem is responsible for your infertility. It is important to remember that no one test is a perfect predictor of fertility.

Nearly 85-90 percent of infertility cases are treated conservatively with drugs or the surgical repair of reproductive organs. Although numerous surgical procedures can correct difficulties or increase female fertility, the surgical interventions for fertility are rare these days as fertility treatments such as laparoscopic surgery, microscopic tubal ligation reversal surgery and tubal surgeries have high success rates.

Endometriosis may be diagnosed by using ultrasonography and endometrial biopsy that are not considered part of the basic infertility investigation. Neither blood tests nor imaging studies alone can correctly diagnose endometriosis. Although ultrasound might identify an ovarian cyst that includes an endometrioma, a laparoscopy is still required to make the diagnosis.

The fertility drugs used today may increase a woman’s chance of becoming pregnant with twins, triplets, or other multiples. If you are pregnant with multiples, additional problems, monitoring and health care visits may be increased. Multiple fetuses have an increased risk of being born prematurely and are also at a higher risk of health and developmental problems.

Male factor infertility, depending on the primary cause, may be approached either medically, surgically, or helped with reproductive therapies. Medical and surgical treatments will normally be handled by a urologist specializing in infertility. A reproductive endocrinologist may also be needed. This specialist may offer intrauterine inseminations (IUIs) or assisted reproductive technology (ART). ART includes all fertility treatments in which both eggs and sperm are handled outside of the body. These procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. The main type of ART to overcome male infertility is in vitro fertilization (IVF), which currently accounts for more than 99 percent of ART procedures; tens of thousands of babies have been born around the world with this procedure. Severe male factor infertility is associated with genetic disorders such as mutations in the cystic fibrosis genes and is treated effectively only with IVF. ART accounts for approximately 10-15 percent of the remaining infertility treatment options.

Overall, many factors will determine how your specialist will treat your infertility. The complexity of infertility requires a substantial fiscal, physical, emotional and time commitment on your and your partner’s part. It may only take a couple of treatments to correct your infertility. However, some couples require numerous appointments and therapies before conception is possible. As mentioned above, medication or even surgery may be necessary to assist with conception, or complex procedures may also be warranted or introduced.

Coping and support

The quest for finding a cause for your infertility may be a strenuous and demanding one both physically and emotionally. Did you know that studies indicate that couples experiencing psychological stress have poorer results with infertility treatments? It will help to relieve any unnecessary anxiety by making sure you that you are aware, informed and understand the success rates, risks, and benefits of the potential therapies that are being offered. After consulting with your doctor, you and your partner will select the option that you feel is most advantageous to create a successful conception.

Don’t forget to keep your close friends and family informed of your progress. Many couples find comfort and support through the anonymity of online groups via social media. Professional help is always available to you both so never hesitate to reach out to your health care team for advice or a reference.

Continue your healthy lifestyle entertaining a moderate level of activity and exercise, and a well-balanced diet. This combination can boost your spirits as your tackle your infertility. Remember, that you always have alternatives to infertility. Adoption, surrogacy, gestational carriers or even deciding on not having any children may be choices you will want to consider. You should discuss these possibilities or another course of action that may appeal to you early in your infertility process as this can lower stress during treatments and disappointment if conception does not take place.

Prevention

It’s important that you try to improve your chances of normal fertility if you are considering becoming pregnant now or in the future. Simply incorporating the basics of good health is paramount. By maintaining a normal weight, eliminating smoking, alcohol and limiting your caffeine level to less than 200 to 300 milligrams a day, and reducing your stress level will improve your chances of normal fertility and the hope for conception to ensue.

On September 1, 2017 Williams gave birth to her daughter Alexis Olympia via emergency C-section. The following day she became short of breath and immediately recognized this sign of a dangerous condition she knew only too well. Gasping for breath she told a nurse she might have another blood clot. The nurse did not take Williams seriously at first suggesting her “pain medication must be making her confused.” Williams trusted her instincts and asserted something was not right. After a negative ultrasound on her legs, a CT scan was performed on her lungs showing several blood clots. Heparinized, she was on the road to recovery. Or was she?

Williams endured harsh coughing episodes opening her C-section wound. An ensuing surgery revealed a hemorrhage at the location of the incision. When finally discharged, She was put on bed rest for six weeks. 

Do you find yourself contemplating pregnancy? Is your research revealing the fun, fabulous and amazing aspects of your impending nine-month journey? Will this be the lucky month for you? What about next month? 

Before your started your pregnancy research, you were most likely very comfortable with your pregnancy decision timetable. After all, if you live in the United States, the USA is the richest and most medically advanced county in the world. Right? 

As your research intensifies you’re discovering some unfamiliar aspects of pregnancy. There are organizations combating various conditions such as Preeclampsia, Stillbirth, Intrahepatic Cholestasis of Pregnancy (ICP) and Gestational Diabetesto name a few. 

Then you stumble upon Maternal Mortality and Morbidity. What? You mean, “I may not make it out of my pregnancy journey alive?” Slowly you realize the risks of pregnancy and delivery day are genuine, yet silently hidden.  

Maternal Morbidity And Mortality

So what exactly is maternal morbidity and mortality?

The Center for Disease Control (CDC) defines Severe Maternal Morbidity (SMM) “to include the unexpected outcomes of labor and delivery that result in significant short or long-term consequences to a woman’s health”.

Maternal Mortality is defined by the CDC as “the death of a woman while pregnant or within 1 year of the end of a pregnancy regardless of the outcome, duration or site of the pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.”

Dr. Priya Agrawal, OB.Gyn, Executive Director of Merck for Mothers, states that although maternal mortality is comparatively rare in the USA, one preventable maternal death is one too many. The United States has a higher rate of maternal deaths than 45 other countries globally and more women will die from child-related causes in the United States than in any other developed country.

In her recent editorial in the Bulletin of the World Health Organization (WHO), Dr. Agrawal informs us that the USA costs of maternity care exceeded $60 billion in 2012. Although maternity costs continue to rise, approximately 700 women in the USA will experience complications during pregnancy or childbirth that prove fatal every year. Sadly, another 60,000 women will endure complications that are near fatal. 

Yet in 2020, Dr. Vishwani Persaad-Sharma, DNP, ARNP-BC of the University of Miami wrote Rethinking maternal healthcare for the 21st century in the United States presenting even more shocking numbers for us to digest. Her research paints a grim picture with 1200 American women undergoing pregnancy or childbirth-related complications resulting in fatal outcomes.

The USA’s maternal morbidity and mortality rates remain extremely problematical. Unbelievably, roughly half of all maternal deaths in the USA are preventable. Dr. Agrawal cites three factors that are influencing the rising maternal mortality and morbidity trend in the USA: 

1.          There is inconsistent obstetric practice. Hospitals across the USA lack a standard approach to managing obstetric emergencies and the complications of pregnancy and childbirth are often identified too late. Nationally endorsed plans to manage obstetric emergencies and updated training and guidance on implementing these plans is a serious and ongoing need.

2.         There are an increasing number of women who present at antenatal clinics with chronic conditions, such as hypertension, diabetes and obesity, which contribute to pregnancy-related complications. Many of these women could benefit from the closer coordination of antenatal and primary care including case management and other community-based services that help them access care and overcome cost and other obstacles. In the USA, women who lack health insurance are three to four times more likely to die of pregnancy-related complications than their insured counterparts.

3.  The general lack of good data and related analysis on maternal health outcomes is another factor. Only half the USA’s states have maternal mortality review boards and the data that are collected are not systematically used to guide changes that could reduce maternal mortality and morbidity. There is no national forum for the states to share either their best practices for reviewing maternal deaths or the relevant lessons that they may have learned.

So what is being done in the USA? 

Medical personnel and community organizations are working to address the above factors. Hospitals are now creating standard approaches for obstetric emergencies. This will help to ensure that wherever a woman gives birth, she will be given suitable evidence-based care. Community initiatives are now managing care for high-risk women to safeguard good health and the management of chronic disorders during and after pregnancy. More states are creating and standardizing maternal mortality review boards.

New changes to nationwide health policies will hopefully improve maternal health outcomes. The USA’s participation in the global dialogue on maternal health is mandatory. Every state needs to rally health providers, policy-makers and communities in making maternal health a priority. With increased awareness of maternal mortality and life-threatening events and concrete actions to ensure that pregnant women get the quality care they need, many fatal and near-fatal complications could be prevented.

Dr. Persaad-Sharma’s message is that “the lives of mothers and infants are invaluable. Without effective and thorough maternal healthcare policies in place in 21st century United States of America, more innocent lives will continue to perish across ethnicities with disparate discrepancies among racial minority mothers and children. The time to act is now; be the change you want to see in society.“

And Globally…

On the global front, to make maternal morbidity and mortality even more profound, maternal losses sustained by underdeveloped countries are much more disturbing as countless numbers of women do not have access to maternity care. For these women, more than 800 a day will die from complications related to pregnancy or childbirth. Statistics show that between 1990 and 2015 maternal mortality worldwide dropped by about 44 per cent. However impressive this appears, it’s estimated 303,000 women died during and following pregnancy and childbirth globally in 2015 and almost all of these deaths occurred in low-resource settings. Alarmingly, almost allglobal maternal deaths are preventable.

Globally, one of the WHO’s foremost priorities is improving maternal health. 

“WHO works to contribute to the reduction of maternal mortality by increasing research evidence, providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to Member States. 

In addition, WHO advocates for more affordable and effective treatments, designs training materials and guidelines for health workers, and supports countries to implement policies and programs and monitor progress.

During the United Nations General Assembly 2015, in New York, UN Secretary-General Ban Ki-moon launched the Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016-2030 (7). The Strategy is a road map for the post-2015 agenda as described by the Sustainable Development Goals and seeks to end all preventable deaths of women, children and adolescents and create an environment in which these groups not only survive, but thrive, and see their environments, health and wellbeing transformed.” 

Every Mother Counts

Christy Turlington Burns is the Founder and CEO of Every Mother Counts. After experiencing childbirth complications following the birth of her daughter Grace on October 23, 2003, Christy learned that hundreds of thousands of women were dying every year because they do not have access to the maternity care that they need. Realizing there is not enough political will or resources dedicated to this issue she devoted her work to understanding the challenges of and opportunities for improving access to maternity care around the world. She founded Every Mother Counts in 2010 following the release of her documentary film, No Woman, No Cry.

Every Mother Counts raises awareness by educating the public about this extremely sensitive subject touching us all. Sadly, most people are not aware of this potential tragedy until it is too late. The hope of this organization is to share their documented stories widely so others will learn from them, making these devastating stories a thing of the past.

Maternal mortality is unacceptably high. Although 99% of all maternal deaths occur in developing countries, it must be remembered that between 1990 and 2013, the maternal mortality ratio for the USA more than doubled from an estimated 12 to 28 maternal deaths per 100,000 births. The rate of maternal mortality is markedly higher among black women in the USA. These women who are expecting or who are new mothers die at rates similar to those of the same women in lower-income countries. Simultaneously, the maternal mortality rate for white USA mothers more closely resembles rates in more affluent nations.

Serena Williams understands this only too well. She agrees that she received excellent care for her postpartum complications for the most part. But concurs, “Imagine all the other women, who go through that without the same health care, without the same response.”

Empowering your knowledge of pregnancy day-by-day and trimester-by-trimester is important. The need for every pregnant woman to understand the joys as well as the perils of her remarkable nine-month journey is vital. It’s just that simple.

By knowing the facts, journaling your pregnancy milestones and tracking your baby’s movements you will be working closely with your health care team, which is key. Taking an active role in your pregnancy is essential. For more information on maternal mortality and morbidity in the USA and globally, please visit the WHO, CDC and Every Mother Counts. 

HOMICIDE: Pregnancy & Postpartum

It’s a fact that nationwide data for Maternal Morbidity and Mortality often fails to account for deaths from external factors, like homicide, according to Maeve Wallace, PhD, of Tulane University in New Orleans.

Analyzing state death certificates in Louisiana showed that homicide was the leading cause of death among pregnant and postpartum women in 2016-2017. Of 119 pregnancy-associated deaths to occur in the 2-year period, 16 (13.4%) were from homicide.

The homicide mortality rate of 12.9 per 100,000 found in the current study is not much less than the nation’s maternal mortality from all causes as reported by the CDC last week for 2018: 17.4 per 100,00, albeit with somewhat different methods.

By creating nationwide maternal mortality review committees to systematically evaluate obstetric-related deaths and make suggestions to prevent such deaths, “is an important step towards reversing its increasing incidence,” Wallace and colleagues say.

“As maternal mortality review committees are being mobilized in response to federal mandates, if we can give them a way to review not only obstetric deaths but violent deaths as well, and to consider the broader context in which they are occurring, they can make recommendations broader in scope,” Wallace said. “[Like] making healthier neighborhoods and cities, and moving out of just a purely clinical realm because these deaths are not happening in the hospital.”

Wallace and other colleagues previously reported a nearly doubled risk of homicide among pregnant and postpartum women using data from 37 states, indicating the estimates in Louisiana reported in this study are similar to nationwide trends.

“Pregnancy is a chance for intervention from violence,” Juanita J. Chinn, PhD, of the Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, Maryland told MedPage Today. She advocates “Increased contact with the healthcare system during pregnancy provides clinicians with opportunities to offer violence preventative services and interventions.”

The National Domestic Violence Hotline is here to help you:

“Deciding if and when to have a child with a partner is a big decision. Pregnancy and parenthood cause physical, emotional, financial and social changes, which can become even more challenging when your partner is abusive toward you.

If you are pregnant and in an abusive relationship, you deserve to prioritize your safety. We can help you create a safety plan and locate resources in your area, if available.” 

If your life is in danger, Call 9-1-1

If not, consider calling the National Domestic Violence Hotline anytime, day or night. Highly-trained advocates are available 24/7/365 to talk confidentially with anyone experiencing domestic violence, seeking resources or information, or questioning unhealthy aspects of their relationship.

• The Hotline at 1-800-799-SAFE (7233)  
• Deaf Callers on video phone (855) 812-1001 or TTY 1-800-787-3224
• You can also chat live via the website.

Be safe mama. You will never be alone.