Answers to All Your Pregnancy Questions
From the Woman's Diagnostic Cyber - Frederick R. Jelovsek MD
Infertility and Getting Pregnant
   
How can I tell pregnancy symptoms from PMS symptoms?
You often can't. Pregnancy symptoms shouldn't start before
before implantation on day 20-21 but usually don't start until
day 26 or later.
Basically, yes. There is a quantitative pregnancy test at the
doctor's office that is not usually run just to confirm pregnancy
unless it is suspected you are having very early miscarriages.
You might talk your doctor into ordering the quantitative beta-
HCG test one time on a day or two before your menses just to
check that you are not a rare person who has very early
miscarriages. Usually physicians don't do that unless you've been
trying 6 months or more, but it wouldn't hurt to ask.
There is no known level of alcohol that is safe to consume during pregnancy. In fact, more and more studies have shown that pregnant women are exceeding the previous acceptable levels of alcohol consumption and new recommendations have been put forth. Alcohol is known to be harmful to fetal development, and any time a pregnant woman drinks beer, wine, liquor, wine coolers or mixed drinks, the alcohol passes through the placenta and reaches the developing baby. This can cause permanent defects to the major organs and central nervous system in development. It is never a good idea to drink alcohol in any form while pregnant, and it is recommended that any woman who suspects a pregnancy avoid alcohol altogether.
Too early. Wait until about 4 or 5 more days and a sensitive
test may pick it up. If negative, repeat it at about 4 days after
missed menses.
Infection after tubal reversal
I assume by "lap" you are referring to laparoscopy rather than
an open incision, laparotomy. The laparoscopy should have a low
occurrence of adhesions afterward. The fact that you don't seem to
form adhesions is favorable too, but with an open laparotomy
there would still be more of a chance for adhesion formation.
At the time of laparoscopy, the doctor will probably do a
tubal insufflation by injecting fluid into the uterus and tubes.
Often this is enough to open adhesions inside the tube. Sometimes
some operative incisions (using laparoscopy instruments) is
needed to open an adhesion right at the end of the tube. If the
re anastomosis site on the one blocked tube is still ok, this is
all that will probably have to be done. If that site is blocked,
you may need more of an open laparotomy to fix it depending upon
what's wrong.
Anovulatory bleeding and trying to get pregnant
The bleeding (spotting) after intercourse is probably due to
either direct irritation of the cervix or from starting up
endometrial bleeding that is due to you basic problem of
anovulation. Since you have had many blood studies done, your
doctors must have some idea of what type of anovulation you have,
i.e., hypothalamic amenorrhea, polycystic ovarian disease,
hyperprolactinemia, etc. Clomid® may be used to induce ovulation
in any of those so that is not helpful.
One of the main problems now it seems, is that the therapy is
focusing on two goals, regulating the bleeding and inducing
ovulation so as to get pregnant, that usually require almost the
opposite therapy. One solution might be to just focus on the
abnormal bleeding and get that straightened out, and then resume
the fertility induction.
With so much abnormal bleeding, it is not safe to assume it
only is dysfunctional, anovulatory bleeding even though you are
young. Mechanical causes (polyps, fibroids) need to be ruled out
with a hysteroscopy and D&C if that hasn't already been done.
Also bleeding due to other unusual diseases such as coagulation
problems (Von Willebrand's disease), thyroid problems (I'm sure
this has already been checked), other medical diseases and
medications need to be ruled out. When all of these have been
done, the next step might be to regulate your periods with
something like Premphase® which is used in the
perimenopausal/postmenopausal period to regulate bleeding and
still produce a monthly menses.
Presuming the Premphase® would regulate you so that there was
no more abnormal bleeding for about 3 or 4 months, then you might
consider retrying the Clomid® therapy to induce ovulation or
whatever your doctor feels is needed.
At this point I would suggest making another visit to your
doctor to discuss the bleeding after intercourse and let him
examine you to make sure there are not local cervical factors,
irritation etc., causing the bleeding. Then discuss the above
plan as you and he think it applies. Agree on any plan or
modification of the above so that you can have a systematic
approach to getting over all of these problems. He will probably
benefit from some regrouping in plan as much as you will.
What counts as trying to get pregnant?
Not really. I see your point though.
Yes.
I would go ahead and make an appointment now. You are
approaching the time when there may be something wrong that can
be corrected. Any of the studies done don't interfere with
getting pregnant so you can still try while the early work-up is
taking place.
My period is a month late
If you have regular monthly periods and you are now one month
late (i.e., 2 months since the first day of your last normal
menstrual period); then no, it is not too early to take a
pregnancy test. In fact if you are pregnant you would probably
see a heart beat on ultrasound by now.
Will bleeding interfere with conception or implantation?
No. The spotting should not interfere with conception.
If you are bleeding heavily such that it can "wash" sperm out
of the cervix, then it will decrease the chance of getting
pregnant. If it's just spotting, it shouldn't affect it.
Implantation occurs about day 7-9 after fertilization. It
implants in the uterus usually in the top or top-back on a very
small area. I see why you are worried about the bleeding. If it
continues heavy it could prevent implantation. It's still very
possible, however, so just wait it out to see what happens.
How long for a tubal reversal to heal?
It takes about 4-6 weeks. Your doctor will probably have you
wait two cycles before trying to get pregnant.
Progesterone and luteal phase deficiency
According to some experts (not all), this indicates a
relative progesterone deficiency in the luteal phase such that an
embryo intending to implant and grow in the endometrium (attach
to uterus) does not see a "ripe" site to attach to. Many experts
believe this has to be demonstrated in a least 2 cycles to
conclude an "inadequate luteal phase". Luteal phase defect can also be diagnosed by a serum progesterone drawn about 7 days after ovulation (day 21) with a value of less than 10 ng/ml.
As far as treatment goes, luteal phase defect is one infertility condition whose
treatment becomes convoluted with the overwhelming
desire to do something, rather than nothing, even
if the treatment is not effective. While
physicians recognize that such a condition as
luteal phase defect exists, its treatment is
unproven.
If a menstrual cycle is less than 28 days or a day
21-22 luteal phase progesterone is below 10 or 14
ng/ml or a BBT does not show 12 days or more of
temp elevation, many women are led to believe that
they should take progesterone supplements under
the premise that they have a luteal phase defect.
This concept can be wrong on two accounts. First
of all. any one cycle can be abnormal and have a
short luteal phase, a biopsy of the uterine lining that is out of phase or a low progesterone level, but
it is not a regular recurring pattern. A woman needs to have
at least two menstrual cycles with either biopsies
that show out of phase endometrium or progesterone
levels on day 7-8 after proven ovulation of less
than 10 ng/ml in order to conclude that luteal
phase defect might play a role in their conception
difficulties.
Secondly, it is unlikely that any progesterone
supplementation either by shot or by vaginal
suppositories improves the ability to get
pregnant. Only one randomized controlled study has
looked at this that I could find. It found no
significant improvement in pregnancy rates. Non
randomized studies have had the same outcome with
most showing no benefit and some occasionally
showing a difference. This kind of evidence would
suggest that progesterone supplementation for
luteal defects is probably not beneficial.
Clomid is another treatment used for luteal
defects and although it improves luteal
progesterone levels, the few studies done do not
show an improved pregnancy rate in the case of
"luteal phase defects".
Well if it doesn't hurt, why not use it on the
chance it might help? Some reasons might be:
- Progesterone sometimes delays menses even
though pregnancy does not occur thus delaying the
next attempt at conceiving.
- We do not know if there are subtle, long term
effects of taking progesterone in early pregnancy
because it has not had large scale, long term
studies.
- There is an unnecessary expense involved and
- it produces false hope.
The intent of this is not to discourage women who
are trying to conceive and may have evidence of
luteal phase defects. Women need to understand
that when no clear evidence for a treatment
exists, accepting an experimental treatment
involves risks. Also, shopping around for a
physician who will give you some treatment rather
than none also involves risks.
Positive Pregnancy Test But Then Menses
There is less than a 1 in 200 chance that you have had a false positive. The test is extremely reliable. It is extremely likely that you had, or have, a pregnancy. There are basically 2 possibilities:
- You have had a "chemical" pregnancy which actually ends in an early miscarriage so that menses is either not even delayed at all
or minimally delayed less than 2 weeks. We know that of all pregnancies, at least 25% end up as these chemical pregnancies. The dBest® test is very sensitive to only 20 mIU and can pick these up. Some of the store tests sensitive at 40mIU will miss them.
Chemical Pregnancies
-
You still are pregnant and have just had bleeding in early pregnancy. Don't test too soon again, but in about 2 weeks, test again
to make sure you are not pregnant.
It is actually a very good sign for you that this pregnancy test is positive even if this pregnancy is just a chemical one. It means you definitely can get pregnant. i.e., the
passageway is open, you ovulate, and the sperm can impregnate an egg.
Let me know how this resolves. There is one other rare category in which the pregnancy test stays positive but the pregnancy does
not progress normally and we become worried about a missed miscarriage or a tubal pregnancy. That is why you should follow the test
to negative or have a blood test (quantitative bHCG) at your doctor's office.
When to get pregnant after a miscarriage
There has always been concern, with data to support it, that if a woman gets pregnant sooner than about 6 months after a previous pregnancy, the complications such as low birth weight, placental problems and preterm labor are more frequent than in a woman who has waited longer after her pregnancy to become pregnant (1, 2, 3, 4, 5). There are many factors involved in the choice or circumstances of becoming pregnant. Also, we do not know if the outcome after a previous term pregnancy is going to be the same as after a pregnany that miscarries (6).
You would think that it would be easy to determine when the best time is to get pregnant after a miscarriage to minimize a future miscarriage (spontaneous abortion) or minimize a problem with a low birthweight or premature infant. It is not easy however, because the decision to try to conceive depends upon many factors which are influenced by a woman's previous reproductive performance. If a woman knows she has difficulty conceiving or is getting older and feels time is running out, she will try to conceive as quickly as possible after a previous pregnancy loss. We know that women who are older or who are subfertile will have higher miscarriage rates (7) so if you include their data, it will always look as if a short interpregancy interval will lead to a higher miscarriage rate.
As far as getting pregnant after a miscarriage, you can start trying whenever you want because we do not know of adverse data following just a spontaneous miscarriage. In fact some older data implies that there is no increase in the abortion rate in women who quickly conceive following a previous spontaneous abortion (8). Following a pregnancy, it appears that the best time to conceive with the least frequency of complications is about 18-23 months (9). Under 6 months the percent increase in problems is enough that most physicians do not recommend becoming pregnant.
You may want to know what the chance of having another miscarriage is if you have had one or more already. Based upon clinically recognized pregnancies, not chemical ones, the chance of a subsequent miscarriage according to one study is (10):
Overall general rate 11%
After one miscarriage 16%
After two miscarriages 25%
After three miscarriage 45%
After four miscarriages 54%
While the evidence does not clearly indicate that conceiving too soon leads to an increased incidence of miscarriage, there is indirect evidence that if you do get pregnant sooner than 6 months after a pregnancy of any type, that the outcome may lead to complications if pregnancy occurs. For that reason, I support taking a break of at least 6 months before trying to conceive again after a miscarriage. If you do get pregnant in that time, o.k. But don't put non stop pressure on yourself to conceive.
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