Pregnancy After Infertility: What to Expect and What Comes Next
Once you are pregnant after a period of infertility, I hope you take some time to relax and enjoy. Oftentimes patients don't give themselves that space and start worrying about what can go wrong in the pregnancy. It is natural and normal to still feel nervous and worried at this point.
You and your Doctor can handle any problems that arise. You will be monitored closely in early pregnancy to make sure everything is progressing.
A-Z Pregnancy Advice from a Fertility Specialist
When you first discover you are pregnant you will have probably done a home urine test. These tests are very sensitive and accurate turning either positive or negative. Anyone with infertility knows these sticks too well. You will be thrilled that you finally got a positive.
This test will be followed up by a quantitative b-hCG (beta sub-unit of the human chorionic gonadotropin protein) blood test. HCG is produced by cells from the embryo which will become the placenta beginning 10 to 12 days after conception. Maintenance of the embryo in the first trimester of pregnancy requires the production of hCG, which binds to the corpus luteum (cyst of pregnancy) of the ovary.
This stimulates the ovary to produce progesterone. Progesterone is required to maintain the uterine lining in which the embryo grows and develops. The b-hCG level rises dramatically in early pregnancy.
Your Doctor will get two levels two days apart. The expected rise between the two days is about 50-60%. Patients usually have heard that the level should double in two days, but recent literature says that there are plenty of healthy pregnancies that do not increase at that rate.
Your first level which is usually done 14 days after ovulation should be above 30. If it went up to 60 in two days that is great if it only went up to 45 that can be fine too. Try not to worry; it is not something you have control of.
For a deeper understanding of this terminology, please review our glossary of fertility terms!
Once you get your two levels and a good rise is documented you can breathe a little easier. In general I tell patients not to tell the "whole" world until you are past 10 weeks, this positive pregnancy test with a good HCG rise is a happy little secret between you and your partner.
Your estrogen and progesterone levels will also be checked along with the hCG level to make sure that it is adequate to support your pregnancy. If it is not adequate enough, your Doctor may order supplementation or increase your dosage of these hormones if you are not already on them.
If your rise was not adequate, your Doctor may get a third level to further follow the early pregnancy. Remember on the day of your first pregnancy test you are 2 weeks pregnant (embryonic age), but by standard dating criteria (based on the date of your last menstrual period) you are considered to be 4 weeks pregnant (gestational age) at that time.
The earliest you and your doctor can look for pregnancy on ultrasound is at about 5-6 weeks (gestational age or 3-4 weeks embryonic age). At that first ultrasound your Doctor will be looking for a gestational sac. The gestational sac represents a fluid filled area which is usually about 1-2 centimeters in diameter.
It is where the early embryo develops. Depending on when the scan is done you and your Doctor may see a structure in the gestational sac called the yolk sac. The yolk sac is visible before the embryo and it represents early embryonic development. The yolk sac is a small circle seen on ultrasound within the gestational sac.
The yolk sac provides nourishment for the developing embryo. The presence of a gestational sac confirms that the pregnancy is in your uterus. In addition the presence of one or two gestational sacs can document implantation of one or two embryos (twins). Pregnancies which are not in the uterus are called ectopic pregnancies and can be dangerous. We will talk about these below.
One to two weeks later you will have another ultrasound to document the presence of the embryo in the gestational sac. The embryo will be measured. This measurement is called the crown-rump-length (CRL). It is hoped that this measurement is within 2-3 days or your expected gestational age (6-8 weeks). It is at this time when you can see the first sign of a heartbeat.
It is usually just a flicker, but it represents the development of the embryonic heart. The heart rate is calculated by the ultrasound machine. Heart rates range between 100-140 beats per minute. This is an amazing thing to see and can be emotional. It is also very reassuring, as less than 15% of pregnancies that have progressed to this point will end in miscarriage.
An additional ultrasound is often done one to two weeks later at 8-10 weeks of pregnancy (gestational age). At this point in time the embryo has usually more than doubled in size and this growth is charted to document proper growth of the embryo. By this point, the heartbeat can easily be seen and its rate is usually greater than 140 beats per minute.
After this ultrasound, which documents good interval growth, and a normal heart rate, you are usually discharged to your Obstetrician. Your Obstetrician will usually see you between 10-12 weeks for an intake visit and set up blood tests and an additional ultrasound to screen the embryo for chromosomal disorders such as Down's syndrome.
You are usually off all progesterone and estrogen supplementation at ten weeks because the embryo-placental unit now makes enough of these hormones to keep the pregnancy progressing. Once you get discharged to your Obstetrician you can relax and think positive that this will be a successful pregnancy.
Key Issues and Concerns in Early Pregnancy:
Do you need hormonal supplementation in early pregnancy?
Many patients who get pregnant after fertility treatments are on progesterone and/or estrogen during the early portion of their pregnancy. If you are not on progesterone (or estrogen) it is because it has been determined by blood tests that you do not need it.
The progesterone and estrogen that your Doctor gives you are meant to help support your early pregnancy. They are usually identical formulations made pharmaceutically to supplement a woman's own secretion of progesterone and estrogen.
Progesterone can be given by intramuscular injection, vaginal suppository, gel, or capsule. Estrogen can be given orally, vaginally, or via a patch. The Food and Drug Administration (FDA) has placed warnings on all reproductive hormones that they should not be used in pregnancy.
The package insert of your medication will say do not take in pregnancy, but this does not apply to you in this early stage of pregnancy. Some hormones have been associated with complications and birth defects and the pharmaceutical companies have not chosen to obtain FDA approvals.
You should always feel free to talk to your Doctor about any concerns. No harmful effects to the mother or the fetus are presently known from the prescription of progesterone or estrogen (estradiol) in the first trimester.
By 10-12 weeks of gestational age, embryo-placental unit hormonal supplementation is no longer necessary.
How should I handle bleeding in early pregnancy?
If you notice vaginal bleeding, do not panic. About 25-30% of women will experience an episode of spotting or bleeding during the first trimester.
A small amount of staining is not uncommon and even moderate bleeding can be okay. Most of the time the bleeding is due to the implantation of the embryo and not the sign of an impending miscarriage. As the embryo's blood supply is being established, it is not uncommon to see some bleeding or staining due to the growth of the placenta into the uterine tissue (the placental cells try to find a blood supply for the growing embryo).
Sometimes there is enough bleeding that it can even be seen on ultrasound and is called a sub-chorionic hemorrhage. This means there is bleeding between the chorion (early placenta) and the uterine lining. If you notice bleeding you should call your Doctors office, lie down, and try to remain calm.
You will probably be instructed to go to your Doctor's office that day or the next for an ultrasound. Hopefully your Doctor will document that everything is fine. You may be placed on limited activity to encourage the bleeding to stop.
What are the chances of miscarriage in early pregnancy? What happens if my hCG levels do not increase normally?
Miscarriages are the loss of an early intrauterine pregnancy. They represent about 15-25% of all initiated pregnancies. There is an increased pregnancy loss rate with increasing age. Most of these early losses are due to abnormalities of the embryo's chromosomes.
Failure of growth of an early gestational sac or embryo or even loss of fetal heart activity after it had been previously documented is considered a clinical pregnancy loss or miscarriage. Treatments includes D&C (dilation and curettage of the uterus), medication to make the uterus contract and release the pregnancy, or allowing the pregnancy to pass naturally.
In general, for women 35 or younger, about 15-20% of pregnancies will end in miscarriage. For women 35-40, about 20-25%, and for women over 40, the risk is greater than 30%. That still means that 70% of all pregnancies do NOT end in miscarriage.
During the first few weeks of pregnancy, about 80% of normal pregnancies will show doubling of the hCG levels each 48 hours. If your numbers do not increase normally, there are 3 possibilities: you could have a normal pregnancy that is in the "slowest" 20th percentile of normal; the pregnancy could be abnormal and in the uterus (a biochemical pregnancy); the pregnancy could be in the fallopian tube (an ectopic pregnancy).
Biochemical pregnancies are pregnancies that implant in the uterus, but do not progress to be seen on ultrasound. Often these are defined by a very slow rise and eventual decline in the hCG level. When this occurs it is emotionally traumatic, but there is nothing you or your Doctor can do to change the fate of the pregnancy.
While emotionally traumatic these usually are not dangerous to your health.
Ectopic pregnancies are pregnancies that implant outside the uterus. About 95-97% of them occur in the fallopian tubes. Ectopic pregnancies represent 2-5% of the pregnancies. Ectopic pregnancies can be treated medically or surgically, depending upon the situation.
If untreated, they can rupture and become a life-threatening condition. Close monitoring by your Doctor of your blood hCG levels and ultrasound is designed to make the diagnosis of an ectopic early to avoid any significant complications.
What should I eat during pregnancy? What foods should I avoid during pregnancy?
You should eat a well-balanced diet supplemented with the Pre-Natal vitamins prescribed by your physician. Sensible eating habits, combined with your prenatal vitamins, are sufficient to maintain your pregnancy.
The average weight gain during the first trimester is 3-5 lbs. However some women gain more and some women lose weight. The body storage of fat for even most slim women are adequate to sustain an early pregnancy.
Avoid all beverages containing caffeine or alcohol as well as all herbal remedies and/or supplements except those approved by your Doctor. You should also avoid foods made with unpasteurized milk products or raw shellfish. Sugar substitutes should be avoided as well.
Because of the risk of mercury contamination which can affect the developing fetal nervous system the FDA suggest pregnant women avoid swordfish, tilefish, shark, and mackerel. You should also limit your consumption of other fish including tuna to less than 12 oz per week. Because of the risk of hepatitis or parasitic infection, any uncooked seafood should be avoided including oysters, clams and raw sushi or sashimi.
What symptoms/side-effects should I expect during pregnancy?
First of all everyone is different. The most common symptom is fatigue. In addition many women complain of breast tenderness, and nausea. Contrary to popular belief not everyone has nausea. If you are experiencing nausea with or without vomiting, remember it is important to stay hydrated by drinking small amounts frequently and to eat small frequent meals.
Nausea tends to be worse when you are quite hungry or full and you will need to experiment to see which foods are best tolerated. For many women, bland starchy foods such as crackers, noodles, soup, etc are well tolerated. It may also be helpful to try an acupressure band - these are commonly sold in drug stores for treatment of sea sickness. Some women find ginger (in ginger ale or sold as ginger capsules) to be helpful.
Many women find prenatal vitamins hard to swallow due to the nausea of early pregnancy. In this case, it is acceptable to break the tablets and take part of one at each meal or to switch to a chewable tablet. If your nausea and/or vomiting are frequent you should talk to your Doctor about the many medications available which help with this problem.
What about exercise?
I advise refraining from any strenuous physical exercise such as high-impact aerobic, and road running. The following guidelines for exercise in pregnancy are provided by the American College of Obstetricians and Gynecologists:
- Regular exercise (at least 3 times per week) is preferable to sporadic activity. Competitive activities should be avoided.
- Vigorous exercise should not be performed in hot, humid weather or during illness.
- Strenuous exercise should not exceed 15 minutes. Additionally, exercise should be preceded by a 5 minute muscle warm-up and followed with a cool down period.
- Activities that require jumping or rapid changes in direction should be avoided because of joint instability. Swimming, biking and walking are ideal during pregnancy.
- A pregnant woman's heart rate should not exceed 120 beasts per minute.
- Women should drink fluids before, during and after exercise to prevent dehydration.
- High impact activities should be avoided.
- Activities such as sitting in a hot tub or sauna should be avoided.
Women who have a history of miscarriage, premature labor, multiple pregnancies, vaginal bleeding or heart disease should consult with their physician about exercise during pregnancy. A woman with a sedentary lifestyle should not begin a fitness program during pregnancy.
If a woman is physically fit, she may be able to tolerate the same level of exercise during pregnancy with only minor modifications. Talk to your Doctor.
Pregnancy Myths and Recommendations:
You should avoid very long, hot baths or Jacuzzis as there is a theoretical risk of slightly increasing the chance of neural tube defects with prolonged elevations of the core body temperature.
Most of the development of the major organ symptoms occurs during the first trimester. For this reason, we suggest that you avoid hair coloring, or exposure to pesticides or chemicals if possible.
Airline travel is safe; however, if you should experience complications, it may be difficult to arrange for medical care. If you are experiencing pregnancy complications and you must travel, please check with your physician first. Whether driving or flying, it is advisable to walk around every few hours to avoid the formation of clots in the legs. You may also want to carry extra fluids and foods for snacks.
Toxoplasmosis, a bacterial infection associated with eating undercooked meat and exposure to cat feces, can cause birth defects if acquired during the first 12 weeks of pregnancy. If you are pregnant, you should not change your cat's litter box. Food should be handled carefully and always cooked appropriately. Gardening chores should be performed with gloves.
Many medications are safe in pregnancy, just be sure to tell your pharmacist that your are pregnant and consult with your Doctor prior to taking any over the counter and prescription medications.
In general diagnostic x-rays are safe if your abdomen is shielded. Lead aprons shield your uterus and your embryo effectively from any significant radiation. Determining the safety of other types of x-rays during pregnancy is more complicated, but it is clear that diagnostic x-rays rarely pose a threat to the embryo or fetus. It is usually recommended that elective x-rays be postponed until after delivery.
Some chemical insecticides have been linked to birth defects. Whenever possible, take the natural approach to pest control. If your neighborhood is being sprayed, avoid being outdoors as much as possible until the odor has dissipated-about 2 to 3 days
It has been reported that latex paints contain unsafe amounts of mercury. Federal regulations now require that paints be reformulated so they don't contain mercury. But because you don't know what hazard may turn up in paint next, painting should be avoided during pregnancy. While painting is being done, try to arrange to be out of the house. Make sure there is adequate ventilation. Completely avoid exposure to paint removers.
Remember that most pregnancies end up healthy and successful. Don't let your history of infertility ruin the joy of finally being pregnant. Talk to your Doctor and the Nursing staff at your center and avoid casual advice. Most of all stay positive and hopeful, and all the best and good luck on your journey!