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Going Long: When the Finish Line May Be Further Than You Think

For all of you runners, swimmers, and cyclists, you know what it takes to prepare for that long-distance jaunt. Aside from what you should eat (#carbLOAD) and what you should wear, how far your legs or arms need to take you is pretty important. Preparation, both physical and mental, is key to crossing that finish line.

The same can be said for individuals and couples going through fertility treatment. Knowing how many rounds or cycles it will take you to reach the finish line (#baby) will help you prepare for the journey. And while this is no straight-up calculation or predetermined training plan, information such as age, ovarian reserve, and fertility history can definitely help us estimate. Here’s how far you might need to go…

There are about 180,000 IVF cycles performed in the US each year. And from these cycles, about 65,000 babies are born. Over the years, the numbers have added up, and nowadays, nearly 2% of babies born each year are a result of IVF. Simply stated, more and more people are doing IVF, and more and more babies are born after IVF. However, the number that is less clear is how many cycles it took each person to get to her personal finish line (a.k.a. a baby).

And while this statistic may elude us, what is pretty evident is that those who hang in there longer (a.k.a. complete more IVF cycles) are more likely to conceive. In fact, a recent Swedish study demonstrated that women who did three IVF cycles had about a 65% chance of pregnancy. This was higher than women who stopped at one or two. And while we are certainly not advocating endless IVF cycles, we are recommending that you go the distance based on your doctor’s recommendations.

If your doctors think you have the potential to push on (you are still making a good number of eggs, you are having advanced embryos transferred, your embryos are passing the genetic screening test), then we recommend that you keep on keeping on. Just make sure that you know how far they think you should go, and in turn, make sure they know how far you want to go.

Going back to our original metaphor, think of it like this… If someone told you that you had to run five miles and then midway through told you it was actually 10 miles (oops!), you would be pretty peeved. You would probably doubt your ability to go the distance and maybe even decide to bow out before the race was over.

On the contrary, if you planned to do a 10 miler but midway through found out the race was only half that distance, you would feel pretty good. Energized and invigorated, you would kick that race’s butt and sprint to the finish line. Fertility treatment might make you go the distance. While we certainly hope the race is over shortly after it starts, if it goes longer we don’t want to leave you out there on the course without the appropriate gear.

Information, preparation, and participation (a.k.a. a doctor who consults with you after every IVF procedure) will guide you through this often-torturous race. But having a good idea about the course before you start will make each passing mile a bit easier.

Chew on This: What Pregnancy Can Do to Your Teeth

Pregnancy is like the ultimate detective. It leaves no stone (or body part) unturned. It will make your hair fall out, your skin stretch, and your feet grow (say goodbye to many of your pre-pregnancy shoes!). And the fun doesn’t end there. Pregnancy also takes a hit on dental health; cavities, gingivitis, periodontitis, and tooth erosion are on the list of pregnancy pleasures.

Here’s what can be on the to-do list of your teeth…

  1. Gingivitis (Gum Disease): Just like your hands and feet, your gums can swell during pregnancy. An increased inflammatory response to plaque can cause your gums to swell and bleed. Those who enter pregnancy with their dentist already on speed dial (a.k.a. you had gum disease before pregnancy) are more likely to experience a worsening during pregnancy. If this is you, make sure to pay particular attention to what your teeth and gums are doing!
  2. Loose Teeth: Due to an increase in hormones, flexibility in your joints and ligaments increases during pregnancy. And while this may make you excel in yoga, it makes your teeth super loose. Beware of sticky foods!
  3. Tooth Erosion: Your teeth like food. Your teeth like water. Your teeth don’t like vomit. Vomit contains gastric acid, and gastric acid can eat away at the enamel of the tooth, causing tooth erosion. Therefore, women with serious morning sickness are at risk for serious tooth erosion. Rinsing your mouth with a basic solution (baking soda + 1 cup of water) can help neutralize the acid.
  4. Cavities: What you take in and what your mouth puts out change during pregnancy. The pH of the mouth shifts to a slightly more acidic level. This acidity, combined with pregnancy cravings (a.k.a. more sweets and sugary foods), increases the risk of cavities. Don’t go to bed without brushing and flossing!
  5. Periodontitis: When gingivitis is ignored, it can become periodontitis. Simply stated, when bacteria make the gums their permanent home destroying the gum and the teeth, you have yourself a case of periodontitis. You can look forward to loose teeth, lost bone, and sometimes, even bacteria in the bloodstream. The latter, in the worst-case scenario, can lead to preterm labor. Don’t let it get to this point. If your gums don’t feel right, go right to someone to check them.

There is a lot about pregnancy that makes you smile and a lot that makes you frown. Whichever way your mouth is going, don’t forget about the 30-plus structures that stand behind them. Your teeth need to last you through pregnancy, postpartum, and beyond. Make sure to take care of them. After age 12, the tooth fairy brings nothing but a bill and a big-time headache!

Don’t Be So Negative….What Your Rh Status Means for You and Your Baby

There are “blood type” diets, “blood type” personalities, and even “blood types” that are tastier to mosquitos (apparently if you are type O, you should go out and buy some more bug spray!). And while most of us have no idea what A, B, AB, or O mean until we visit our first American Red Cross blood drive, your blood type is actually pretty important in the land of obstetrics. Although most of us don’t think past those three letters (and four groups), the plus or minus that comes after the A, B, AB, and O is equally as important as the letter. The negative or positive denotes the Rh factor. If there is a mismatch between the negative and positives in a pregnant woman, just like those AA batteries you are always in need of, this system won’t work the way it is supposed to.

Let’s start with the simple stuff…

1. There are four basic blood groups; A, B, AB, and O. What distinguishes A from B or AB from O are the antigens (a.k.a. the proteins) on the surface of red blood cells.

2. The symbol, plus or minus, which follows the letter is referring to the presence (+) or absence (-) of the Rh factor. Rh stands for rhesus, and Rh or Rhesus factor is another antigen that is found on red blood cells. Rh antigen is present or + in Rh (+) individuals and absent or – in Rh (-) individuals.

Moving on to a couple of fun facts that will make you look smart at a cocktail party…

3. The most common blood type is O+.

4. The universal blood donor (you can give to anyone) is blood type O-.

5. The universal blood recipient (a.k.a. you can take from anyone) is AB+.

6. You inherit your blood type from your parents, and you will pass your blood type on to your children.

Last, the essential stuff for anyone who has been or will be PREGNANT….

7. Rh-negative women need special attention. If untreated AND pregnant with an Rh-positive baby, they have the potential of forming antibodies against the Rh factor that is covering their baby’s red blood cells. And while this may not be a big deal in their current pregnancy (antibodies are like Rome; they were not built in a day), it will be a major deal in future pregnancies. Therefore, all Rh-negative women should receive a medication called RhoGAM (a.k.a. RhoD or Rh immune globin) during their pregnancy to prevent the formation of these antibodies.

8. RhoGAM is an injectable medication that contains a small amount of antibodies pooled from blood donors…it works to kill off any Rh-positive blood cells lingering in the immune systems of Rh-negative women. Think of RhoGAM as a stun gun to the immune system of an Rh-negative pregnant woman. Basically, it will “daze and confuse” her immune system so that she doesn’t have a chance to make antibodies to the Rh factor her body is seeing during pregnancy. Problem solved. And in the past, this was a big problem that not only cost a lot of perinatal morbidity but also mortality. So kudos to those who racked their brains and “birthed” RhoGAM.

9. When it comes to most things pregnancy, it takes two to tango. Therefore, just because you are Rh-negative doesn’t mean that your baby will be. If your partner is Rh-positive, there is a good chance your little one will be too (and that’s when you have a problem on your hands)! To be safe, all Rh-negative women will be given RhoGAM during pregnancy (remember, we won’t know your little one’s Rh factor until birth). The good news is that the majority of pregnant women will only need to roll up their sleeves and stick out their arms twice, once at 28 weeks and once following delivery. This is because in most cases maternal and fetal blood don’t say, “It’s nice to meet you” until delivery. However, because this introduction may speed up to the third trimester in about 2% of pregnant women, we give a precautionary dose at 28 weeks.

10. Unfortunately, two times may not be the “RhoGAM charm.” If bleeding should occur during the pregnancy or if you undergo an invasive procedure such as a CVS or an amniocentesis, your blood and your baby’s blood might get mixed up. Therefore, to be extra careful, we recommend you get another shot within 72 hours of the bleeding or the procedure.

11. Rh-negative women that are NOT given RhoGAM are at serious risk during their NEXT pregnancy. So while many of us have the “I will deal with that tomorrow” attitude when it comes to things that don’t impact us immediately but can hurt us in the future (think not paying your bills and dealing with your credit score later), you really shouldn’t mess around with RhoGAM. Antibodies to Rh take some time to form. Therefore, while your current passenger might pass through without a problem, the next baby on board could be at serious risk if a woman is NOT given RhoGAM during the current pregnancy. Don’t push this one to the side; this sort of credit your next child can’t afford!

Given that 85% of individuals are Rh+, this incompatibility issue does not come up every day. Simply stated, most moms and their babies are in sync when it comes to Rh status. However, given the serious impact an untreated Rh mismatch can have on a woman and her future children, it is something that we OBs get pretty pesky about. We have to be doubly POSITIVE so that nothing NEGATIVE happens. And while we can’t validate the stuff out there which suggests that As may be “more responsible and patient” while Bs are more “passionate and creative,” we can tell you that your blood type means a lot for your baby (and the babies that you may have to come). That much, we are triply super positive about!

On the Road to Delivery…GBS

While the title may have you doing a double take (and maybe even looking for some directions on how to decode GBS), rest assured, you are not lost out there on the road. You are in your home, your apartment, your office, or maybe even in the car (although hopefully not driving and reading!) hanging with your girlfriends at Truly, MD. But if you are nearing the end of pregnancy, you are probably getting pretty good at navigating the streets between home base and the hospital. And although we may not know the quickest way to get you to the labor floor, we definitely know how to get you up to speed on all things third trimester. First stop: Group Beta Streptococcus (a.k.a. GBS).

GBS is a type of bacteria. And although it may not be on your daily bacteria radar (think strep throat or staph skin infection), it is pretty important to us OBs. GBS took center stage in the OB world of the 1970s when it was identified as a culprit in the land of perinatal morbidity and mortality—that is, newborn illness and death. The newborns of pregnant women with GBS in their vaginal canal who were not given antibiotics during labor were at risk for some pretty heavy hitters. Think sepsis, meningitis, and death. Pregnant women were not immune to the negative effects of GBS. They, too, were at risk for things like UTIs and uterine infections.

Despite its bad-guy tendencies during pregnancy, GBS lives fairly peacefully within the vaginas and the rectums of non-pregnant women. Don’t bother me, and I won’t bother you. Given its Jekyll and Hyde persona, we only start to look for the presence of GBS in a woman during the latter half of pregnancy, when it can really turn into Hyde. To uncover whose vagina/rectum is “covered” in GBS and whose is not, your OB will perform a screening test on you between 35 and 37 weeks. And although it may sound scary, it’s no more than a cotton swab test of the vagina and the rectum. Those that test positive are given antibiotics during labor. Those that test negative are not. Pretty simple.

The ACOG has made it their business to get in the business of all pregnant women when it comes to GBS because, like the old adage says, when GBS is bad, it is very, very bad. Anything that can be done to decrease the bad is a major bonus…cue screening for GBS. The universal screening of all pregnant women has done a very, very good job at stopping most widespread GBS infections in newborns, particularly in the first six days of a baby’s life. In fact, since national guidelines for screening and treating pregnant women who test GBS positive were implemented, there has been nearly an 80% reduction in early onset (the first six days of life) neonatal sepsis due to GBS. Pretty impressive stuff.

Women who go into labor before their GBS test was performed (a.k.a. preterm labor), women who have previously given birth to a GBS-infected newborn, or women who test positive for a GBS UTI during pregnancy are automatically treated with antibiotics for GBS during labor. Basically, in these cases where the risks are high, it’s better to be extra safe and add an extra layer of protection. It’s sort of like extra insurance for a driver with lots of points on his license. While he may never speed or get ticketed again, given that his chances are higher, you want extra protection—we’re not saying we know anyone like this!

For most women, the GBS test comes and goes without a bump in the road. It’s sort of like passing a yield sign on the road. You know it’s there. You slow down somewhat, but you don’t really pay it much mind (we didn’t say that we offered good advice on driving!). Don’t fear the results. Positive or negative, we are pretty good at directing you to the right path. No one gets lost out here on this road; think of us as your GPS for your GBS!

Double Duty…Why Two Is Not Always Better Than One

It would be nearly impossible to count the number of times patients tell us the following regarding how many embryos to put back into the uterus: “I want two…it’s like two for the price of one!” “I want to be one and done!” “It’s like getting a twofer!”

And while we understand the desire for two (trust us, the thought of minimizing the number of times one is pregnant does sound appealing), twins are not just double strollers, matching onesies, and names that start with the same first letter. Twins and triplets-plus can be complicated, not only for the babies but also for the mother. Therefore, serious thought needs to be put into how many embryos are put back into the uterus.

Old-school fertility doctors routinely transferred several embryos into the uterus at one time; twins, triplets, and even quadruplets were sort of the “cost of doing business.” Back in the day, our IVF techniques weren’t so great. The procedures were new, and there were a lot of unknowns. To increase a patient’s chance of getting pregnant, multiple embryos were put in. Although even then, “the more the merrier” wasn’t our motto, (women are not meant to carry litters!), we were limited in our ability to identify which embryos had the best chance of making a healthy baby.

Fast-forward 20-plus years, and we are actually really, really good at this stuff. Not only do we know exactly what a three-day-old embryo needs to grow in versus a five-day-old embryo (can you believe it they are already picky eaters at this age!) but we also actually have the ability to check them and make sure they have the right number of chromosomes!

Now, while we can’t tell if they will look like you or your partner or go to Harvard or Yale, we can take a few cells and check to make sure they have the correct number of chromosomes. (The magic number is 46!) When this technique is done and a healthy embryo is found, we almost routinely only put one back in because even this guy or gal more than half the time makes a baby.

If you are considering an IVF cycle or are maybe even in the midst of one, make sure to have a long and serious discussion with your doctor about the number of embryos to transfer back in. Nowadays, not every IVF center is the same; many have the ability to grow embryos in the laboratory to day 5, rather than the traditional day 3. Although two days may seem inconsequential when it comes to most things in life, for an embryo, it’s a big deal. Just these 48 hours gives the embryo time to develop and the embryologist who is watching the embryo develop more information to pick the one that has the best chance of making a baby!

If you are lucky enough to have several A-plus embryos and your doctor only recommends putting one back in, the others can be frozen. Yup, we said frozen. Don’t worry; frozen embryos are not like frozen chicken! Embryo freezing has come a long way, and now in many centers, frozen embryo transfers have a better chance at making a baby than a fresh one. Simply stated, you won’t lose anything from freezing the extra embryos and putting only one embryo back in at a time. Sticking with the “one and done concept,” many couples get all the embryos they will ever need in one fresh cycle, thanks to good freezing techniques!

It’s sometimes hard to imagine that anything can go wrong in twin pregnancies. Nowadays, our schools and parks are teeming with twins; it really has become all the rage! But take it from us, not every twin pregnancy ends in a cute Anne Geddes photo. Twins have a higher chance of almost all risky pregnancy complications. On the fetal side, these include stillbirth, preterm delivery, and the serious problems that can come along with having a preterm baby: neurologic, cardiac, pulmonary, gastrointestinal, and serious developmental issues. Additionally, a high percentage of twins will experience some delay (motor and verbal skills) in the first two years of their life that requires treatment.

On the maternal side, women carrying twins or more have a much higher chance of serious medical complications. These include diabetes, high blood pressure (preeclampsia), heavy bleeding, hyperemesis (significant nausea and vomiting), Cesarean Section, and post-partum depression. Although most twins and most moms of twins will be running (actually, probably sprinting) and laughing in no time, there are a number of twins that will suffer permanent consequences from prematurity. The risks are real and should not be ignored.

And partners of those who have twins don’t get off easily, either. Sure, they don’t have to endure the insane stretch marks, the prominent varicose veins, and crazy swelling that multiple babies in one uterus at one time can bring, but let’s face it, double the work comes with added stress on the relationship. Studies have shown that divorce/separation rates are higher in families of multiples. Having a baby is not easy, sleepless nights and long days can be beyond difficult; imagine multiplying that by two!

We live in America too, and trust us, we get it. Other than pounds, for most of us, more or bigger always seems to be better. Why have one of something when you can have two? While we are not going all one-child-policy on you, we are advocating having one child at a time. It will be healthier for you and healthier for your unborn children. While twins are adorable and the bond they share is unlike any other sibling relationship, we are big fans of taking it one step at a time if possible.

When building a family, slow and steady is the best and safest way to get to the finish line.

Metformin Madness…Will It Make Me a Momma?

Any medication that promises to make you pregnant (or at least markedly increase your chances) and make you lose weight seems too good to be true. Wait, so I can eat ice cream and French fries while losing weight and getting pregnant? Count me in! But like most things that sound too good to be true, so is the hype surrounding metformin.

Metformin is a medication that is traditionally used to treat diabetes. It lowers sugar and insulin levels: hence, why it is used for diabetes. For women with PCOS, in whom insulin levels are high, metformin can not only improve the abnormal glucose/insulin situation but also improve ovulation rates. When metformin was released as an ovulatory agent, it became all the rage for women with ovulatory dysfunction. It was handed out like candy to anyone who had even the slightest ovulatory issues. However, while it was in the medicine cabinets of thousands of women, it didn’t stand up to all the hype. It didn’t turn ovaries of stone into sand—many ovaries still stood their ground.

Turns out, metformin is not a magic potion. A large randomized control trial (randomized control trials are the gold standards of medical research) did not show that metformin was even in the same ballpark as Clomid. Women who took Clomid ovulated and got pregnant at a much higher rate (about three-fold higher) than women who took metformin. Additionally, the metformin-Clomid combination was no better than Clomid alone. The only group of women in whom metformin was semi-magical was overweight/obese women with metabolic disturbances (elevated sugar and triglyceride levels, abnormal liver function, and high cholesterol). In these women, metformin combined with diet and exercise could be quite helpful in kicking the ovaries into gear. Additionally, this dynamic duo can significantly improve your overall health, wellness, and longevity.

With the pluses come the minuses. Metformin can make your stomach feel a little funky; be sure to talk to your doctor if you experience GI side effects (bloating, diarrhea, etc.). It is also important to have your kidney and liver functions measured while taking metformin, as it can do some not-fun things to your kidneys and your liver. While there are certainly occasions and cases where metformin is the magic ingredient, it’s not the “butter” in the ovulation concoction. It may help with the flavor, but it isn’t the force behind what gets the ovaries going.
Don’t fool yourself into thinking that metformin is magic. You still need to eat right, exercise, and maybe even take some Clomid. We will find some cocktail that makes your ovaries shake!

Why Am I Making Milk…I Have Never Even Been Pregnant! Prolactinomas

Looking down at your shirt and seeing two stains over the nipples can be disconcerting, to say the least. Yes, if you are breastfeeding it’s par for the course (words from girls in the know…never leave home without nipple pads postpartum!), but if you are eons away from pregnancy it can be beyond confusing. However, there are certain instances, which are not super uncommon, where this can happen. In most cases, it comes from the overproduction of a hormone produced in the brain called prolactin. Here’s a preview of what this prolactin can do.

Think Ps…prolactin is made in a part of the brain called the pituitary. While you can’t see it and probably have never even heard of it, the pituitary is a pretty powerful hormone in the world of OB/GYN reproductive hormones. The pituitary is not only known for its good looks and funny personality but also for the production of hormones that initiate periods, help with pregnancy, and promote overall health and wellness. While post-pregnancy you want that pituitary to be making prolactin in overdrive, pre-pregnancy, you don’t want to hear more than a peep from it.

Normally, prolactin production is kept in check by other hormones. They control the production and release of prolactin into the bloodstream. However, when these hormones are not functioning properly or there is a tumor that is producing prolactin, that’s when things can get milky.

Although classically we talk about women and breast discharge, in reality most women who have elevated prolactin levels may never know it. Contrary to popular belief, the levels actually need to be fairly elevated for milky breast discharge to occur (FYI: the medical term for this discharge is galactorrhea). Most women come to the doctor complaining of irregular or lack of periods and/or infertility. In the evaluation for these conditions, the elevated prolactin is identified. In many ways, it’s a good problem to have. It is most often easily fixed and causes no significant medical problems.

Prolactin tumors, prolactinomas, are some of the most common benign brain tumors. They can be small (micro) or large (macro) and are often the culprits for elevated prolactin and milky discharge from the nipples. While the word tumor can send everyone into a tizzy, they are most often treated with oral medications. The medications, bromocriptine and cabergoline, work to decrease the prolactin levels and therefore decrease the symptoms. For most women, taking them can be a no brainer—they can reduce your prolactin levels, reset the system, and ultimately turn your periods and your fertility back on.

While prolactinomas are definitely at the top of the list for causing elevated prolactin, there are other problems that could cause this problem. Culprit No. 1 is pregnancy. Even if you don’t think you could be pregnant, we are always going to ask. Other potential causes include medications (particularly antidepressants), chest wall stimulation (massage) or a lesion (think herpes zoster), hypothyroidism, or other tumors in the brain.

When trying to determine what, where, how, and why (it sounds like a game of Clue!) the prolactin is elevated, we usually start with a repeat blood test. Yes, you read that correctly. We have you come in and repeat the levels to confirm that they are actually elevated! However, this time we ask you not to eat and to come in first thing in the morning. Food and late-night fun can throw off the accuracy of the prolactin hormone test.

If the repeat levels are high, then it’s the real deal. Our next move is to send you for an MRI of the brain. This will tell us if it is coming from a benign tumor in the brain, and if so, how big it is. The bigger, the more bothersome and the better chance that you will need surgery. Luckily, most prolactinomas are “micro” (less than 1 cm), requiring only medical treatment. If the MRI is negative, we start the hunt for Professor Plum in the kitchen with the candlestick (a.k.a. we look for other potential problems).

Why do we care? Well, it’s not just that milky discharge is driving up your dry cleaning bill! It may also be preventing you from getting regular periods and getting pregnant. Additionally, no period means low estrogen, which means a risk for bone breakage. For women who are nowhere near being ready for a baby, the easiest thing to do is to put them on the birth control pill. This will control their periods and make sure they are getting the appropriate amount of estrogen. For women who are ready for a plus one, we initiate medical treatment (cabergoline or bromocriptine) to drive down the prolactin levels and allow ovulation to occur.

For many, prolactin is a word as foreign as incinta (that means pregnant in Italian!). You may never say it, hear it, or think of it. However, it doesn’t mean you won’t find yourself in Italy pregnant and need to know how to say pregnancy! In the same vein, you or one of your girlfriends may experience milky breast discharge and start to freak out.

Don’t freak out. You are not a cow. You are not alone. This is not uncommon. Go speak to your GYN—they will get to the bottom of this, get treatment going, and stop the milk from flowing.

When There Is More Than Your Plus One in Your Pelvis

Pregnancy can be a tight squeeze. By the end, not only are your clothes not fitting, but also your organs seem to have a limited place to hang out. It can be difficult to breathe, sit, stand, and walk. You name it, it’s hard to do it. And if you are carrying more than one (#twins, #triplets), it can be a doubly or triply painful situation. The pelvis and abdomen of a pregnant woman is like Manhattan real estate—it’s limited, to say the least. So, when other “things” have taken up home like ovarian cysts and fibroids, it can be an unpleasant situation. However, before you rush to “sell” them off, listen to what we have to say.

The most commonly encountered uninvited houseguests in pregnant women are ovarian cysts and uterine fibroids. They usually have taken up residence and despite the rent hikes are refusing to move. Sometimes, they can stay put, and sometimes they need to be evicted. Here’s the lowdown on what’s legit and what needs to leave when it comes to cysts and fibroids.

When it comes to cysts, most of the time they can stay. In fact, it’s not uncommon to detect cysts during pregnancy. For many women, it is the first time we have seen a “picture” of their ovaries (say cheese!). The ultrasound is the mainstay for fetal evaluation—most women have at least two if not more ultrasounds performed in their pregnancy. During these exams, the ovaries are not camera shy; we usually get a good look at them. Most flash us a smile and never bother you or us again. We might look for them later in pregnancy to ensure that, if a cyst was present it is stable in size, but we infrequently act to take them out. And the numbers tell us why: adnexal masses (cysts in the ovaries/tubes) are seen in about 0.05 to 3.2% of all live births. Cancer is diagnosed in ONLY about 4 to 8% of these cysts. The bottom line is, they are very, very rare, and therefore we usually need to do nothing more than watch them from the outside.

Most cysts encountered in pregnancy are BENIGN and include dermoids (mature teratomas), corpus luteum, and para (adjacent to the ovary) simple cysts. Because nearly 50 to 70% of ovarian cysts during pregnancy will vanish like the bunny in a magic show, we usually leave them alone (only about 2% will cause you any acute problems requiring surgery). Those that won’t step out of the spotlight and need to come out tend to be larger (>5cm) and more complex (a.k.a. scary looking). They are usually removed in the second trimester, as this is the safest time to perform surgery in pregnancy.

Let’s call an Uber and travel from the ovaries to the uterus (a short trip even with price surging!). Here in the uterus, fibroids are often the most common foe faced during pregnancy. While they are sometimes dealt with before pregnancy even occurs, in most cases they are not. As they are very rarely the sole cause of infertility, most women don’t even know they are there until they are plugging along in pregnancy. Again, that trusty ultrasound that we use to capture your baby’s first pics will often identify fibroids that you never even knew existed. For those with infertility or recurrent miscarriages, fibroids will likely have presented themselves long before pregnancy. However, unless they’re inside the uterine cavity or significantly distorting the uterine cavity, they can usually stay put. Preventative surgery is not so popular.

In those women who have fibroid symptoms (bleeding, pain, pressure, etc.) it’s a different situation. You must take care of yourself and your uterus! If the symptoms are mild, we recommend holding off on surgery until you are ready to start trying. Surgery done as close to the time of desired pregnancy will cut down on the risk of recurrence. Although you will need about 3 months’ respite to let your uterus recover, you can pretty much get back on the field in no time (keep this in mind as you attempt to plan out your life).

If your symptoms are major or are causing your infertility, there is no better time than now to act. Don’t wait, as it won’t make your life or your symptoms any better. It will just make you more frustrated and fed up!

Newsflash…if you had a big fibroid removed before pregnancy and your surgeon said they “went through and through the muscle,” you are most likely going to need a C-Section. A uterus that has been sliced and diced, poked, and prodded may not be as strong as one that has never been disturbed. By performing an elective C-Section before labor starts, we can reduce the risk of a uterine perforation (uterus opening at the incision). This makes things way safer for everyone involved!

The reality is that most women with fibroids do just fine during pregnancy. Despite the influx of estrogen and progesterone, most don’t grow, and those that do usually only do so in the first trimester. On occasion, this brief rapid growth can cut off blood flow to the fibroid causing “degeneration” and significant pain.  However, most women don’t even remember that their fibroids are there. In very few cases do fibroids cause serious problems; when they do, it’s the following that we are on the lookout for:

  • Increased risk of miscarriage.
  • Preterm delivery and labor.
  • Abnormal fetal position.
  • Fetal growth restriction.
  • Placental abruption.
  • Labor dysfunction (and the need for a C-Section).
  • Heavy post-partum bleeding.

Even with these potentials on the horizon, removing fibroids in pregnancy is almost NEVER an option. A pregnant uterus has lots of blood. Lots of blood makes surgery very scary, and very scary surgery is nothing that anyone is interested in doing. That means you should wait until pregnancy is over to deal with your fibroids!

Unfortunately for the potential buyers out there (ourselves included!), the market is not about to crash. In fact, most say there is nothing more stable than real estate in the long run. Therefore, don’t move or remove “things” just because you have a plus one or maybe a plus two on the way. Their additional presence may be pesky, but unless there is a major problem pre-pregnancy (bleeding, pain, infertility), let them stay in their rent-controlled apartments. If they start to make too much noise, we have ways to deal with them!

The Lowdown on What to Do When You Can’t Get Anything to Stay Down: Nausea in Pregnancy

Praying to the porcelain god, hugging the bowl, or tossing one’s cookies—whatever you want to call it, vomiting is not fun. In fact, it may be one of the most un-fun bodily processes. Add to that unremitting nausea, and you have got yourself quite a pair. And while this dynamic duo is usually only welcomed after select occasions—a stomach virus, food poisoning, or after a serious night out on the town—in pregnancy, it can be a daily event. The hormones secreted by pregnancy (a.k.a. hCG and estrogen) can make you pretty sick—so sick, even getting out of bed to brush your teeth may seem impossible.

Nausea and vomiting in early pregnancy is VERY common. Nearly 75% of women will feel nauseous or vomit at some time during their pregnancy. However, the extreme cases (medically termed hyperemesis gravidarum) are VERY rare. And although nausea and vomiting in pregnancy can happen to any lucky lady, it is more likely to happen in women who are pregnant with multiples (more placenta = more hormones = more nausea), have a history of hyperemesis in a past pregnancy, have a family history of hyperemesis, are prone to motion sickness, or have a personal history of migraines.

Although persistent nausea and vomiting won’t kill you, it will likely make you feel like you’re dying. You can’t work, you can’t work out, and you can barely move. So, what can you do to give the baby barfing the boot?

First, if possible, start taking a prenatal vitamin at least three months before you conceive. Some prep time can help prevent the nausea that women can experience with prenatal vitamins.

Second, try to limit the time you spend around smells that make you sick (goodbye, garlic!).

Third, trade in three large meals for six small ones. The less you need to digest, the less likely you are to lose it!

Fourth, stay away from spicy and fatty foods, and fifth, shelve any pills with iron.

Last, think about investing in ginger pills. Not only has ginger been shown to be beneficial for your immune system, but studies also show that it may be the secret to curtailing your nausea. And although the medical jury is still out on acupressure, acupuncture, and electrical nerve stimulation to the inside of the wrist, it can’t hurt to try.

When simple measures fail and you are still BFF with your toilet bowl, it’s time to bring out the big guns (a.k.a. medications). Your OB will likely start with something like vitamin B6 or vitamin B6 plus doxylamine. If this doesn’t do the trick, they may amp it up with prescription anti-nausea medications. However, before you go this route, it’s important to have a chat with your OB about what’s coming up and when before you take anything else down.

If this still doesn’t cut it and you’re cutting weight like a wrestler before a big fight, your OB may consider admitting you to the hospital for intravenous nutrition. Severe causes call for serious measures. Nutrition can be delivered through an IV if need be.

Although it is very rare for this fight to go the distance, if you find yourself still battling nausea in the second trimester, consider adding an antacid or reflux medication. Often, women start to experience reflux in the second trimester. As your little one grows, so does your uterus. As your uterus grows, the space between your uterus and your upper abdominal organs (think stomach) shrinks. Pressure on the stomach can cause things to come back up (a.k.a. reflux), which can lead to nausea and even vomiting.

In cases where nausea and vomiting start after nine weeks or there are other atypical symptoms (abdominal pain, fever, headache), it’s important to reach out to your doctor—ASAP. Not all nausea and vomiting in pregnancy is normal. Sometimes it can indicate that something serious (appendicitis, kidney infection, kidney stones) is going on.

The good news about nausea and vomiting is that, while it can make you miserable, it usually doesn’t do anything miserable to your body or to your baby. Even when the only thing your stomach can stomach is saltines and ginger ale, your baby will be just fine.

Whether you call it “puking,” “barfing,” “hurling,” or “vomiting,” we call it no fun. But it will pass, and we will do our best to get you through it, one day at a time!

I Am Ready to Race Again; Is It Too Soon? Pregnancy Interval

For any of you who have competed in a long-distance competition (be it a run, a swim, a hike, or a bike), you know what it feels like to cross that finish line. Total euphoria—combined with a fair amount of exhaustion, pain, and lots of blisters! The first thought that runs through your head, after the “I can’t believe I actually made it” moment is either “When can I do it again?” or “I am NEVER doing that again!”

The first group is already planning their next race, mapping out their training schedule, and thinking about how they could have done it better. While the “Okay, I can check that off my bucket list group” is looking for the nearest bar, a bath, and a bed. In many ways, pregnancy, labor, and having a newborn is very similar to the training and racing of a long-distance competition.

While the “Yes, let’s do it again” and the “No, I am so out” camps in pregnancy and parenthood are more fluid than the participants in long-distance competitions, (hard-core Group B members may move into Group A), people usually have a pretty set idea about how many times they want to be pregnant, how many times they want to give birth, and how many children they want.

Most of us even have a pretty good idea about how close together we want our kids to be (medically termed birth spacing). Whether you want them back-to-back or you prefer to space them apart is a personal decision. But how soon you can hop back on the baby machine is dependent on more than just your feeling ready. It also depends on factors out of your control such as if you had a C-Section or a vaginal delivery, if issues like high blood pressure or diabetes complicated your pregnancy, and if you required any additional procedures post-delivery. These all can hold you up even if your heart is ready to race again.

Regardless of what went down during your pregnancy, the time between delivery and a pregnancy should be AT LEAST 18 months. Any shorter inter-pregnancy interval can increase the chance of preterm delivery, premature placental separation (placental abruption), pre-eclampsia (high blood pressure in pregnancy), placenta previa (particularly after a C-Section), low birth-weight babies, and autism.

While the definitive reason behind why these events occur more frequently is debatable, fingers seem to point towards the “maternal depletion hypothesis.” Pregnancy and the stressors of a newborn takes a lot out of you, and your body needs time to re-fuel and re-energize before it starts the race again. Stressing the system before it is ready to function can interfere with its ability to do its job well.

Among the organs in the body that need a break, the uterus is at the top of that list, especially after a C-Section. The uterus is a muscle, and a muscle that is injured (particularly cut and sewn back together) needs to heal. Without adequate time to heal, there is a higher chance that it will open (a.k.a. rupture which is life threatening to  you and the baby) in the subsequent delivery. Furthermore, women who had a C-Section and want to try for a vaginal delivery in their next pregnancy (vaginal birth after cesarean section=VBAC) need extra-extra time to rest their uterus before it is pushed to push.

You don’t have to decide which group you are going to side with moments after crossing the pregnancy finish line (#delivery). Labor can be long and exhausting. Give it some time before you wave the “Yes, I want another baby” or “No way; I am done” flags. Even if you are raring to go moments after the race is over, give it time before you line up at the next start line. Hydrate, stretch, rest—do whatever it takes to get you ready to go again. The time off will do you good—and your next pregnancy.