Category Archives: Health

UNDERSTANDING RECURRENT PREGNANCY LOSS – Part 1: CAUSES

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Having a pregnancy loss can be heartbreaking. Having multiple miscarriages can be truly devastating. Each new pregnancy brings hope, but also great anxiety; each new miscarriage aggravates the feelings of loss, grief and sense of failure… 

It is natural to want answers. Knowing the reason of a pregnancy loss can help you make sense of what has happened. Furthermore, finding the cause of the problem will help prevent it from happening again, or at least reduce its risk. Things are not so simple though when it comes to recurrent miscarriage: most of the times, investigations don’t come out with a clear answer…

The purpose of this article is to help you understand recurrent pregnancy loss and to present the most recent scientific information regarding its cause, diagnosis and treatment. Due to the extensiveness of the subject, this first article will deal only with the known causes of repeated miscarriage; two other articles on testing and treatment will follow.

What is Recurrent Pregnancy Loss?

A pregnancy loss is the spontaneous loss of a pregnancy before 24 weeks of gestation. Recurrent Pregnancy Loss (RPL) is considered after the loss of two or more pregnancies; this includes pregnancies after spontaneous conception or after assisted reproduction (e.g. IUI and IVF/ICSI). Other pregnancy complications such as ectopic pregnancies and molar pregnancies are not included. 

  • Primary RPL is a term used for women who have not had a baby before their pregnancy losses. 
  • Secondary RPL means they have had at least one baby before their losses. 

It is estimated that RPL affects 1 to 2% of couples.

What causes RPL?

There are several factors that may be responsible for RPL. But you should know that in about half (50%) of the RPL cases, no cause is found. This is called unexplained RPL.

Here are some of the causes that are related to multiple miscarriages:

1) Age

The older you are, the greater your risk of having a miscarriage. If a woman is aged over 40, more than 50% of pregnancies end in a miscarriage. The same is true for RPL. Miscarriages may also be more common if the father is older, although it is not clear whether paternal age is related to repeated miscarriages.

2) Genetic problems

  • Genetic defects resulting in an abnormal fetus can be a major cause of miscarriage. About half of all miscarriages in the first three months of pregnancy are due to chromosomal problems, although most of the times this is of random occurrence .
  • In about 4 in 100 couples (4%) with recurrent miscarriage, one partner will have an abnormality on one of their chromosomes. Although this may not affect the parent, it may sometimes cause a miscarriage.

3) Thrombophilia

Thrombophilia is a condition in which your blood clots more than usual; it may be inherited (passed down genetically) or acquired (not inherited). Thrombophilia is not only related to RPL, but also to other pregnancy complications.

  • Inherited thrombophilia is due to certain gene defects. According to the gene involved, it may be related to early or late repeated miscarriage.
  • Antiphospholipid syndrome (APS) is an acquired thrombophilic condition. It is uncommon but strongly related to RPL.

4) Abnormal hormone levels

Miscarriage can occur when the uterine lining does not develop sufficiently, therefore the fertilized egg does not have the best environment for implantation and nourishment; this can be the result of abnormal hormone levels.

Women with thyroid problems and women with diabetes (or insulin problems) are usually at a higher risk for miscarriage due to hormonal imbalances. Women with polycystic ovaries syndrome, are also at risk. In addition, elevated prolactin levels can also disrupt normal uterine lining development.

5) Problems of the uterus

The shape of the uterus may cause miscarriage, usually by interfering with the implantation of the fertilized egg.

  • A septum, that is a fibrous wall which divides the uterine cavity, can cause poor implantation and pregnancy loss.
  • Uterine fibroids, polyps, adhesions may eventually cause pregnancy loss by blocking the opening of the fallopian tube(s) or if their position is affecting the normal functioning of the uterine lining. Their relationship though with RPL is less clear.
  • Another probable cause of miscarriage is an incompetent cervix, meaning the cervical muscle is weak and cannot remain closed; as the developing fetus grows puts pressure on the cervix, it starts to shorten and open, resulting in miscarriage.

6) Immune Causes

It has been suggested that some women miscarry because their immune system does not respond to the baby in the usual way. This is known as an alloimmune reaction. Although numerous immunological factor have been investigated, there is no clear evidence to support this theory at present, and further research is needed.

7) Sperm defects

Sperm DNA is the most important part of the sperm, as it contains the genetic information that will be passed on to the baby. DNA can be damaged during sperm production and transport; this damage is known as DNA fragmentation. The recents years it has become evident that high levels of sperm DNA fragmentation seem to increase the likelihood of pregnancy loss.

Sperm DNA fragmentation can be provoked by stress, smoking, recreational drugs, obesity and other unhealthy lifestyle factors. 

8) Infections

Certain infections have been proposed as the cause of RPL, such as rubella, herpes simplex, ureaplasma, cytomegalovirus and chlamydia. However, the role of these infections in recurrent miscarriage is unclear and probably null. A persistent infection of the endometrium (chronic endometritis) may be related to RPL, but more research is needed to know this for sure.

9) Environmental Factors

Certain toxins you may be exposed to can also result in fetal damage or miscarriage, especially if you experience regular exposure. Toxins such as organochlorine pesticides, certain heavy metals (selenium, lead cadmium), organic solvents, anesthetic gases (occupational exposure), have all been blamed for causing RPL. Likewise, lack of certain micronutrients (zinc, copper, vitamin E) have been proposed as possible causes of RPL. 

Although exposure to possible hazardous substances should be avoided during pregnancy (this is true for all pregnant women), there are insufficient data to recommend protection against a certain occupational or environmental factor in women with RPL.

10) Lifestyle-related factors 

  • Studies also indicate that the use of marijuana, tobacco, alcohol and excessive consumption of caffeine can all affect fetal development and result in miscarriage. Although their relationship with RPL is not clear, it is recommended that women limit or avoid their use during pregnancy.
  • Being overweight or significantly underweight have been both associated with miscarriages, as well as with pregnancy and childbirth complications. While maternal obesity is a strong risk factor in RPL, the association with very low weight is less clear. Male overweight may also be a negative factor, since is responsible for DNA damage (see above). Striving for a healthy, normal weight is recommended, both for the female and male partner. 
  • Intensive exercise or no exercise at all have been both blamed as a cause of RPL, but there is not clear scientific evidence and further research is needed. Moderate (leisure) physical activity seems to be safe, and beneficial for other pregnancy complications, such as diabetes and hypertension of pregnancy.
  • Whether stress increases the chances of another pregnancy loss in the next pregnancy is a major concern for all couples with RPL. Studies to date indicate that there is an association between stress and pregnancy loss, but it is not whether the stress is a result or a causal factor in RPL.

 

Read the second part here: Understanding Recurrent Pregnancy Loss – Testing (coming soon)

 

Photo credits

futurelab-ksa.com

 

TRYING TO GET PREGNANT: 14 FERTILITY MYTHS DEBUNKED

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We live in the era of informatics. Knowledge is easily accessible to us: we can learn virtually anything by just googling it. But paradoxically too much information many times leads to misinformation.

When it comes to fertility issues, there is a lot of disinformation going around. Therefore, it is no surprising what a recent survey showed: knowledge regarding ovulation, fertility, and conception issues is limited among women, and many tend to believe certain myths and misconceptions.

These are 14 fertility myths most people believe, but that science has debunked:

MYTH #1.  Maternity wise, 40s is the new 30s

Our life expectancy is longer, and we tend to postpone maternity due to career or study purposes. From that aspect, the 40s can be easily regarded as the new 30s. Unfortunately, this is not true for our ovaries: by the age of 30, a healthy woman has about a 20% chance of conceiving each month, by the time she reaches 40 her odds drop to about 5%.

This is one of the most commonly believed misconceptions: unaware of the age-related fertility decline, many women start seeking  help to conceive in their 40s, when they may have already missed the opportunity to become parents. 

You should be aware that there is a biological clock, and it’s ticking! If for personal reasons you cannot have a child right now, you may freeze your eggs to use them in the future.

MYTH #2. Certain sex positions increase the chances of getting pregnant

You will find plenty of (mis)information on this topic! In general, it is said that the best positions for getting pregnant are the missionary position (the woman lying on her back, her partner on top) and the “doggy position” (rear vaginal penetration, with the woman on her hands and knees) because they provide the deepest penetration, allowing the man to ejaculate closer to the opening of the cervix. 

In fact, there’s no scientific evidence to prove that. This belief is largely based on a single study that looked at the position of the penis in relation to these two sex positions, but it didn’t address pregnancy chances at all.

Therefore, no position seems to be better when it comes to maximizing your chances of making a baby. Sperm can be found in the cervical canal just a few seconds after ejaculation, and within 5 minutes in the tube, regardless of the coital position.

MYTH #3. Lifting your legs in the air for 20 minutes after having sex will help you get pregnant

You have probably heard this one: “lie in bed with your feet in the air after having sex to increase your chances of getting pregnant”. In fact, this is not (totally) true. You may lay in bed for 10-15 minutes after intercourse, as by this time the sperm have largely reached the cervix, and many may even be inside the tube.

In fact, a new study challenged both beliefs: women having artificial insemination were split into two groups – one that rested on their back with their knees raised for 15 minutes after the procedure and one that got up immediately. It turned out that, after several courses of treatment, 32% of the immobile group fell pregnant, compared with 40% per cent in the active group.

Therefore, there is no need to put pillows under your bottom during intercourse to get an advantageous tilt, or to perform cycling motions with your feet in the air.

MYTH #4. If we have sex every day the sperm becomes too weak, reducing our chances of getting pregnant 

How often should we make love to boost our chances of pregnancy? You will find all sorts of advice on the web: every other day, 3 times a week, every single day! Which one is correct?

One thing is clear: abstinence intervals greater than 5 days impair the sperm number and quality. Nevertheless, there is not much difference whether men ejaculate every day or every other day. Most fertility specialists used to recommend intercourse every other day, as this would increase sperm quality, particularly in men with lower sperm counts (oligozoospermia). However, recent studies show exactly the opposite: oligozoospermic men had better semen quality with daily ejaculation!

Recent scientific evidence suggests that making love every day confers a slight advantage: the highest chances of pregnancy (37% per cycle) were associated with daily intercourse, although sex on alternate days had comparable pregnancy rates (33%). On the other hand, we should keep in mind that the “obligation” to have sex every day may induce unnecessary stress to the couple, resulting in lack of sexual desire, low self esteem, and ultimately reduced frequency of intercourse.

Therefore, reproductive efficiency is highest when you have sex every day or every other day. The optimal frequency, though, is best defined by each couple’s own preference.

MYTH # 5. We only have sex when I ovulate, on day 14 of my cycle

Ovulation (when the egg drops from the ovary into the tubes) occurs once a month, usually between day 11 and day 21 of the cycle (measured from the first day of your period).

Each woman ovulates on her own schedule. While it is usually said that a woman with a 28-day cycle ovulates on cycle day 14, that’s not necessarily true: a study found that fewer than 10 percent of women with regular, 28-day cycles were ovulating on day 14.

We know that sperm cells are able to survive in the reproductive tract of a woman for about 5 days, and that once the egg is released, it will die in about 12-24 hours. Therefore, the fertile period -or “fertile window”- is a 6-day interval ending on the day of ovulation.

To boost your odds to become pregnant, have sex before and during ovulation, every day or every other day. If your cycles are irregular and you cannot figure out your fertile days, you may use an ovulation predictor kit, or otherwise visit a specialist, who can help you find your fertile window.

MYTH # 6. Smoking doesn’t affect our chances of getting pregnant. I will quit smoking as soon as I get pregnant

You are most likely aware that smoking during pregnancy is dangerous, as it can lead to miscarriage, premature birth, low-birthweight babies and -according to recent studies– congenital malformations.

But you should also know that smoking is harmful for your fertility: smoking as few as five cigarettes per day is associated with reduced fertility, both in women and men, and this seems to be true even for secondhand smoking. It has been estimated that smokers may have a 10-40% lower monthly fecundity (fertility) rate, and that up to 13% of infertility is due to smoking.

Smoking can affect ovulation, as well as the ability of the fertilized egg to implant in the uterus. The effect of tobacco is so harmful for the ovaries that menopause occurs, on average, one to four years earlier in smoking women than in nonsmoking ones.

Men are also affected by tobacco: decreases in sperm density, motility, and abnormalities in sperm morphology have been observed in men who smoke, which impact a man’s ability to fertilize an egg. 

Therefore, before trying for a baby, do yourself a favor … and put out the cigarette for good!

MYTH # 7. You don’t need to worry about your age. There’s always IVF

Another common misconception! Many women believe that, if age-related infertility strikes, they can overcome their problem by getting treated with in vitro fertilization (IVF). In fact, just as natural fertility declines with age, success rates with IVF also decline as a woman gets older.

According to the USA Center for Disease Control and Prevention (CDC), women younger than 35 years old have 33% chances of having a baby after IVF; for women ages 38 to 40 the success rate drops to 17%, while those 43 to 44 years old have only 3% chances of giving birth after IVF (using their own eggs).

IVF is not a guarantee to have a baby, and does not extend a woman’s reproductive life. Despite the number of celebrities having babies in their mid-40s and beyond, they may have not necessarily used their own eggs. While every woman has the right to keep her privacy, there is a wrong perception left that fertility treatments can extend a woman’s fertility span. There is a very low probability of improving success of conceiving after age 43 by using assisted reproduction using your own eggs. Nevertheless, you may opt to use oocyte donation (eggs of a younger woman) if age-related infertility stands in the way of parenthood.

MYTH # 8. A woman can’t get pregnant if she doesn’t have an orgasm

For men, things are clear: no orgasm, no pregnancy, as ejaculation occurs during orgasm. Well, that’s not entirely true: semen can be released during intercourse prior to orgasm in the so-called pre-ejaculation fluid, or pre-come (read more here).

For women though, getting pregnant has nothing to do with an orgasm. But could female orgasm improve the chances for conception? The answer is not clear.

Researchers have wondered for years about the purpose of female orgasm, and many theories have been proposed: 

  • Just the pleasure it provokes, so that women want to reproduce and preserve the species!
  • The “poleaxe” hypothesis: orgasms make women feel relaxed and sleepy so that they will lie down after sex and the sperm reach their destination more easily.
  • The “upsuck” theory: the contractions of the uterus “suck up” the sperm released in the vagina and help them travel through the uterus to the tubes.
  • Pair bonding: the hormones produced during orgasm (such as oxytocin and prolactin) contribute to warm feelings towards her partner.

Orgasms are not necessary to get pregnant, but there are plenty of good reasons to have one! Nevertheless, it is not uncommon that women trying to conceive link the desire for an orgasm with their desire to have a baby; this leads to psychological pressure and difficulty achieving orgasm, adding frustration to a process that is supposed to be pleasurable…

Try not to consider the orgasm just as goal to get pregnant. Enjoy the intimate time with your partner, without any pressure. If you have an orgasm, great. If not, that’s fine, too!

MYTH #9. We’ve already had one child, so conceiving again will be easy

Perhaps, but it’s no guarantee. Many individuals experience secondary infertility, or difficulty conceiving a second or subsequent child. 

Secondary infertility may be caused by age-related factors, both for you and your partner. Sometimes, a new underlying medical condition develops. Eventually, a fertility issue that always existed gets worse; while it didn’t prevent pregnancy before, now it has become a problem. A previous pregnancy may actually be the reason you don’t get pregnant again: surgical complications or infection after childbirth may have provoked scarring, which may in turn led to infertility.

Things change with time. Even if you got easily pregnant on your own before, if you’re struggling to have another child talk to your doctor, who can advice you on the next steps to follow.

MYTH #10. Infertility is a woman’s issue

Typically, the causes of infertility break down like this: 

  • Approximately one third of the couples struggle with male infertility;
  • In another third, the problem is female infertility;
  • The remaining third will either face both male and female fertility issues, or a cause will never be found (unexplained infertility).

Common causes of female infertily are: age, PCOS (polycystic ovary syndrome), tubal or pelvic issues, endometriosis, and family history. 

Common causes of male infertility tend to be from prior surgery, infection, or a problem present at birth.

As part of the preliminary work-up to determine the cause and treatment of infertility, both women and men will need to undergo clinical and specialized complementary exams.

MYTH #11. Men’s age doesn’t matter

While some men can father children into their 50’s or 60’s, men’s fertility isn’t age-proof: it starts declining in their 40s, although less drastically as compared to women’s fertility.

As a man ages, the concentration of mobile, healthy sperm and semen volume overall will decrease. It is clear now that men over the age of 40 have higher chances of having children with chromosomal abnormalities, causing miscarriages in their female partners. Moreover, researchers have found a direct link between paternal age and an increased risk of autism and schizophrenia. 

A man’s age does matter. While men may not have a complete drop off in fertility like women do, “advanced paternal age” is something couples should be aware of. Men’s biological clock is also ticking!

MYTH #12. If I take good care of my general health, my fertility will be in check too

Whereas a healthy body and mind may boost fertility in certain cases, most infertility situations cannot be resolved by a lifestyle or diet change, particularly those related to age.

It is a common belief that certain diet types can help you get pregnant. There is no evidence that vegetarian diets, low-fat diets, antioxidant- or vitamin-enriched diets will increase your chances of having a child.

A woman’s weight plays a role in fertility: those who are either very thin or obese may find it hard to conceive. If you are trying to get pregnant, learn more about some lifestyle tips to boost your chances of getting pregnant here.

MYTH #13. If a man can ejaculate, his fertility is fine

Many myths surround male fertility and their sexual performance. It is a common (and unfortunate) myth that if a man’s fertility is compromised, this means his sexual performance is the problem. This is not true. Problems with sperm count, shape, and movement are the primary causes of male infertility. 

Another common myth is that you can tell there is a problem with the sperm just by looking at the semen. In fact, even men that have no sperm cells at all (azoospermia) usually have normal-looking semen. 

For the vast majority of men with infertility, there are no visible or obvious signs that anything is wrong. Healthy erectile function and normal ejaculation are not guarantee that the sperm is in good shape.

That said, erectile dysfunction can be a possible symptom of infertility; it may due to low testosterone levels or a physical injury. Difficulty with ejaculation can also be a signal certain medical problems. But these are uncommon signs of male infertility.

If you are struggling to get pregnant, have your partner check in with his doctor. A semen analysis will help clarify whether his sperm are fit for conception.

MYTH #14. The birth control pill will affect your future fertility

All scientific evidence agrees that hormonal contraceptives do not make women sterile. Moreover, they may confer increased likelihood of pregnancy with long-term use, and in certain cases they can also preserve fertility. Read more on the contraceptive pill here.

 

To summarize:

Myths and misconceptions regarding fertility and conception are, unfortunately, widely disseminated. This is a serious problem, as misinformation may lead not only to unnecessary stress, but also to take wrong decisions…

Get yourself well informed! Consult your gynecologist, who can help you with any concerns you have. Your doctor can also give you some tips on lifestyle changes to optimize your fertility, prescribe some exams, and tell you when to come back if you don’t achieve pregnancy on your own.

Last, a good piece of advice: if you want to get pregnant, have lots of sex – as much as you want, whenever you want – and enjoy it! After you have had sex, do whatever you want – just don’t smoke 😉

 

Photo credits

Intro: pixabay.com; 1: rma-fl.com; 2: motherandbaby.co.uk; 3: romper.com; 4: pixabay.com; 5: wsaw.com; 6: babycenter.com; 7: nexter.org; 8: irishtimes.com; 9: health.clevelandclinic.org; 10: thefertilechickonline.com; 11: businessinsider.com; 12: hayatouki.com; 13: livescience.com; 14: pinterest.com

HPV TEST: A NOVEL TECHNIQUE TO PREVENT CERVICAL CANCER

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You have probably heard the term Pap test and know that you should be getting it regularly. Pap tests are important because they allow us to detect abnormalities in the uterine cervix before they turn into cancer. Thus, Pap tests have saved millions of women’s lives for more than 70 years now.

Nevertheless, as valuable as this test has been for so many years, new technology has come to improve even further our ability to find pre-cancer or early cancer of the cervix. This novel exam is called the HPV test.

In this article you will find all the information you need to know regarding this new technique, which is becoming a routine exam in most countries.

Background

  • Cervical cancer is the second-most-common cancer affecting women worldwide. It is a type of cancer that can easily be prevented, as its cause is known: the human papillomavirus (HPV, read more here).
  • Not all types of HPV are responsible for the development of cancer of the uterine cervix. Approximately 15 types of HPV are related to cancer, these are known as high-risk types or oncogenic viruses.
  • While most HPV infections resolve without treatment, infections with high-risk HPV strains that persist over time can cause precancerous changes in the cervix.
  • Precancerous conditions are not cancer, but if these abnormal changes are not treated, they may become cervical cancer. It may take 10 years or more for precancerous conditions to turn into cancer, but eventually this happens within a shorter time period.
  • Pre-cancer lesions of the cervix do not cause any symptoms. Symptoms only appear in advanced cancer. That is why all healthy women should undergo preventive exams.
  • The mainstay of cervical cancer screening for the last 70 years has been the Pap test (also called Pap smear or Test Papanicolaou). During the procedure, cells from the cervix are gently scraped away with a brush and then examined for abnormal growth, usually called cervical dysplasia,  CIN (cervical intraepithelial neoplasia), or SIL (squamous intraepithelial lesions).
  • More recently, newer technologies have become available to test for the cancer-causing types of HPV and determine if you may be at risk. This test is called the HPV test.

What is the HPV test?

  • The human papillomavirus (HPV) test detects the presence of the types of HPV virus that can lead to the development of cervical cancer.
  • The HPV test is available only to women. Although men can be infected with HPV and pass the virus along to their sex partners, no HPV test yet exists to detect the virus in men.

Why test for HPV?

  • The Pap test is a simple test that has saved uncountable women lives. However, it is not 100% accurate. The Pap test detects certain cervical abnormalities that will never progress to cancer; on the other hand, it may miss abnormal cells even when they are there.
  • Thus, knowing whether you have a type of HPV that puts you at high risk of cervical cancer will provide valuable information on the next steps in your health care, such as follow-up monitoring, further testing, or treatment of precancerous cells.
  • Recent studies have shown that HPV testing is more effective than Pap smears at detecting precancerous lesions.
  • A Pap test plus an HPV test (called co-testing) is the most effective way to find pre-cancer or early cervical cancer in women 30 and older.

Who should do the HPV test?

The HPV test is recommended if:

  • You are age 30 or older. The HPV test may be done alone or in combination with a Pap smear.
  • Your Pap test showed atypical squamous cells of undetermined significance (ASCUS). ASCUS is a common finding in a Pap test; it may be a sign of HPV infection, although many times it is just related to benign cervical polyps, a bacterial infection, or low hormone levels (menopause).
  • You had a surgical removal of a precancerous lesions, usually 6 months after the treatment. This is called “test of cure”.

Although recommendations vary in different countries, all women aged 30 to 65 years old should have the HPV test every 3 to 5 years.

Routine use of the HPV test in women under age 30 is not recommended, nor is it very helpful. HPV spreads through sexual contact and is very common in young women. Most of the times, HPV infections clear on their own within a year or two. Since cervical changes that lead to cancer take several years — often 10 years or more, younger women are usually advised to follow a watchful waiting instead of undergoing treatment for cervical changes resulting from an HPV infection.

What are the risks of HPV testing?

Although the HPV test is very accurate, it carries (like any other test) the risk of false-positive or false-negative results.

• False-positive. This means that the test showed a high-risk HPV when you really don’t have it. A false-positive result could lead to an unnecessary follow-up procedure, such as colposcopy or biopsy, and undue anxiety over the test results.

• False-negative. A false-negative test result means you really do have an HPV infection, but the test indicates that you don’t. This might cause a delay in appropriate follow-up tests or procedures.

How should I prepare for an HPV test?

The HPV test is usually done at the same time as the Pap test. You can take these measures to make both tests as accurate as possible:

  • Avoid intercourse, douching, or using any vaginal medicines or spermicidal foams, creams or jellies for two days before the test.
  • Try not to schedule the test during your menstrual period. The test can be done, but a better sample of cells can be collected at another time in your cycle.

How is the HPV test done?

  • The HPV test, alone or in combination with the Pap test, is performed at the doctor’s office and takes only a few minutes.
  • While you lie on your back with your knees bent, your doctor will gently insert an instrument called a speculum into the vagina.
  • The speculum allows the visualisation of the cervix. Samples of the cervical cells are taken using a soft brush.
  • Usually this doesn’t hurt, sometimes it may cause a mild discomfort.
  • After the procedure, you can do your normal daily activities without any restrictions.
  • Ask your doctor about when you can expect to receive your test results.

What do the results mean?

Results from your HPV test will come back as either positive or negative.

  • Positive HPV test. This means that you have a type of high-risk HPV that is linked to cervical cancer. While most women who are infected with HPV will never develop cervical cancer, it’s a warning sign that cervical cancer could develop in the future.
  • Negative HPV test. A negative test result means that you don’t have any of the types of HPV that cause cervical cancer, and you will continue with normal monitoring.

Depending on your test results, your doctor may recommend one of the following as a next step:

  • Normal monitoring. If you’re over age 30, your HPV test is negative and your Pap test is normal, you will follow the generally recommended schedule (differences apply for each country).
  • Colposcopy. In this follow-up procedure, your doctor uses a special magnifying lens (colposcope) to more closely examine your cervix.
  • Biopsy. Done in conjunction with colposcopy, a sample of cervical cells (biopsy) is taken to be examined more closely under a microscope.
  • Removal of abnormal cervical cells. To prevent abnormal cells from developing into cancerous cells, your doctor may suggest a procedure to remove the areas of tissue that contain the abnormal cells.

The bottom line…

It is true that a visit to the gynaecologist may sound frightening. You may be too busy, and feel that you don’t have the time. You may believe that you are not at risk for cancer. While all this may be true, you should know that every sexually active woman is at risk for cervical cancer, the HPV test is a simple, painless test that takes 5 minutes to be done, and will prevent some serious issues in the long run. Have your HPV test! Five minutes of your time can save your life!

References

  1. The HPV DNA test – American Cancer Society
  2. Gynecological Cancers – Centers for Disease Control and Prevention
  3. Cervical Cancer Screening: Pap and HPV tests – National Cervical Cancer Coalition
  4. Cervical Screening – National Health System UK

Photo credits

telegraph.co.uk; cmdrc.com; twitter.com; erewashccg.nhs.uk; everydayhealth.com; healthxchange.sg; margaretmccartney.com

VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC): ALL YOU NEED TO KNOW BEFORE MAKING YOUR EDUCATED CHOICE

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“Once a Cesarean, always a Cesarean” has been the standard recommendation for many years. But the increasingly high cesarean section (C-section) rates around the world have led doctors to reassess the risks of a cesarean section versus delivering vaginally after having a previous C-section.

Repeat C-section or VBAC? The answer is not straightforward. Both options do come with some risks, and those risks vary depending on the woman and the specific pregnancy.

Here’s what you need to know about a vaginal birth after cesarean section and what you should discuss with your doctor if you want to try delivering your next baby vaginally.

1) What is a vaginal birth after cesarean delivery (VBAC)?

If you’re pregnant again and your last baby was born via cesarean section, this time you have two choices about how to give birth:

  1. an elective repeat caesarean section (ERCS), or
  2. a VBAC. “VBAC” stands for “vaginal birth after cesarean” and refers to giving birth through the vagina after a woman has already had a C-section. Vaginal birth also includes deliveries assisted by forceps or ventouse.

Planning for a vaginal birth after caesarean (VBAC) or choosing an ERCS have different benefits and risks (see below).

A TOLAC (trial of labor after cesarean delivery) is the attempt to have a VBAC. If it is successful, TOLAC results in a vaginal birth. If it is not successful, you will need another cesarean delivery.

2) What are my chances of giving birth vaginally after having a C-section?

As long as you are an appropriate candidate for a VBAC, there are good chances to succeed: about 60 to 80% of women who attempt a VBAC will deliver vaginally.

There are certain factors which affect the chances of success, both related to the mother and the baby (see below). Nevertheless, it’s impossible to predict with certainty who will be able to have a vaginal delivery and who will end up with a repeat c-section.

A previous vaginal delivery, particularly previous VBAC, is the single best predictor of successful VBAC and is associated with a VBAC success rate of 85–90%.

3) Am I a good candidate for a VBAC?

Planned VBAC is appropriate for the majority of women who:

  • are pregnant with one fetus (as opposed to twins/multiples),
  • their baby is positioned head down (cephalic presentation),
  • have a pregnancy at term (37+0 weeks or beyond),
  • have had one previous lower segment caesarean delivery.

4) When is VBAC contraindicated?

Planned VBAC is strongly discouraged in the following cases:

  • Three or more previous caesarean deliveries. See below in case you have two previous C-sections.
  • The uterus has ruptured during a previous labor, as this increases considerably your risk (7 times higher) of a recurrent uterine rupture with the next pregnancy.
  • The previous caesarean section was “classical”.  In the vast majority of women, the uterus is cut horizontally, in its lower segment. This is called a low-transverse uterine incision. Rarely, a vertical incision in the upper uterus is required, this is known as a “classical” incision. Occasionally, a J- or T-shaped cut is performed. In both cases of vertical and J/T-shaped incision there is higher risk for uterine rupture. Therefore, it is very important to know which incision was performed in your previous C-section. You should note that the type of scar on your skin does not necessarily match the one on your uterus.
  • A previous uterine surgery, such as fibroid removal (myomectomy), as this increases the risk of uterine rupture.
  • There is other pregnancy complications that requires a C-section.There are certain absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. placenta previa)
  • Breech presentation (the baby comes with buttocks and/or feet first) or other abnormal presentations.
  • Multiple pregnancies (twins or more).


5) What factors reduce my changes of having a successful VBAC?

In general, the chances of success are lower in the following situations:

  • The reason for the previous c-section is likely to be problem this time around. Let’s say that a woman who already had a vaginal delivery and then had a c-section because her baby was breech (buttocks or feet first) is much more likely to have a successful VBAC than one who had a previous c-section after achieving full dilation and pushing for three hours, which may signal a narrow basin.
  • Labor is induced (did not start spontaneously).
  • You are older than 40 years old.
  • You are overweight.
  • The baby is big (over 4,000 grams estimated weight, or 8.8 pounds).
  • Advanced gestational age at delivery (more than 40 weeks).
  • Having a short time between pregnancies (less than 19 months).
  • You have preeclampsia (high blood pressure) at the time of delivery.

You should discuss with your practitioner about your individual chance of success and carefully weigh the benefits and the risks.

6) What are the benefits of a VBAC?

C-section is a major abdominal surgery, and as such is associated with certain increased risks as opposed to a vaginal birth. Therefore, a successful VBAC entails:

  • Shorter recovery period
  • Less post-partum pain.
  • Lower risk of infection.
  • Less blood loss, reduced need for a blood transfusion.
  • Less chances of needing an emergency hysterectomy (uterine removal).
  • Lower likelihood of damaging other organs (bladder and bowel).
  • Lower risk of developing a blood clot (thrombosis) in the legs (deep vein thrombosis) or lungs (pulmonary embolism).
  • Reduced risk of pelvic adhesions (internal scar tissue that forms between the organs, which may be responsible for chronic pain, infertility or intestinal obstruction).
  • Decreased chances of breathing problems for your baby. About 4-5% of babies born by planned C-section have breathing problems, compared with 2-3% following VBAC; the risk is  slightly higher if you have a planned caesarean section earlier than 39 weeks. In fact, breathing problems are quite common after caesarean delivery, but usually do not last long.
  • Many women would like to have the experience of vaginal birth, and when successful, VBAC allows this to happen.

If you plan to have more children, VBAC may help you avoid certain health problems linked to multiple cesarean deliveries. In fact, C-section complications, such as haemorrhage, emergency hysterectomy, bowel or bladder injury, adhesion formations are all higher with the increased number of cesarean deliveries. Moreover, every C-section you have raises your risk in future pregnancies of placenta complications, such as placenta previa (the placenta lyes low and covers the cervix) and placenta accreta (the placenta implants too deeply and doesn’t separate properly at delivery). Both conditions can result in life-threatening bleeding and a hysterectomy. If you know that you want more children, this may figure into your decision.

7) What are the risks of a VBAC?

  • One of the most feared complications of a VBAC is the possibility of uterine rupture, that is, the scar of the uterus tears or separates. Even if you’re a good candidate for a VBAC, there is a 0.7% risk (that is, 7 out of 1000 woman undergoing a VBAC) that your uterus will rupture at the site of your C-section incision. If this happens, it may result in severe blood loss for you, eventually life-threatening, and possibly oxygen deprivation for your baby, which may result in brain damage (in 8 out of 10,000 cases) or even death (in 2-3 out of 10,000 cases). While this risk is very small overall, it is higher as compared to a scheduled C-section.
  • Regardless of uterine rupture, VBAC carries in increased risk of long-term neurological damage or even death. Again, the risk is very small, but is higher in women who undergo an unsuccessful VBAC than in women who have a successful vaginal delivery or a scheduled C-section.
  • If you end up being unable to deliver vaginally, you could endure hours of labor only to have an unplanned C-section. This may be very frustrating for certain women, as their expectations for a vaginal birth are not fulfilled.
  • You may need an assisted vaginal birth using ventouse or forceps, which may lead to increased risk of having a tear involving the muscle that controls the anus or rectum (third or fourth degree tear).
  • You may need to have an emergency C-section during labour. This happens in 25% of women. An emergency cesarean carries more risks than a planned C-section. The most common reasons for an emergency caesarean section are if your labour slows or if there is a concern for the wellbeing of your baby.

You should note that while a successful VBAC is less risky than a scheduled repeat C-section, an unsuccessful VBAC requiring a C-section after the onset of labor carries more risk than a scheduled C-section. And the risk of complications is even higher if you end up needing an emergency cesarean.

8) Can I have a VBAC if I have two prior C-sections?

According to the American (ACOG) and British (RCOG) guidelines, women who have had two prior lower segment caesarean deliveries may be offered VBAC after careful counselling. Nonetheless, they should be aware that the risk of uterine rupture is increased up to 5 times (0,9 to 3,7%).

VBAC after 2 previous C-sections is highly controversial, and may not be acceptable for certain physicians or institutions.

9) What to expect during a VBAC 

  • VBAC should take place in a hospital or maternity that can manage situations that threaten the life of the woman or her fetus, and should NOT be attempted at home.
  • You should meet all the criteria, and have none of the contraindications for VBAC above-mentioned.
  • Factors that may reduce or increase the likelihood of success will be thoroughly discussed, and are different for each woman and each pregnancy.
  • Best candidates for VBAC are those women whose labor starts spontaneously, as induced labor (started with drugs or other methods) reduces the chances of a successful vaginal delivery and carries 3 times higher risk of complications.
  • You will be advised to present yourself at the hospital at the earliest sign of labour for careful assessment.
  • Your baby’s heartbeat will be monitored continuously during labour; this is to ensure your baby’s wellbeing, since changes in the heartbeat pattern can be an early sign of problems with your previous caesarean scar.
  • An intravenous (IV) line is indispensable in order to promptly manage any eventual complication.
  • You’ll have to refrain from eating anything during labor in case you require an emergency c-section later.
  • You can choose various options for pain relief, including an epidural.
  • The following signs may be indicators of uterine rupture, and warrant an emergency C-section:
    • Persistent fetal bradycardia (the baby’s heart rate drops; this is the commonest sign of uterine rupture).
    • Vaginal bleeding.
    • Uterine scar tenderness.
    • Pain between contractions.
    • Cessation of contractions.
    • Pain “breaking through” the epidural analgesia, or excessive epidural requirements.
    • Palpation of fetal parts outside the uterus.
    • Haematuria (blood in the urine).

It is important that you understand that uterine scar rupture may be silent, and that even an emergency C-section may not prevent serious complications, both for you and your baby.

In conclusion:

  • Successful VBAC has the fewest complications.
  • The greatest risk of adverse outcomes associated with VBAC occurs when a VBAC results in an emergency caesarean section.
  • It is often impossible to predict who will be able to have a successful VBAC and who require a repeat C-section.
  • Spontaneous (not induced) VBAC has a 1:150 risk of uterine rupture.
  • Uterine rupture is a rare but potentially life-threatening condition, both for the mother and her baby.
  • Even an immediate emergency C-section may not prevent serious complications, both for the mother and her baby.
  • The absolute risk of severe fetal problems and death associated with VBAC are very low, but higher than for planned C-section.
  • Babies born via planned C-section have increased risk of neonatal respiratory problems, which are usually short-lived.
  • Planned C-section is associated with an increased risk of placenta praevia/accreta complicating any future pregnancies; other complications such as pelvic adhesions are higher as the number of C-sections increases.

VBACs are controversial, and it may be challenging to decide whether is the best choice for you. Find a practitioner willing to support VBAC, discuss with him/her your options. Give yourself plenty of time to inform yourself and consider carefully the pros and cons of each option.

References

  1. The American College of Obstetricians and Gynecologists (ACOG) – Vaginal Birth After Cesarean Delivery FAQ 070, December 2017 (For patients)
  2. ACOG Practice Bulletin Number 184 – Vaginal Birth After Cesarean Delivery, November 2017
  3. Royal College of Obstetricians & Gynaecologists (RCOG) –  Birth options after previous caesarean section – July 2016 (For patients)
  4. Royal College of Obstetricians & Gynaecologists (RCOG) –  Birth After Previous Caesarean Birth – Green-top Guideline No. 45, October 2015
  5. National Health System (NHS) UK – Clinical Guideline for: The Management of Vaginal Birth After Caesarean (VBAC). July 2016

Photo credits

1.Parents.com; 2.EvolutionaryParenting.com; 3.goldengateobgyn.org; 4.Healthymummy.com; 5.YouTube.com; 6.Scarymummy.com; 7.geoscripts.meredith.services

EGG DONATION IN GREECE: ALL YOU NEED TO KNOW

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Assisted reproduction techniques help thousands of couples with infertility to circumvent their problem and become parents. Nevertheless, when it is not possible for a woman to conceive due to poor egg quality or from having no eggs at all, she may still become pregnant by using eggs from a donor.

The first pregnancy with egg donation was reported in 1983, and ever since, more and more women are choosing this procedure to achieve their dream of having children. The main reason for this trend is that women are increasingly postponing childbearing until later on in life, when their fertility is often reduced; another reason is that over the years, the process has become highly successful due to recent technologies advances and improved freezing techniques.

What is egg donation?

Egg donation is a form of assisted reproduction by which a woman donates her ova to enable another woman to conceive. These oocytes are fertilized by the recipient’s husband sperm, or alternatively by a donor sperm.

The resulting embryos are transferred into the recipient uterus, which has been adequately prepared to receive them. The difference with routine in vitro fertilization (IVF) is that the egg donor is not the recipient; that is, they are two different women.

If pregnancy occurs, the recipient will have a biological but not a genetic relationship to the child, and her partner (if he provided the sperm) will be both biologically and genetically related.

What are the indications for egg donation?

Egg donation may be considered in the following situations:

  • Premature ovarian insufficiency: a condition in which menopause begins earlier than usual, usually before the age of 40 years old. In most cases the cause is unknown, but it may be the result of certain diseases, chemotherapy, radiotherapy or surgical removal of the ovaries. Egg donation is also suitable for women who were born without ovaries.
  • Low ovarian reserve: when there is a decrease in the number of eggs, resulting in reduced chances of pregnancy. Generally, this is due to advanced reproductive age, as the number of oocytes -and therefore fertility- decreases rapidly after the age of 35-40 years old.
  • Genetically transmitted diseases: women affected by, or carriers of a significant genetic disease who would prefer not to pass this disease on to their child.
  • Previous history of failure with IVF: especially when egg quality seems to be the problem.

Who are the egg donors?

1) Anonymous, voluntary donors: According to the Greek law, candidate egg donors are covered by anonymity and are required to sign a specific consent for the donation of their genetic material. In order to accept a woman into an egg donation program she should meet the following requirements:

  • Age between 18 and 35 years old.
  • She should be healthy, non-smoker, with no personal or family history of genetic diseases.

By law, the donor receives financial compensation only for the loss of working days, travel and other expenses incurred during the treatment cycle in which she participates. In any case, egg donation is an altruistic, anonymous and voluntary act.

2) Egg sharing: Women undergoing IVF may agree to donate their surplus oocytes to other women with infertility.

3) Known donor: a person who is known to the recipient, usually a close relative of friend. According to the Greek law, oocyte donation is an anonymous procedure, that is, the donor has no access to the child born, nor the recipient to the donor. Therefore, in Greece the donation of ova to known persons is forbidden by law.

Evaluation of the egg donor


Each candidate donor, after being fully informed about the egg donation program, completes a thorough questionnaire on her family, medical and psychological history. In addition, she is the subject of a series of exams to determine whether her health is in good condition and she can respond properly to the hormonal therapy.

The evaluation involves a comprehensive physical and gynecological examination, as well as the assessment of her psychological and mental status, her genetic material and reproductive system.

In addition, donors undergo the following laboratory testing:

  • Blood type and Rhesus
  • Hepatitis B & C
  • HIV 1 & 2
  • Syphilis
  • Hemoglobin electrophoresis
  • Sickle cell trait testing
  • Cystic fibrosis (CF) mutation
  • Fragile X testing
  • Conventional karyotype. It is also possible to a perform a molecular karyotype, upon request of the recipient couple.

A donor is ineligible if either the questionnaire or the screening tests indicate the presence of risk factors, or clinical evidence of an infectious or genetic disease.

Evaluation of the recipient couple 


Adequate screening and preparation of the recipient couple are essential for the success of an egg donation program.

According to the Greek law, a woman is considered suitable to receive oocytes when her uterus has normal morphology and functionality and has not exceeded the age of 50 years.

The evaluation of the recipient couple is similar to that of couples undergoing routine IVF. First, the physician obtains a thorough medical history from both partners.

The assessment of the woman includes an in-depth physical and gynecological examination, a detailed pelvic ultrasound and laboratory testing. Briefly, the ovarian function, her blood group, and exposure to certain infections are examined. In addition, a Pap smear test and cultures for certain microbes (Neisseria gonorrhoeae, Chlamydia trachomatis, etc) are obtained.

In some cases, the uterine cavity is evaluated with hysterosalpingography (HSG), sonohysterography or hysteroscopy. If the woman is over 45 years old, a more thorough assessment of her cardiac function, pregnancy-induced hypertension and gestational diabetes risk are recommended. The effect of advanced maternal age on pregnancy will be discussed extensively, as well as any medical conditions that may affect pregnancy.

An embryo transfer trial before the actual procedure (“mock” embryo transfer) is strongly recommended. It allows to determine the best way to place the embryos into the uterus, and ensures that there are no unexpected obstacles along the way. Sometimes the cervix is very narrow and hinders the transfer of the embryos into the uterus; this may result in significantly reduced chances of pregnancy. In case of a narrow or distorted cervical canal, a cervical dilation may be recommended.

A treatment trial in a previous cycle with the same medications used for the endometrial preparations is proposed when possible, in order to assess the uterine response to hormone therapy.

The male assessment includes a semen analysis, blood group and genetic testing, among other exams.

According to the Greek law, the recipient couple should be tested for syphilis, hepatitis B and C, HIV-1 and HIV-2 within the six months preceding the treatment cycle.

The procedure

Preparation of the donor for egg retrieval 

The donor follows the procedure of a standard IVF. Initially, she undergoes ovarian stimulation, that is, she receives a combination of hormonal medications in order to achieve the development of a sufficient number of oocytes within the ovaries; egg development is monitored by ultrasound and blood exams at regular intervals. When the oocytes are at the appropriate size, ovulation is triggered by an injection of human chorionic gonadotropin (hCG). Oocyte retrieval, scheduled approximately 34-36 hours after hCG administration, entails the use of a needle which is inserted through the vagina into the ovaries, whereby the eggs are aspirated under ultrasound guidance. The procedure is carried out under a mild sedation.

The ova obtained are evaluated for their maturity and then fertilized with the partner’s sperm, which has been processed in the laboratory. Donor sperm may be also utilized when indicated.

The male partner should provide the semen sample the day of the donor’s egg retrieval. Alternatively, if the presence of the partner is not possible on that day, the semen can be cryopreserved (frozen) at an earlier time.

Preparation of the recipient for embryo transfer

In order for the embryos to implant into the recipient’s uterus, the endometrium (uterine lining) must be prepared and synchronized with the donor cycle.

There are numerous protocols for endometrial preparation. Briefly, women who still have menstrual period may receive an injectable medication for temporary suppression of the ovarian function. When the donor starts ovarian stimulation, the recipient receives a hormone called estradiol to achieve endometrial growth. Estradiol can be administered orally or through a transdermal patch. Ultrasound assessment of endometrial thickness -and occasionally blood tests- are performed during this period. On the day after the donor receives hCG, the recipient begins treatment with progesterone. Progesterone causes endometrial maturational changes that allow the embryo to implant. Progesterone can be administered by intramuscular injection, vaginally or orally. Besides estradiol and progesterone, other medications may be prescribed if required.

The embryos are transferred into the recipient’s uterus, usually within three to five days after fertilization of the eggs in the laboratory. Embryo transfer is done using a thin catheter inserted through the cervix into the uterus. If the recipient couple has extra embryos, they will be cryopreserved (frozen). Thus, it is possible to transfer these embryos at a later time without the need for another egg donation.

Hormonal therapy with estradiol and progesterone continues until the recipient takes a blood pregnancy test (β hCG). If the test is positive, the hormones are continued during the first trimester of pregnancy.

Success rates with egg donation

Since egg donors are young and healthy women, success rates are higher than those obtained with conventional IVF. The age of the recipient does not seem to affect the success of the procedure. According to data from the National Agency of Medically Assisted Reproduction, the pregnancy rate with egg donation in Greece is 54%.

Nevertheless, the greater the number of attempts with donor-egg IVF, the higher the odds of success. Thus, it is estimated that the success rates after the third attempt reach almost 90% in most cases.

Many factors play an important role in the success of the procedure: adequate evaluation and preparation of both donors and recipients, optimal synchronization between them, high laboratory standards and well-trained scientific staff, will all have a positive impact on pregnancy rates in an egg donation program.

Risks of egg donation 

1) For the donor:

Egg donation is a very safe procedure. Nevertheless, it is not entirely risk-free. Medicines taken to stimulate the ovaries, oocyte retrieval and the anesthesia required are all possible sources of complications. Briefly, the side effects of medications are usually mild, as one of the most feared complications in assisted reproduction, ovarian hyperstimulation syndrome is very rare in these cases. The remaining risks are estimated as follows: anesthesia risks: 1 / 10,000; risk of severe bleeding from oocyte retrieval: 1 / 2,500; risk of infection: less than 1/500.

It should be noted that the fertility of women who become egg donors is in no way affected. In fact, the eggs donated would have been otherwise discarded by their bodies.

2) For the recipient:

The possibility a donor transmits an infectious disease to the recipient is virtually non-existent, provided that proper evaluation of the egg donor has been performed, as dictated by the Greek law.

The most common risk for the recipient is the occurrence of a multiple pregnancy (twins) if more than one embryo is transferred. In any case, in egg donation cycles, the transfer of more than two embryos is strictly forbidden by the Greek law. If the couple is opposed to the possibility of a twin pregnancy, then only one embryo may be transferred (single embryo transfer, SET).

Pregnancy complication risk in recipiens with advanced age should be assessed individually for each case.

3) For the child:

To date, thousands of children have been born with this procedure, and the available data is reassuring, and equivalent to that of conventional IVF: the rate of birth defects is the same as the general population.

THE LEGISLATION IN GREECE 

On Egg Donation

  • Egg donation is an altruistic act, voluntary and with no financial benefit. Donors are compensated only for the working days they lose as part of the donation process and their travel expenses.
  • Donation of ova and sperm is allowed in Greece provided donor anonymity is ensured.
  • Egg donation is not allowed to women over 50 years old.
  • Donors must sign an oocyte concession consent.
  • Recipients sign a document stating that they are married and accept to undergo in vitro fertilization with egg donation. If they are not married, they should sign a notary act stating that they wish to undego IVF using the egg donation method.

On Assisted Reproduction

On January 27 2005, the law 3305/2005 on the application of assisted reproduction techniques was reported.

The Greek law on medically assisted reproduction is one of Europe’s most flexible. It safeguards the couple who wants to have a child based on medical, biological and bioethical principles. Its main purpose is, ultimately, the protection of the child to be born.

Basic principles of the current legislation

Some of the key points of the in-force law are the following:

1) Assisted reproduction methods are legal and allowed for women up to the age of 50 years, as this is considered the limit for natural conception.

2) The donation of ova and sperm is permitted, but the consent of the spouse or partner is also required.

3) Pre-implantation genetic diagnosis is allowed with the purpose of diagnosing whether the resulting embryos are carriers of genetic diseases. Consent of the concerned individuals is required.

4) Sex selection is prohibited unless a serious sex-related hereditary disease is avoided.

5) Cloning for reproductive purposes is prohibited.

6) Cryopreservation of genetic material or fertilized eggs is permitted.

7) The use of a gestational carrier (surrogacy) is allowed. A surrogate is a woman who carries a pregnancy for another couple or woman, who wishes to have a child but is unable to get pregnant for medical reasons. The surrogate woman must undergo medical and psychological examination. There should be no financial transaction other than the costs resulting from pregnancy exams, loss of work, etc. The procedure requires a special permit from a judge.

8) Assisted Reproduction Units are established and operate with the permission of the competent Authority, which shall give its agreement and verify that the legal requirements are met. For any violation, it sets administrative and criminal penalties.

9) The law sets age limits for sperm donors (younger than 40 years old) and egg donors (younger than 35 years).

10) Single women are allowed to conceive with assisted reproduction.

11) Donors must undergo clinical and laboratory testing and are not admitted to donation programs if they suffer from hereditary, genetic or infectious diseases. The use of fresh semen from donor is not permitted; only frozen semen may be used.

 

More info at gofertile.eu

FACT OR MYTH? TRUTHS, HALF-TRUTHS AND MISCONCEPTIONS ABOUT THE BIRTH CONTROL PILL

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When introduced in the 1960s, the birth control pill became a symbol of female liberation

The contraceptive pill made its appearance more than 50 years ago. Emerging during a period of social and political upheaval, it  gave women the possibility to choose how and when to have a family, and to enjoy their sexual life. Thus, it is regarded as one of the greatest scientific inventions of the 20th century and one of the utmost symbols of female liberation.

From the very beginning though, this revolutionary method of contraception has been a source of controversy: some people thought it would create “a society with unbridled sexuality likely to undermine the foundations of the family”; others feared harmful effects and the birth abnormal children.

Fifty years later, the pill remains even more controversial than before and -paradoxically enough- more and more women are “liberating” from their “liberator”: the pill’s popularity is on the decline, a trend observed in many countries. The reasons behind this shift are many, but fear of side effects seems to the most recurrent. Arguably the web and social media, with the spread of countless personal stories with dramatic headlines and numerous pill scares have influenced women’s perception on the pill’s risks. But are these fears legitimate? How dangerous is the contraceptive pill? What is true and what is false?

Let’s see what science answers to the pill’s most common assumptions…

1) The pill harms your future fertility

FALSE. All scientific evidence agrees that hormonal contraceptives do not make women sterile in the long run. Sometimes it may take three to six cycles for fertility to fully return, but within a year after going off the pill, women trying to conceive are as likely to get pregnant (80%) as those who were never on the pill. In certain cases of long-term use, there may be even increased likelihood of pregnancy within 6-12 months after discontinuing it.

Moreover, hormonal birth control may preserve fertility by offering protection against pelvic inflammatory disease, endometriosis, ectopic pregnancy, ovarian cysts, ovarian and uterine cancer (see below).

2) The pill reduces sexual desire

MOSTLY FALSE. In most cases, birth control pills don’t affect libido (sexual desire): out of 10 women taking the pill, 7  experience no change in their sex drive, 2 observe increased libido, and 1 will feel less desire.

Recently, a study provided evidence that the pill does not kill desire: contextual factors, such as the relationship with the partner, stress, fatigue, family problems, recent childbirth, have a more considerable impact on sexual drive than the type of contraception used.

3) The pill makes you fat

MOSTLY FALSE. A recent extensive review study showed no evidence that birth control pills cause weight gain in most women. Although some persons may gain some weight when they start taking it, it’s often a temporary side effect due to fluid retention, not extra fat. And, like most side effects, it usually goes away within 2 to 3 months.

A woman’s weight may fluctuate naturally due to changes in age or life circumstances. Because changes in weight are common, many times they will wrongly attribute their weight gain or loss to the use of the pill.

4) The pill increases the risk of blood clots

TRUE. From the 1960s it is known that combined contraceptives pills may increase the risk of venous thrombosis, that is, a blood clot obstructing a vein, a serious and potentially life-threatening complication. Combined contraceptives contain synthetic versions of the hormones estrogen and progesterone. It is the estrogen that is mostly associated with the formation of blood clots, but the latest years it became evident that the type of progesterone also influences the risk. Indeed, the most “modern” formulations of the combined pill – the so-called third and fourth generation – containing the synthetic progesterones gestodene, desogestrel and drospirenone are associated with higher risk of thrombosis.

The European Medicines Agency (EMA) provides the following values ​​for the incidence (frequency) of deep vein thrombosis in 100,000 women of childbearing age:

  • 5 to 10 in non-pregnant women who do not use oral contraceptives,
  • 20 for women using a second generation combination pill (containing levonorgestrel),
  • 40 among women taking third and fourth generation pill.

Factors that may increase the risk of thrombosis are smoking, high blood pressure, obesity, age over 35 years, and a family or personal history of vascular accidents.

Although these figures may look scary, they should be analyzed in perspective:

  • In absence of risk factors, the absolute risk of thrombosis is very low.
  • The mortality rate of clotting events is about 1%. Thus, the odds of dying as a result of having a clot attributable to the use of the pill would be about 2 to 4 per million women.
  • The risk remains considerably lower than that related to pregnancy and birth (estimated  1 in 1000- 2000 deliveries).
  • Indicative of this is the 1995 pill scare in the UK, when a warning was issued on the increased risk of thrombosis related to third generation pills. This led many women coming off the pill, resulting in 12,400 additional births and a 9% abortions rise in 1996.

Overall, the odds of having a thrombotic episode related to the pill are very low, in particular with combined pills containing low dose of estrogen (30 or less micrograms) and old-generation progesterone (such as levonorgestrel).

The minipill, also known as the progestin-only birth control pill, is a form of oral contraception that does not contain estrogen, and its progestin dose is lower than that in the combined formulation. Although its efficacy is slightly reduced as compared to the combined pill, the minipill does not increase the risk of venous thromboembolism or arterial thrombotic accidents (see below).

5) The pill increases the risk of heart attack and stroke

TRUE. An extensive review study looking at arterial vascular accidents attributed to the pill (myocardial infarction and ischemic stroke) showed that the overall risk of arterial thrombosis was 60% increased in women using oral contraceptive pills compared to non-users. Unlike venous thrombosis, the risk did not vary according to the type of synthetic progesterone. However, it was twice as high in women taking pills with higher doses of estrogen (the older formulations of contraceptive pills).

Therefore, the combined pill containing levonorgestrel and low dose estrogen (no more than 30 µg) is the safest oral form of hormonal contraception. The minipill may also be considered in high risk women (see above).

6) A woman should not take the pill if she smokes

TRUE.  There is some evidence that smoking may decrease the effectiveness of hormonal birth control. When taking the pill, smokers experience more frequently irregular bleeding than non-smokers; this could signal that the efficacy of the pill is lowered, but more research needs to be conducted to better understand the effect of smoking on the pill’s action.

But what we do know for sure is that smokers who take combined oral contraceptives have increased risk of venous thrombosis and heart disease (see above). This risk is higher for women that smoke more than 15 cigarettes/day, are older than 35 years old or take formulations with high estrogen levels.

If you are under 35 years old and smoke, you should be extremely careful about using the pill, and the decision to take it should be individualized considering other risk factors such as personal and familiar history of high blood pressure, high cholesterol or heart disease. Smokers aged 35 or over should not take the combined contraceptive pill.

If you smoke you may opt for the mini pill, which does not seem to increase the risk of venous thromboembolism or arterial thrombotic accidents; otherwise you should discuss with your doctor about another contraceptive method, such as the intra-uterine device (IUD).

7) The pill causes mood changes and depression

DEBATABLE. Most studies have shown no effect of the pill on depression and mood changes; some studies have even found a protective effect. In 2016, an extensive review on hormonal contraception and mood changes confirmed the existing evidence, and concluded that “… negative mood changes are infrequent and combined hormonal contraception may be prescribed with confidence”.

However, a recent publication came to challenge this assertion. Danish researchers went through the health records of more than a million women using hormonal contraception. They found that those on the combined pill were 23% more likely to be prescribed an antidepressant than those not on hormonal contraception. For those on the minipill (and on other progesterone-only methods, including the hormonal IUD), the figure rose to 34%. It increased even further, to 80% more likely, for girls 15 to 19 years old on the combined pill.

There are a few important points to consider about these results:

  • Depression is a complex condition whose cause is still poorly understood. Several factors seem to play a role: genetic, environmental, psychological and social. Therefore, it is very difficult to evaluate the link between depression and hormonal contraception.
  • The Danish study does not prove that hormones are responsible for the depression – “association” does not necessarily translate into “causation”.
  • The risk of being diagnosed with depression peaks at two to three months of contraceptive use, but then begins to fall.
  •  Even if these findings are confirmed, the number of affected women remains small: 2.2 out of 100 women who use hormonal birth control develop depression, compared to 1.7 out of 100 non-users.

In conclusion, the pill may have impact on some women’s emotions, but further research is needed to establish whether hormonal contraceptives are indeed the cause of depression and mood changes.

8) The pill is 100% reliable

FALSE. Theoretically, with perfect use, the pill is 99.7% effective at preventing unwanted pregnancy. However, there are many factors that may interfere with the pill’s level of effectiveness: forgetting to take it, not taking it as directed, certain medications or medical problems…Therefore, when it comes to real life, the pill is about 92% effective: about 8 in 100 women using the combined pill will get pregnant in a year.

In any case, the birth control pill remains one of the most reliable contraceptive methods.

9) If you take the pill you don’t need the condom

FALSE. A survey conducted in France showed that “…one in ten young women 15 to 20 years old is not aware that the pill does not protect against HIV and sexually transmitted infections (STI)”. As stated before, the pill is a very good at preventing unwanted pregnancy but it offers no STI protection at all. In fact, the only contraceptive method that protects against sexually transmitted infections is the condom. Read more here.

10) The pill causes cancer

TRUE AND FALSE. The pill seems to increase the risk of certain cancers, but it protects again others. Overall, with the use of oral contraceptives the risk of endometrial and ovarian cancer is reduced, whereas the risk of breast and cervical cancer appears to be increased.

The protective effect on ovarian and endometrial cancer (the lining of the uterus) has been consistently demonstrated in many studies. This effect increases with the length of time oral contraceptives are used and continues for many years after a woman stops using the pill.

Long-term use of oral contraceptives is associated with an increased risk of cervical cancer. This correlation is not completely understood, as virtually all cervical cancers are caused by certain types of human papillomavirus (HPV). It has been suggested that women who use the pill may be less likely to use condoms, therefore increasing their risk of being exposed to HPV.

An extensive analysis of more than 70 studies suggested an increased risk of breast cancer among current and recent users of hormonal contraception. The risk was highest for women who started using oral contraceptives as teenagers. However, by 10 years after cessation of use, their risk was similar to that in women who had never used it.

Since most studies so far have evaluated birth control pill older formulations with higher doses of hormones, until recently it was assumed that the newer-generation pills available now would be safer regarding breast cancer risk. Yet a new study from Denmark found that even with the current pills, hormonal contraception users experienced a 20% increase in the risk of breast cancer compared to non-users; the odds rose among women who used hormones for more than 10 years. The risk was similar in magnitude to that of older pill types.

Whether oral contraceptive use increases the risk of liver cancer is not clear: while some studies found more cases of hepatocellular carcinoma ( a type of liver cancer) in women who took the pill for more than 5 years, others did not confirm this correlation.

Hormonal contraception seems to have a protective effect on colo-rectal (bowel) cancer, but this has not been yet consistently proven.

Since the pill seems to reduce the frequency of certain cancers and increase the risk of others, an interesting question arises: Does the pill increase the overall risk of cancer? The answer is NO. A recently published study provided epidemiological data on more than 40,000 women followed for more than 40 years. The results showed that users of oral contraceptives are protected from colo-rectal, endometrial, and ovarian cancer; this beneficial effect lasts for many years after stopping the pill. An increased breast and cervical cancer risk was seen in current and recent users, which appears to be lost within approximately 5 years of stopping oral contraception, with no evidence of either cancer recurring at increased risk in ever users with time. These results are reassuring and provide strong evidence that most women do not expose themselves to long-term cancer harm if they choose to use oral contraception; indeed, many are likely to be protected.

11) The pill has many bothersome side effects

TRUE AND FALSE. Some women refuse to take the pill because they fear certain annoying symptoms. Indeed, the birth control pill is a medication, and as such, it has possible side effects.

The most common adverse reactions associated with use of combined contraceptives include changes in bleeding patterns, nausea, breast tenderness, headaches, missed periods, vaginal discharge and visual changes with contact lenses; few women may also experience changes in sexual desire and mood changes, or temporary weight gain related to fluid retention (see above). In general, these side effects are not a sign of illness, and usually stop within the first few months of using the pill.

While some women may experience bothersome symptoms, the pill provides important non-contraceptive health benefits:

  • Decreased risk of certain cancers (see above)
  • Improved bone mineral density (in older women)
  • Protection against pelvic inflammatory disease
  • Prevention of ovarian cysts
  • Reduction of menstrual bleeding problems
  • Prevention of menstrual migraines (with non-stop formulations)
  • Protection against iron-deficiency anemia
  • Reduction of ovulation pain
  • Treatment of acne
  • Treatment of bleeding from fibroids
  • Treatment of dysmenorrhea (painful periods)
  • Treatment of excess hair on face or body
  • Treatment of premenstrual syndrome (PMS)
  • Reduction of endometriosis symptoms
  • Reduction of polycystic ovarian syndrome symptoms
  • Induction of amenorrhea for lifestyle considerations (when you need to stop your period for a while; you can also advance or delay your period with the pill)

So, how dangerous is the pill?

There is no perfect contraception method. I wish there were. And it is true that hormonal contraception, like any other medication, may have annoying side effects and serious health risks. Does it mean that no one should take the pill? Of course not!

We should keep in mind that severe risks are very rare and most bothersome symptoms are short-lived; in addition, the pill offers many non-contraceptive health benefits. But when discussing about the pill’s pros and cons, sometimes we forget a very important issue: the birth control pill is one of the most effective contraceptive methods. And effective birth control prevents from unwanted pregnancy, which may have not only devastating psychological consequences, but may also lead to severe physical harm.

Therefore, the potential problems of the birth control pill should be analyzed in perspective: we shouldn’t just pay attention to downsides, forgetting to place them in context with the upsides. Every woman considering taking the pill should thoroughly discuss with her healthcare provider not only the possible risks, but also its significant benefits, which for many women will be greater than the harms.

 

Photo credits

Heading: vintag.es; 1: thebump.com; 2: breakingmuscle.com; 3: thejewel.com; 4: health.harvard.edu; 5: newhealthadvisor.com; 6: pinterest.com; 7: pinterest.com; 8: pinterest.com; 9: blog.path.org; 10: purelyb.com; 11: buzzfeed.com; Conclusion: bigthink.com

PREGNANCY SYMPTOMS: WHAT TO EXPECT THE THIRD TRIMESTER

Posted in Health, Pregnancy by

Almost there! The third trimester is full of expectation, as the moment you will hold the baby in your arms approaches. But the excitement comes with a lot of uncomfortable symptoms…

The third trimester lasts from the 7th through the 9th month of pregnancy, that is, from week 28 till the moment you give birth, usually around week 40. This period can be challenging and tiring, as your womb grows and creates a lot of discomfort. Most of the symptoms you will experience are those that appeared during the second trimester, although they will be more intense now: back pain, leg swelling, sleep problems, itchy skin…

But keep a positive attitude! Read this list with the most common symptoms of the last three months of pregnancy and learn what you can do to relieve them. We will focus on the symptoms that appear during the third trimester, or that are somewhat different now. This is what you can expect:

1) Abdominal muscle separation

As your uterus grows, it pushes against the abdominal wall and stretches its muscles (the ‘six pack’ muscles), which will start separating in the middle and cause a bulge, or gap  in the middle of the abdomen. This condition, called diastasis recti abdominis, is more evident when the abdominal muscles are tense, such as during coughing or getting up from a lying down position. Diastasis recti can cause lower back pain, making it difficult to carry out certain activities, such as lifting objects.

Not all women develop abdominal muscle separation; you are more likely to get it if you are older than 35 years-old, have a multiple pregnancy or carry a large baby, or have repeated pregnancies.

What can you do about it:

  • Muscle separation lessens in the months that follow delivery, although some degree of separation may remain. Certain exercises will help you regain abdominal strength after childbirth.
  • During pregnancy, avoid aggressive abdominal exercises (such as sit-ups), which may provoke or worsen diastasis recti.
  • If abdominal muscle weakness associated with diastasis recti is interfering with your daily activities, seek the advice of your care provider or a specialized physiotherapist, who can indicate certain strength and postural correction exercises.

2) Breast leakage

By the end of pregnancy, you may notice a yellowish fluid leaking from your nipples, and this is normal. This substance, called colostrum, will nourish your baby in the first few days after birth.

While some women leak quite a lot of colostrum, others don’t leak at all. Leaking won’t make any difference to how much milk you will produce once your baby is born.

What can you do about it:

  • If you just leak a few drops, then you don’t need to do anything. But if it bothers you, you may wear nursing pads inside your bra to absorb the milk.
  • You should call your doctor or midwife if the nipple discharge becomes bloodstained.

3) Carpal tunnel syndrome

Tingling, numbness, weakness and pain in the hands during the last trimester are usually caused by a condition called carpal tunnel syndrome (CTS).

CTS is common in pregnancy, and happens due to the fluid retention in the tissues of the wrist, which in turn squeezes a nerve (the median nerve), that runs down to your hand and fingers. Women that keep doing forceful or repetitive hand and finger movements (such as long hours at a computer, or the use of vibrating equipment) may have worse symptoms.

What can you do about it:

CTS usually disappears without treatment after childbirth, when pregnancy-related fluid buildup is relieved. In the meantime, you may try the following:

  • Avoid activities that may be causing symptoms.
  • Wear a wrist splint to keep your wrist straight, especially at night, when the symptoms can be more bothersome.
  • Do exercises to stretch and strengthen the muscles in the hand and arm.
  • Alternative therapies, such as acupuncture might help relieve hand pain.
  • If nothing works, talk to your doctor, who may prescribe certain medications.
  • Surgery is the last resort treatment, but unless CTS become intolerable, it will be delayed until after birth.

4) Dreams and nightmares

You knew about the sleep problems during pregnancy. But you may get surprised, even disturbed when you start getting frequent and vivid dreams, occasionally nightmares; you may also realize that you remember your dreams more clearly.

The exact reason of these changes in the dream pattern is not clear, but they seem to be related to hormonal and emotional factors, as well as the frequent sleep disruptions that come with pregnancy (read more here).

What can you do about it:

  • If your dreams are just more frequent or more vivid, you will just have to cope with them.
  • However, if you have frequent nightmares, that are too disturbing, don’t let you sleep or cause you intense anxiety, you may consider sharing them with a friend, your doctor, or a therapist.

5) Clumsiness, waddling

You may have noticed that, as pregnancy progresses, you get clumsier: things fall from you hands, you bump into doors, you may accidentally fall down! It is not just you, clumsiness is normal in pregnancy and is related to many factors: you are heavier and your growing womb changes the center of gravity, making it more difficult to move; your “pregnancy brain” makes it harder for you to concentrate on your activities; in addition, a hormone called relaxin relaxes all the joints in your body. Therefore, you won’t have the balance or dexterity you used to have.

The same reasons explain why, at the end of pregnancy, you will start waddling, which in turn will make you even clumsier!

What can you do about it:

Clumsiness is normal and there is not much you can do to prevent it. However, it is important that you take measures to protect yourself -and others- from accidents:

  • Avoid situations where you have a high risk of falling, such as standing on a ladder, using stairs, riding a bicycle, etc.
  • Wear comfortable shoes, that should not be neither too flat or too high (read more here).
  • Pay attention whenever you walk on wet, icy, or uneven surfaces.
  • Avoid gaining too much weight, which will make clumsiness much worse.
  • Call your doctor if, besides clumsy, you feel dizzy or lightheaded, your have blurred vision, headache, or any pain.

6) Emotional changes

As you get closer to childbirth, your anticipation grows, so do your anxiety, fears and concerns! Besides all the hormonal-related emotional changes, you may start getting worried about the delivery itself, as well as all the changes the baby will bring, your role as a parent, etc (see here).

What can you do about it:

  • Stay calm, mild physical activity can help (read here), eat well (here), indulge yourself with a beauty treatment! (here).
  • Taking childbirth classes can help you feel more prepared to face labor and delivery.
  • Discuss your emotions and fears with your doctor or midwife.
  • Sharing your feelings with friends, your partner or other moms-to-be can be very helpful.
  • Nevertheless, if you feel constantly down or overwhelmed, if you have negative or suicidal thoughts, if you can’t go ahead with your daily life you must discuss it with your doctor.

7) Fatigue

Forget the energy you had during the second trimester: fatigue is back! Carrying extra weight, waking up several times during the night to go to the bathroom, and dealing with the anxiety of preparing for a baby can all decrease your energy level.

What can you do about it:

  • Eat healthy, frequent and small meals: it’s a good idea to keep with you healthy snacks that you can grab whenever you feel out of energy.
  • If you work, take regular, small breaks; you may even consider taking a quick nap!
  • Light exercise can make you feel more energetic: walking, swimming or prenatal yoga are good options, but listen to your body! Don’t force yourself.
  • Check with your doctor if you feel extremely tired, so that she/he may do some blood test to rule out anemia or other problems.

8) Forgetfulness (“Pregnancy brain”)

It’s not a myth: intense forgetfulness, known as “pregnancy brain” is a normal symptom of pregnancy, which nevertheless can be very annoying!

It is mostly related to pregnancy hormones, but sleep disturbances and fatigue can make it worse.

What can you do about it:

Don’t worry! Your brain will work normally again after delivery. Well, sort of, as you will have to deal with the sleepless nights while taking care of your baby 😉

In the meantime, these tips may help:

  • Stay organized! Write down what you need to do, technology may help: reminders on your phone or to-do lists in your computer will make it easier.
  • Ask for help: cut down on what you’re responsible for by delegating some jobs to others.
  • Eat well: certain foods may boost your memory: eating plenty of choline-rich foods and DHA-rich foods during pregnancy may help boost your -and your baby’s- brain function.

9) Frequent urination, urinary incontinence

As your baby grows, the pressure on your bladder increases, causing a constant feeling you need to go to pee. This may be worse during the night, because when you lie down, the fluids you retained in your legs and feet during the day make its way back into your bloodstream and eventually into your bladder.

Many women also experience stress urinary incontinence, that is, they lose some urine when they cough, laugh, sneeze, lift heavy objects, or exercise.

What can you do about it:

To reduce frequent urination:

  • Avoid beverages that contain caffein, which has diuretic effect.
  • It’s not a good idea to cut down on fluids, as your body needs plenty of them during pregnancy. Instead, you may reduce fluid intake in the hours before you go to bed.
  • Lean forward when you urinate: this helps empty out your bladder better.

To avoid incontinence:

  • Empty your bladder before exercising.
  • Wear a panty liner to catch any unexpected leakage.
  • Kegel exercises, which strengthen the muscles of the pelvic floor, can also help minimize stress incontinence.

You should inform your doctor or midwife if you feel pain or burning with urination, if your see blood when you wipe or if you feel the urge to pee even when you produce just a few drops at a time. These could be signs of a urinary tract infection (UTI).

10) Heartburn

Another symptom you may have experienced during the first three months of pregnancy, got better during the second trimester but now came back! While the heartburn you experienced during the first trimester was hormone-related, now your enlarged uterus is to blame, as it crowds the abdomen, pushing the stomach acids upward.

What can you do about it:

  • Eat small, frequent meals, don’t eat too much before going to bed.
  • Avoid too spicy, greasy, acidic or sweet foods.
  • Don’t lie flat, sleep with two or more pillows to have your head at a higher level than your body.
  • Call your doctor if you can’t cope with heartburn, who can prescribe you an antiacid medication that is safe for pregnancy.

11) Pelvic pain

Once you’re in your third trimester, you may experience pain and pressure in your pelvic region, as the weight of your growing fetus presses down on certain nerves that run into the legs; for the same reason you may also feel tingling, numbness and pain along the outer thigh; which can be very annoying for some women.

Relaxed pelvic joints are a common cause of pelvic pain: toward the end of your pregnancy the hormone relaxin helps the ligaments become loose in preparation for childbirth. This hormone can also loosen your pelvic joint, and even cause it to separate a bit. It’s common to feel pain near your pubic bone, and you may also feel like your legs are unstable. This is called Symphysis pubic dysfunction (SPD).

Your fetus’s head can also to rub your tailbone, causing tailbone pain and pressure. The condition is called coccydynia and occasionally the pain can be very intense.

Braxton Hicks contractions can also cause pressure and tightening in the pelvis (see below). Constipation also can cause pelvic pain or discomfort (see here).

What can you do about it:

Be patient! Once your baby is born, all the pressure-related symptoms will be gone; in addition, relaxin production will cease and the joints will be firm again, easing your pain. In the meantime:

  • Get plenty of rest;  a change of position that shifts the pelvic pressure away from the nerves responsible for the pain should provide some relief.
  • Avoid lifting heavy things.
  • Warm compresses on the painful the area may ease soreness.
  • Pelvic support belts can help stabilize the area.
  • If the pain is severe enough, ask your doctor about painkillers.

12) Swelling

During the second trimester some women experience some swelling of the ankles and feet. Now, swelling – or edema will be also evident in the hands, face and upper legs.

Swelling is normal and is caused by the excess blood and fluids your body produces to meet the baby’s needs. This extra fluid will also soften the body and help it expand as the baby grows, and prepare the joints and tissues to open more easily during delivery.

Swelling is usually worse with warm weather, if you stand up for long periods of time, if you consume too much caffeine or salty foods, or if your diet is low in potassium.

What can you do about it:

  • Reduce salt intake, avoid adding extra salt to meals.
  • Avoid caffeine consumption.
  • Eat foods high in potassium (such as bananas).
  • Minimize outdoor time when it’s hot.
  • Avoid long periods of standing or sitting.
  • Move regularly your feet, or keep your legs elevated while sitting.
  • Wear comfortable shoes (read more here).
  • Avoid clothes that are tight around your wrists or ankles.
  • Wear supportive tights or stockings.
  • Get plenty of rest, swimming may also help.
  • Use cold compresses on swollen areas.

13) Shortness of breath

As your pregnancy progresses you may start feeling breathless after minimal amounts of physical exertion, or even when talking!

Mild breathlessness is totally normal; during early pregnancy is due to pregnancy hormones, which make you take more and deeper breaths, so that you get additional oxygen for the baby. But in the third trimester, shortness of breath  is mostly related to your expanding uterus putting pressure on the lungs and diaphragm, making it harder to take a deep breath.

What can you do about it:

  • Don’t overdo it with your daily activities or while exercising; when you feel breathless, slow down.
  • Make room for your lungs to take air: stand up straight, don’t sit down for long periods of time, sleep propped up on pillows.
  • If the shortness of breath is severe, you have chest pain or a quick pulse, call your doctor immediately.

14) Vaginal discharge

Increased vaginal secretions are completely normal and start during the first trimester. These discharge helps prevent infections travelling up from the vagina to the womb.Towards the end of pregnancy, the amount of discharge increases and can be confused with urine; close to delivery it may even contain streaks of thick mucus and some blood (this is called “bloody show”; we will discuss more about it in another post). Vaginal secretions should be white or clear, and should not smell unpleasant.

What can you do about it:

  • You may wear panty liners, but do not use tampons.
  • Prefer cotton underwear, avoid string or thongs that may cause intense rubbing, which together with the increased discharge can favor yeast or other infections.
  • Avoid vaginal douching (which is never a good idea, but especially during pregnancy).
  • Pay attention to washes and wipes that could be irritating, increasing your chances of a vaginal infection.
  • Call your doctor or midwife if you have discharge that is yellow, green or foul-smelling, if you have intense itching or burning, symptoms that may show that you have a vaginal infection. Likewise, call your healthcare provider if you have a lot of watery, vaginal discharge, which may signal that you broke your water bag.

15) Vulvar varicose veins

If you feel something “like worms” on your genital area, together with some pressure, swelling of discomfort in the vulva, don’t panic! These are dilated vulvar veins and occur due to the increased blood flow to the area, and the pressure the growing uterus puts on the veins of your lower body. Vulvar varicosities are seen quite often during pregnancy, either alone or with varicose veins of the legs, or hemorrhoids. Long periods of standing, exercise and sex can aggravate them. Occasionally though, they are completely asymptomatic, and the only way you’ll know you have them is because your doctor tells you.

What can you do about it:

Most of the times, vulvar varicosities don’t affect your mode of delivery, and they go away on their own after birth. If they are bothersome, you may try the following:

  • Wear support garment specifically designed for vulvar varicosities.
  • Avoid standing for long periods of time.
  • Swimming helps lift the baby from the pelvis and improves blood flow, relieving your pain.
  • Elevate your hips slightly when lying down to promote circulation; you may place a folded towel beneath your hips.
  • Cold compresses applied to your vulva may ease discomfort.

What else to expect

Baby movements

  • During the second trimester and beginning of the third, your baby has plenty of room in the womb, so most likely you will feel pushing, swirling, twisting, and kicking. But as he/she grows bigger, there is less space for movement; thus probably you won’t get the punches and kicks you were used to. Instead, you’ll feel more wiggles, stretches and turns. Although by the end of pregnancy mobility may be reduced when he gets engaged in the pelvis, the baby should keep moving until the moment he is born.
  • Keep in mind though that the baby is not constantly on the move: there are times when she sleeps. Towards the end of your pregnancy, the baby rests for about 20 minutes at a time, but occasionally the rest periods may be as long as 50 or 75 minutes.
  • Although you may have read or heard you need to count the baby’s kicks, there is a huge variation among babies, and no normal values for baby’s kicks have been determined; therefore, a written record of your baby’s movements is not necessary. Since every baby has a different pattern of waking and sleeping, what is important is to follow up on your baby’s own pattern of movements. If you notice a change in your baby’s pattern of movements, or are worried at any stage, contact your midwife or doctor, so that they can check the baby’s wellbeing with certain specific tests.
  • At some point you may not be sure whether you felt your baby kicking. Keep in mind that you’re more likely to be aware of your baby’s movements when you’re lying down rather than sitting or standing. Therefore, in the doubt, have a snack, particularly something sweet, lie down on your side and wait. You may also try making some noise, or playing loud music. If your baby starts moving around, most likely everything is fine.

But you should contact your midwife or doctor right away if you notice any of the following:

  • You don’t feel several movements while lying on your side for two hours.
  • Your baby doesn’t start to move in response to noise or some other stimulus.
  • There’s a big decrease in your baby’s movements, or a gradual decrease over several days.

Weight gain

  • You should aim for a weight gain of about 1-2 kg per month during your third trimester, but it is not unusual to lose 1 or 2 kilos by the end of pregnancy, as your stomach gets compressed by the baby and you get a feeling of fullness even with small meals. In total, you should have put on about 12 kg (8-16 kg). However, your doctor may recommend that you gain more or less weight if you started out your pregnancy underweight or overweight.
  • It is very important that your weight gain doesn’t exceed these limits, as it may lead to several complications in pregnancy and delivery, such as high blood pressure, gestational diabetes, backache or delivery complications due to increased fetus weight. Not to mention that it will be more difficult to get back to your pre-pregnancy weight…

Braxton Hicks contractions

  • Pressure or tightening in the pelvis that comes and goes could be contractions, but if they’re sporadic and not painful, they’re most likely Braxton Hicks contractions. They usually begin as early as the second trimester; however, they are most commonly experienced in the third trimester.
  • Braxton Hicks are also called “practice contractions” because they are a preparation for labor. They are irregular in intensity and frequency, usually painless or just uncomfortable (although sometimes they may be painful).
  • As Braxton Hicks intensify close to the time of delivery, they are often referred to as “false labor” and they may help prepare the uterus for delivery. These practice contractions may be more intense or frequent when you are too tired, your baby is very active, after sex or due to dehydration.

If you are not sure whether the contractions you feel are true or false labor, try the following:

  • Lie down, get some rest and wait.
  • Take a warm shower or bath.
  • Drink some fluids.

If none of these steps works at any stage of pregnancy; or if you are less that 37 weeks pregnant and you have contractions every 15 minutes or closer that persist over two hours, contact your health care provider.

Signs of Labor

When getting closer to the due date, most certainly you will start wondering: What are the signs labor is coming? How will it feel? and mainly: Will I understand when it’s time? A post answering these questions will follow soon… Stay tuned!

When to worry

Any of these symptoms could be a sign that something is wrong with your pregnancy. Call your doctor right away if you experience any of these symptoms:

  • Severe abdominal pain or cramping
  • Severe nausea or vomiting
  • Bleeding
  • Severe dizziness or fainting
  • Rapid weight gain or intense swelling
  • Fever (unrelated to a cold)
  • Pain or burning during urination
  • Watery vaginal discharge
  • Abundant green, yellow, foul-smelling discharge.

This list of not exhaustive; do not hesitate to contact your healthcare provider for any other symptom you are unsure whether it’s normal or not.

References

  • NICE: Antenatal Care- Routine Care for the Healthy Pregnant Woman. March 2008, UK
  • HAS: Comment mieux informer les femmes enceintes? Avril 2005, France

Photo credits

Intro: Flickr.com; 1) lifeopedia.com; 2) sheknows.com; 3) momjunction.com; 4) answerforsleep.com; 5) health.com; 6) Flickr.com; 7) healthymamabrand.com; 8) healthywomen.org; 9) intimina.com; 10) baby-pedia.com; 11) onlymyhealth.com; 12) medicmagic.net; 13) dnaindia.com; 14) pinterest.com; 15) amazon.com; Baby movements: babycenter.ca; Weight gain: parenthub.com.au; Braxton Hicks: birthcentered.com; When to worry: herb.co

GENITAL HERPES: ALL YOU NEED TO KNOW

Posted in Health by

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Just got diagnosed with genital herpes? You are not alone! You should know that this is a very common condition, and that usually does not cause any serious health problem; however, anxiety, anger or even depression are common feelings every time the virus makes its appearance… And, as with HPV infection, misinformation makes things worse…

In this article you will find the most important facts regarding genital herpes:

Getting to know genital herpes

Genital herpes is a sexually transmitted infection (STI). It is caused by a virus called herpes simplex virus (HSV).

The herpes virus causes painful sores and blisters in the genital area, the anus, the thighs and the buttocks. Sometimes though, the HSV infection causes no symptoms at all; in fact many people are infected with HSV and don’t know it.

There are two types of HSV: HSV-1 and HSV-2. In general, type 2 affects the genital area and HSV-1 is the main cause of cold sores on the mouth or face. However, both types can cause either genital or oral infections.

How common is it?

It is estimated that 1 or 2 in 10 people (10-20%) are infected with the HSV; of those, 80% don’t have any symptoms. Genital herpes is more common in women than in men.

How did I get genital herpes? 

  • As stated before, genital herpes is sexually transmitted: the HSV is spread through direct contact with herpes sores during vaginal, oral or anal sex. The virus can be passed to others during a first infection, with subsequent outbreaks or even if there are no evident sores (see below).
  • The HSV dies quickly away from the body; thus, it’s extremely unlikely -if not impossible- to get genital herpes any other way than by sexual contact, such as from towels, toilet sits or hot tubs.
  • It is possible to get infected by sharing sex toys with a partner who has the virus.
  • Infected people can transmit the virus to other parts of their own bodies (for example if you touch your cold sore on the mouth and then you touch your genitals). This process, known as autoinoculation, although theoretically possible is extremely rare, as our body develops -in most cases- antibodies that protect us against autoinoculation.

Is there any way of knowing how long I’ve had the herpes virus?

When a person is first infected with HSV, symptoms appear about 2–20 days after the virus enters the body.

However, many people have genital herpes for years or even decades without knowing it; that is, the virus remains silent for years, and at some point it becomes symptomatic. This situation can create misunderstanding in a monogamous couple, as a person assumes his/her partner was unfaithful, which may not be true.

What are the symptoms of genital herpes?

The symptoms are different the first time and the recurrent episodes.

–During the first herpes infection you may have:

  • flu-like symptoms: such as fever, chills, muscle aches, fatigue and nausea;
  • swelling of the lymph nodes in the groin;
  • stinging or burning feeling while urinating.
  • sores: initially small, fluid-filled blisters, often grouped in clusters; the area where the sores appear may be swollen and tender. Over a period of days, the sores open and release fluid, become crusted and then heal without leaving scars.

The first outbreak of genital herpes may last 2-4 weeks.

After this first infection, HSV remains in the body for life, within some specific nerve cells. Under certain circumstances (see below), the virus becomes active again: it travels along the nerves back to the genital area, and causes a new outbreak of sores. This is called a recurrence.

-During the recurrent outbreaks the symptoms are:

  • a prodrome: a burning, itching, or tingling sensation in the lower back, buttocks, thighs, or knees;
  • few hours later, sores may appear, usually without fever or swelling in the genital area.

The sores heal more quickly, within 3-7 days in most cases. Also, recurrent outbreaks usually are less painful.

What can trigger herpes outbreaks?

Although it is not always clear why or when the herpes virus will reactivate, certain factors are known to trigger herpes outbreaks. The most common are:

  • Stress: either physical (fatigue) or emotional (depression, anxiety).
  • Weak immune system: caused by sickness, infections, certain medications, etc.
  • Trauma or irritation of the genital area: due to vigorous sex, intense sweating, tight clothes, etc.
  • Exposure to sunlight or ultraviolet light.
  • Hormone fluctuations: some women may notice that outbreaks are more common right before their period, or during pregnancy.
  • Excessive alcohol consumption.
  • Certain foods: some studies (here and here) have found L-arginine, an amino acid present in food can aggravate or cause more frequent herpes outbreaks. Foods high in arginine include: nuts (almonds, walnuts, cashews, peanuts), grains (whole wheat, oats, brown rice, flour products), chocolate and caffeinated beverages.

How often will I have symptoms of genital herpes?

  • The frequency and intensity of the outbreaks vary with each person. While some people have frequent, painful outbreaks with many sores, others have only rare and mild symptoms.
  • Outbreaks usually are most frequent in the first year after infection. For many people, the number of outbreaks decreases over time.

Is genital herpes a serious condition?

  • Genital herpes is not life threatening in itself.
  • One of the biggest problems of genital herpes is the emotional burden. The fact that genital herpes causes painful symptoms, imposes certain limitations on sexual activity, and it’s a lifelong condition may lead to frustration, anxiety, anger and depression (read more here). Don’t hesitate to discuss your feelings with your doctor, who can advise you how to cope with them.
  • Having herpes sores makes it easier for HIV (the virus that causes AIDS) to enter the body. Moreover, having both viruses together may make each one worse.
  • A pregnant woman can pass herpes on to her baby (see below). Therefore, it is very important that you inform your doctor if you are pregnant and have herpes.

How can I find out if I have the herpes virus?  

If you think you have genital herpes you should consult a healthcare provider, who can diagnose herpes by performing a physical exam and certain laboratory tests:

  • If sores are present, a sample of fluid taken from a sore can show if you have the virus and what type of HSV it is. The sample may be tested with several techniques, of which cultures and polymerase chain reaction (PCR) are the most utilized.
  • Blood tests can detect the antibodies our body produces to fight the virus; these tests can show the type of HSV as well.

How is genital herpes treated?

  • There is no cure for genital herpes.
  •  However, antiviral medications – aciclovir, famciclovir and valaciclovir – can reduce the duration of the outbreak and make symptoms less severe. There is some evidence that these drugs also reduce the risk of giving herpes to someone else.
  • When taken on a daily basis, medications can decrease or completely prevent the outbreaks. This is called suppressive therapy and is indicated, among other situations, in persons suffering very frequent outbreaks (usually more than six episodes per year).

How can genital herpes be prevented?

  • Condoms may reduce your risk of passing or getting HSV, but do not provide complete protection: areas of skin that have the virus but are not covered by the condom can spread the infection.
  • Avoid sexual intercourse if you or your partner has visible sores on the genitals; likewise, you shouldn’t receive oral sex from someone who has a sore on the mouth. Also, pay close attention to the prodromic symptoms announcing an outbreak: sexual contact should be avoided from the time you feel the prodrome until a few days after the sores have gone away.  Although less contagious, herpes can be spread even if there are no visible lesions, through a process known as shedding (means that the herpes virus is active on the skin). Unfortunately, there is no way to know when a person is shedding.
  • Wash your hands thoroughly after any possible contact with sores, in order to avoid reinfecting yourself or passing the virus to someone else.
  • In certain cases, suppressive therapy may be proposed to reduce the risk of passing the infection to your partner.
  • Once you got the virus, avoiding known triggers may reduce the frequency and intensity of outbreaks: a good diet, enough rest, stress management may all help.

Will herpes affect my pregnancy or my baby?

  • If you are pregnant and infected with HSV you may pass it to your baby, who may eventually develop a severe infection called neonatal herpes.
  • Although the virus may rarely spread through the placenta, most babies get infected during a vaginal birth, with the passage through the infected birth canal (vagina).
  • This is most likely to occur if you first become infected with HSV during pregnancy and if you have your first outbreak late in pregnancy. It is possible to transmit the virus even if you were infected before pregnancy and you have a recurrent outbreak near delivery, but the risk is much lower.
  •  In certain cases, you may be offered herpes medicine towards the end of your pregnancy to reduce the risk of having any symptoms and passing the virus to your baby.
  • If you have sores or warning signs of an outbreak at the time of delivery, you may need to have a cesarean section to reduce the odds of infecting your baby.

Can I breastfeed my baby if I have the herpes virus?

  • In most cases you will be able to breastfeed; in fact, herpes virus is not transmitted through breast milk.
  • Whether you breastfeed or not, the baby may get infected by touching a sore on your body. To avoid spreading the virus, cover your sores and thoroughly wash your hands before holding your baby. If you have a herpes blister on your breast don’t nurse from that side until the area has completely cleared up.

 

References

Centers for Disease Control and Infections: Genital Herpes: CDC Fact Sheet (USA)

The American College of Obstetricians and Gynecologists: Genital Herpes (USA)

British Association for Sexual Health and HIV: 2014 UK National Guideline for the Management of Anogenital Herpes (UK)

Haute Autorité de Santé: Prise en charge de l’herpès cutanéo-muqueux chez le sujet immunocompétent (France)

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 3)

Posted in Health, Pregnancy by

In the Part 1 of Home birth: Smart choice or risky business? we analyzed the issues of personal satisfaction, maternal safety and baby’s risks. Part 2 dealt with hospital transfers, water birth and the situation in the Netherlands. Check out the last three reasons women choose home birth, and read the final conclusion to decide whether home birth is a clever or a dangerous option…

7) “Home birth is cheap”

home-birth-call-the-midwifeHome birth is cheaper… provided that no transfer is needed and nothing goes wrong

Cost-effectiveness is an important issue in every country with an organized health system. Countries like England or the Netherlands, where the National Health System (NHS) covers the cost of deliveries, have calculated that is cheaper that women deliver at home, avoiding a more expensive hospital admission. For example, the UK NHS “prices” home birth £1066 and birth at a hospital £1631. The economical factor is one of the reasons certain professional organizations support home labor, such as the Royal College of Obstetrics and Gynaecologists (RCOG) which states that: “home birth is the most cost-effective place for delivery”.

But this cost analysis has been challenged, as it does not take in consideration the high transport rates; in fact, a Dutch report calculates a general 3-fold increase of costs in patients transported during labor, when the costs of the midwife, the transport system, the obstetrician and the hospital are included. In addition, the costs derived from the maintenance of an adequate transport system (ambulances and trained staff) should not be neglected. Assuming increased neonatal risks, admissions to the neonatal intensive care unit, the lifetime costs of supporting neurologically disabled children and potentially increased professional liability costs resulting from a complicated home birth can potentially inflate the costs.

Indicative of these unexpected expenses is the article Home birth: What the hell was I thinking?  A journalist from The Guardian went on a mission following a home birth. After managing to deliver her child at home, both the woman and her baby had a complication and needed to be transferred to a hospital. Since the baby and the mother were not allowed to be in the same ambulance, two ambulances were required…

Regarding the costs arising from a private home birth, the situation varies in different countries; in the USA home births are not covered by health insurances, and a couple is expected to pay $1500 to 4500 to the midwife. Hospital births can range from $3,296 to 37,227, although they are usually covered totally or partially by the insurance. Of note: a doctor gets paid about $2500-4000, same as a midwife. Ιn Europe, a couple is expected to pay about 2000-3000 €; recently the Italian newspaper La Stampa published the article Home birth: a 3000 €  luxury that does not convince doctors.

8) “Birth is not a disease, it’s a natural thing. Mother nature can’t go wrong”

home-birth-birth-in-natureUnassisted childbirth: don’t try this at home – or anywhere else

Indeed, Mother nature is great. If you think about it, the whole process of labor and delivery seems to be so perfect, almost magical… But “natural” is not a synonym of “risk-free”. Sometimes Mother nature can play strange games. We may believe we have everything under control, but things may flip just in a second: think earthquakes, or tsunamis… Exactly the same thing applies to childbirth: even when someone seems to be “low risk”, disaster can strike without any warning …

“Childbirth is inherently dangerous,” writes in her blog Amy Tuteur, an American obstetrician gynecologist. “In every time, place and culture, it is one of the leading causes of death of young women. And the day of birth is the most dangerous day in the entire 18 years of childhood”. Finally, she adds: “Why does childbirth seem so safe? Because of modern obstetrics. Modern obstetrics has lowered the neonatal mortality rate 90 per cent and the maternal mortality rate 99 per cent over the past 100 years.”

The absolute confidence in a woman body’s ability to deliver is expressed by supporters of unassisted childbirth (UC), the “hard core” version of home birth, which, although practised already since the 70s, it has lately seen a resurgence. Also known as freebirth, DIY (do-it-yourself) birth, unhindered birth, or unassisted home birth, it refers to women that intentionally deliver without the assistance of a physician or midwife; they may be completely alone (“solo birth”) or assisted by a lay person, such as the spouse, family, friend, or a non-professional birth attendant. There are no data on safety of UC, except that coming from a religious group in Indiana (USA) that found a perinatal mortality rate 2,7 times higher, and a maternal mortality rate 97 times higher than the state average.

Among the most famous UC advocates is Janet Fraser who, ironically, lost her baby after five days of home labour; in spite of that she continues to advocate for freebirth. In fact, UC is not endorsed by any scientific organization, as it is considered too dangerous. According to André Lalonde, executive vice-president of the Society of Obstetricians and Gynaecologists of Canada (SOGC):“Freebirth is the equivalent of playing Russian roulette with your child”.

9) “I have the right to deliver wherever I want”

home-birth-collageA home birth oxymoron: right to privacy vs. social media exposure

This is a very complex issue with ethical and legal connotations, which has originated intense debate among experts. Even scientific organizations differ in their recommendations. For example, The American College of Obstetricians and Gynecologists, until recently opposed to home births, has decided to temper its position: “…hospitals and birthing centers are the safest setting for birth, but it respects the right of a woman to make a medically informed decision about delivery.” On the other side, the American College of Nurse-Midwives (ACNM) maintains that “every family has a right to experience child birth in an environment where human dignity, self-determination, and the family’s cultural context are respected” and that “every woman has a right to an informed choice regarding place of birth and access to safe home birth services”. Let’s analyze the ethical and legal aspects of home birth:

Ethical issues

These are some of the ethicals dilemmas related to home birth:

Mother vs child safety. Although hospital birth seems to increase maternal interventions in all studies (apparently without increasing severe risk), the baby’s safety remains a subject of debate; taking though in consideration all the studies, there seems to be increased risk for the baby. Let’s take for example the Birthplace study (which is in somewhere in the middle). This study found that, particularly for first time mothers, the baby’s risk is 3 times higher (of which more that half of the cases are death and brain damage). Is it ethically acceptable for a woman to value her birth experience over her baby’s welfare? Is maternal emotional wellbeing so important to justify risking the baby’s health?

Respect for dignity and privacy. “Dignity” may have a different meaning for each person. Some home births supporters feel that the presence of a doctor and the hospital staff make them feel “degraded”; moreover “for some women the possibility of the loss of privacy is a major issue, because privacy is a valued possession”.

Is it not contradictory that so many women, zealous advocates of home birth and their right to privacy, do not hesitate to publish their home birth photographs and videos -some of them with incredible details- in every social media site, where they are exposed to the eyes of millions of people?

Self-determination. In order to make truly informed decisions about childbirth options, women need to be informed of what they are and have the possibility to discuss them. Is it ethical to offer the option of home birth knowing that there is increased risk for her baby? 

In theory, the person informing the pregnant woman should inform her objectively and avoid being paternalistic. The problem is that, informed decision-making implies accurate assessment of risks and benefits, but the safety of home birth remains debatable. Is it possible to inform objectively a pregnant woman about home birth? Or the information will be biased according to the health care provider beliefs or experiences?

Other possible ethical issues:

  • In the home birth situation, are a woman’s reproductive rights and medical responsibility incompatible with each other?
  • Where do a woman’s rights end and medical responsibility begins, especially considering that the physician is also responsible for the baby’s welfare?
  • In case of a baby adverse outcome that could have been prevented in a hospital setting, what will be the psychological consequences for the couple?
  • What is the psychological burden of a home birth in a family’s older children witnessing a home birth? What if a complication occur in their presence?

Legal issues

Legal issues can affect a woman’s decision to give birth at home in different countries. In certain places, home births are restricted, and even possibly criminally punishable, and family homes have been turned into crime scenes when women who have opted for homebirths experienced complications. In others countries, there are no regulating laws.

In Europe, the European Court of Human Rights (ECtHR) ruled in 2010 that Hungary had violated Article 8 of the European Convention on Human Rights (ECHR) because it had interfered with a woman’s right to choose where to give birth. Ms Ternovszky wanted to give birth at home but argued that she was prevented from doing so because a government decree dissuaded health care professionals from assisting home births. This case was the first decision by an international human rights organization on the right to choose the circumstances of giving birth, and was heralded by home birth advocates across Europe.

However, in a recent case against the Czech Republic, the Human rights judges decided that national authorities of each country has “considerable room for manoeuvre” when regulating home births, a matter for which there is no European consensus and which involves complex issues of health-care policy as well as allocation of State resources.

So, is home birth a smart choice or a risky business?

The Monty Python satirize the medicalisation of childbirth in The Meaning of Life

As an obstetrician who supports natural birth, I hear many times the women’s complaints about the excessive medicalization of childbirth. And I feel that sometimes they are right. However, being a mother myself, I never regretted my choice of a hospital birth for my children. After having helped so many women deliver their babies, I have seen many times complications that were totally unpredictable. Occasionally, these sudden complications are so serious, that we have to run -literally- from the delivery room to the operating room to save the baby or the mother! Therefore, even when having skilled professionals attending your home birth, even in countries with very organized structures, the distance to a hospital can prove fatal. Is for this reason that, in my opinion, a hospital birth is without any doubt the best choice for every woman. A birthing center attached to a hospital may also be a good choice.

True, the studies results are controversial, but for me “almost as safe as a hospital birth” is not enough to make me change my mind.

True also, a hospital birth is related to more epidurals, cesarean sections, instrumental deliveries and episiotomies. Regarding the epidural, if you can do it without one, that’s great! But sometimes labor pain is unbearable, and it’s not uncommon to see women without any pain relief who, when the moment to push comes, they are so exhausted and their pain is so overwhelming that they literally lose it. On the contrary, women with an epidural can be more focused and relaxed. The bottom line is: natural birth is not for everybody. And women don’t have to feel guilty because they chose to have an epidural. It’s better to have nice memories of your birth, and for that the epidural can help!

Whether too many cesareans sections are being done is a topic more controversial than home birth itself, and it would deserve a separate article. But what I can say is that, when cesarean sections are done in a judicious way by a conscious physician, they can save your life and your baby’s life. Since hospital births result in better neonatal outcome, it is clear to me that most interventions are an inevitable trade-off to save more babies or to avoid severe damage. The same goes for the controversial fetal monitoring, which may lead to more cesarean sections, it may not decrease perinatal mortality, but it reduces by 50% the risk of  brain damage. Personally, I would do anything in my power to reduce the chances of having a brain damaged baby.

Of course, a lot that should be done -and can be done- to improve hospital birth: create home-like conditions to help women be relaxed and empowered, allow women to walk during labor, give them possibility to push and deliver in any position they wish, avoid unnecessary interventions such as systematic episiotomies, etc. I believe that some efforts are slowly being done worldwide, but we still have a long way to go!

In conclusion, a woman has the right to choose where to deliver; however, until the risks are clarified, maternal wellbeing may undermine the child’s welfare. Therefore, in my opinion, a natural hospital birth is the safest choice. Natural hospital birth IS possible! You just need motivation and a supportive team…

Hospitals should increase their efforts to provide women with a friendly environment so they can deliver their babies in comfort and total safety. Every baby is precious, every mother is precious!

Photo credits

7) screenterrier.blogspot.gr; 8) news.com.au; 9) vimeo.com, Wikimedia Commons, thebirthhour.com, Flickr.com, vimeo.com, homebirthaustralia.org, mindfulmamabirth.com, Flickr.com, huffingtonpost.co.uk, lifedaily.com

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 2)

Posted in Health, Pregnancy by

In the first part of this article we analyzed three important issues related to home birth: personal satisfaction, the mother’s safety and the baby’s risks. Check out the next three reasons women choose a home birth…

4) “I plan to have a home birth, but if something should happen I will go to a hospital”

home-birth-preparing-for-home-birthEven when properly prepared for a home birth, transfer to a hospital is commonly required

As previously mentioned, hospital transportation is a common event: about 1 out of 2 first time mothers and 2 out of 10 second or subsequent time mothers need to be transferred to a hospital; moreover, hospital transfer is almost always perceived by the couple as a negative and disruptive experience (see part 1).

The need for transportation to a hospital can occur before, during of after birth, and can be related to the mother, the baby or both. The top reasons may vary in different countries, although prolonged labour is the first cause of transfer in almost every study, followed by pain relief or the midwife’s unavailability at the onset of labor.

In the UK, the most common reasons for transfer are:

  • Prolonged labour (32.4%)
  • Meconium staining (12.2%)
  • Repair of a perineal tear (10.9%)
  • Abnormal fetal heart rate (7.0%)
  • Retained placenta (7.0%)
  • Request for regional analgesia (epidural, spinal) (5.1%)
  • Neonatal concerns (postpartum) (5.1%)
  • Others (20.1%)
Australian Caroline Lovell died of complications after giving birth to her daughter in a pool. Justice found that her death was preventable.

Home birth activist Caroline Lovell died of complications after giving birth her second child at home. Her death was preventable, justice says.

Other reasons include:

–During labor: maternal fever, fetal malpresentation, shoulder dystocia (baby’s shoulders getting stuck inside the mother), cord prolapse, uterine rupture, acute bleeding, placental abruption, vasa previa, acute sepsis.

–After birth: tears of the vagina or cervix, sphincter rupture, uterine atony, placenta accreta, increta, or percreta.

–Baby-related (post partum): unexpected very low or very high birthweight, neonatal depression, signs of respiratory distress, unexpected malformations, acute sepsis.

These are some important facts to keep in mind:

  • Maternal and fetal necessity for transport is often impossible to predict.
  • For unpredictable, extremely sudden complications, even rapid transport may not prevent the baby or the woman from death or severe harm, such as shoulder dystocia, sudden cardiopulmonary arrest, or maternal exsaguination (bleeding to death, read Caroline Lovell story here).
  • Women with severe hemorrhage  may already be in shock when arriving at a hospital. Even though the adequate treatment can be immediately instituted, death may nevertheless occur.
  • Perinatal mortality is higher when transport to the hospital is required.

5) “At home I can have a water birth”

home-birth-poolThe latest years there has been an increasing demand for water birth

Immersion in water during labor and delivery, although available for several decades, has seen a greatly renewed interest the latest years. In fact, even certain hospitals and birth centers have incorporated birth pools to their facilities. The results of studies analyzing maternal and fetal benefits and risks of water birth are inconsistent, and many times contradictory. The American College of Obstetricians and Gynecologists (ACOG) has just reviewed the subject and a few days ago (November 2016) published an updated statement. What are then the proposed pros and cons of water birth?

home-birth-waterbirth-babyThe benefits

For the mother. A Cochrane study  found the following results:

  • Less need for regional analgesia (epidural, spinal, or paracervical; studies show a slight reduction, RR 0.90; 95% CI 0.82–0.99)
  • Shorter duration of the first stage of labor (32.4 minutes shorter in water immersion)
  • Improvement in satisfaction among those women delivering in water.
  • Studies results are contradictory regarding the reduced occurrence perineal tears (including third-degree and fourth-degree lacerations) and need for episiotomy.
  • One study found less antepartum transfers to hospitals, both from home and midwifery birth units.

Other possible benefits: Increased feelings of relaxation, warmth, privacy, improved ability to maintain control during labor (here, here, here).

For the baby. Supporters of water birth believe that the transition to the outside world is less traumatic for babies born in water as the warm water of the pool may feel like the amniotic fluid; thus water-born babies are supposedly calmer than babies born in air. In fact, no benefits for the newborn were found with maternal immersion during labor or delivery, neither in 2 systematic reviews including 12 studies and 29 studies respectively, neither in the 2009 Cochrane systematic review, or any individual trials included in ACOG’s review.

home-birth-water-birth-realThe risks

For the mother. ACOG’s review did not find increased risk for maternal infections or postpartum hemorrhage. However, this conclusion must be tempered by the lack of data on rare serious outcomes, such as severe morbidity and mortality.

For the baby. Most studies found that immersion during labor does not increase fetal or neonatal risk. However, concerns have been expressed that immersion during delivery may predispose the infant to potentially serious neonatal complications. Several studies have reported several serious adverse outcomes among neonates delivered in water, these include :

  • Infection: cases of severe infections with certain bacteria, mainly Pseudomonas aeruginosa (here, here) and Legionella pneumophila (here, here, here, here) have been observed, some of which were fatal. The bacteria causing infections my come from the woman’s body, the water or the pool itself. Recently, a fatal infection by a virus (adenovirus) was reported in a baby born from a mother with gastroenteritis giving birth in a pool.
  • Water aspiration (drowning or near-drowning): it has been claimed that babies delivered into the water do not breathe or swallow water because of the protective “diving reflex”; however, it has been demonstrated that in compromised newborns the diving reflex is overridden, leading to gasping and aspiration of water. Actually,  it seems that even healthy babies may be at risk of water aspiration, which may result in hyponatremia and seizures.
  • Umbilical cord avulsion (cord “snapping” or cord rupture): this complication may happen in 1 out of 288 water births and occurs when the baby is lifted out of the water; in some instances the affected newborns have required intensive care unit admission and transfusion.

Other possible inconvenients:home-birth-bloody-water-birth

  • The mess: setting a pool at home may be messy and even challenging in certain situations, such as living in a small apartment.
  • Unpleasant environment: women may feel uncomfortable about accidentally defecating in the pool; which, as stated above, may also predispose the baby to severe infections.
  • Disappointment with pain relief: for some women, immersion in water is not enough to relieve pain.
  • Monitoring and emergencies: it may be difficult to quantify blood loss (see photo); in cases of concern about the baby’s heartbeat, monitoring may be difficult; moreover, in the event of a severe maternal complication (such as fainting or heavy hemorrhage) it may be difficult to move the pregnant woman out of the water.

Several professional organizations, including the Royal College of Obstetricians and Gynaecologists and the American College of Nurse–Midwives, support healthy women with uncomplicated pregnancies laboring and giving birth in water. According to ACOG, immersion in water during the first stage of labor may have benefits for the mother and may be offered to healthy women with uncomplicated pregnancies; however, there are insufficient data regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery. Therefore, until such data are available, “it is the recommendation of the American College of Obstetricians and Gynecologists that birth occur on land, not in water”. The British National Institute for Health and Care Excellence (NICE) recommendations are in agreement with the ACOG.

6) “In the Netherlands women have been delivering at home for more than fifty years”

home-birth-netherlands-1948The Netherlands has the highest percentage of home births in the Western world

The Netherlands is a country with a long tradition of home birth, with well-trained midwifes, organized transport system and short distances to hospitals. However, it is one of the few countries in the world where the incidence of home births is decreasing: in 1965, two-thirds of Dutch births took place at home, but that figure has dropped to about 20% in 2013. Moreover, Dutch women have to pay an extra amount (around €250) when deciding for a “nonindicated hospital birth” under the guidance of an obstetrician or a midwife (here). According to Professor Simone Buitendijk, head of the child health programme at the Netherlands Organisation for Applied Scientific Research, “… home birth rates have dropped like a stone. Soon, there will not be enough demand to justify the infrastructure” she says. “Then the system will collapse – and let there be no misunderstanding: we won’t be able to rebuild it”.

This drop in home births seems to be related to the increasing awareness of the media, patients, and obstetricians about the risks of home birth (here). Even more skepticism originated the results of the Euro-Peristat study: the Netherlands is one of the countries with the worst perinatal outcomes of Western Europe.

 

Read the third part here:  Home birth: smart choice or risky business? (Part 3)

Photo credits

4) birthbootcamp.com, dailymail.co.uk; 5) flickr.com, mthoodwomenshealth.com, popsugar.com, gravidanzaonline.it; 6) currystrumpet.com