TRYING TO GET PREGNANT: 14 FERTILITY MYTHS DEBUNKED

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

PREGNANCY SYMPTOMS: WHAT TO EXPECT THE FIRST TRIMESTER

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Pregnancy usually comes with a lot of joy… but sometimes it can be pretty overwhelming! Especially the first trimester, when your body starts changing. These changes are not the same for all women, though: while some women feel great and full of energy, others feel completely miserable…

Food cravings, nausea, mood swings… You have most likely heard about these pregnancy symptoms, but… what is normal? What to do about them? When to call your doctor?

In this article you will find a list of 16 common symptoms you may experience during the first trimester of pregnancy (weeks 0 to 13), you will learn why they happen, what you can do about them, and when to call your doctor -or midwife.

1) Abdominal cramping and backache

Pregnancy symptoms back painWhy it happens: one of the earliest pregnancy symptoms, this slight cramping confuses many women who believe they’re about to have their period. Abdominal and back pain are caused by normal, mild uterine contractions related to the increasing pregnancy hormones.

What can you do about it: nothing, unless pain gets intense or comes with vaginal bleeding.

When to call your doctor: if you experience strong pain, or if you have pain and bleeding, in order to rule out certain pregnancy complications (see vaginal bleeding) or other conditions unrelated to pregnancy.

2) Acne

Pregnancy symptoms acneWhy it happens: this is a very common symptom -pimples appear in about 50% of women- and sometimes can be quite intense. The β-HCG hormone (beta – human chorionic gonadotrophin), which raises from the beginning of pregnancy has androgenic effect (mimics male hormones), leading to increased skin oil production and the appearance of acne.

What can you do about it: most of medications used to treat acne are not allowed throughout pregnancy -isotretinoin, one of the most effective acne medications is also one of the most dangerous during pregnancy. Be patient! pregnancy acne will resolve after childbirth.

In the meantime, just get some good medication-free skin care:

  • wash your face and body with a gentle cleanser, alcohol and oil-free,
  • avoid over-cleansing as it may have the opposite effect,
  • shampoo regularly and avoid oily hair mousse,
  • do not pop your pimples, since it may cause permanent scarring.

When to call your doctor: If your acne is severe, you may consult a dermatologist to get the most adequate care for your skin type.

3) Bloating and constipation

Pregnancy symptoms constipationWhy it happens: during pregnancy a hormone called progesterone relaxes the bowels wall and slows down their activity in order to allow the absorption of more nutrients to feed your growing baby. The downside: you may feel bloated, gassy and get frequently constipated.

What can you do about it: 

  • increase your fiber intake,
  • avoid foods that cause bloating (beans, cauliflower, etc),
  • drink plenty of fluids,
  • engage in physical activity.

When to call your doctor: if constipation really bothers you, ask your doctor for a laxative or stool softener that is safe for pregnancy.

4) Breast swelling and tenderness

Pregnancy symptoms breast pain 2Why it happens: your breasts, under the influence of the high hormones, start getting ready for breastfeeding, thus they engorge and receive more blood supply; this will cause tenderness and swelling.

What can you do about it:

  • wear a support bra (you may need to get a bigger size),
  • avoid lacy or wired bras.

When to call your doctor: if you get severe breast pain or redness, or if you palpate any lump.

5) Dizziness and fainting 

Pregnancy symptoms dizzinessWhy it happens: your blood vessels dilate to increase blood supply to the womb and to your baby, leading to a drop in blood pressure, which can make you feel dizzy, lightheaded, or even faint. Dizziness can also be due to low blood sugar, especially if you are not eating adequately.

What can you do about it:

  • avoid prolonged standing,
  • rise slowly when you get up from sitting or lying down,
  • be especially careful if you drive or execute activities that require special concentration,
  • eat healthy, frequent meals (every two to three hours),
  • drink plenty of fluids to raise your blood pressure.

When to call your doctor: if your experience intense dizziness, especially if you have bleeding or intense abdominal pain, to rule out a miscarriage or an ectopic pregnancy (see vaginal bleeding).

6) Fatigue and sleepiness

Pregnancy symptoms fatigueWhy it happens: from early pregnancy, your body has some extra work to do! Your metabolism increases and you start preparing the placenta; these changes together with the high progesterone levels are responsible for this constant feeling of drowsiness and intense fatigue. Your body reminds you that you should get some rest, so you will be stronger to carry your baby!

What can you do about it:

  • take naps and rest when possible,
  • eat healthy,
  • drink plenty of fluids,
  • avoid standing up for long periods of time.

When to call your doctor: if you feel that your drowsiness affects your daily activities, inform your doctor who can rule out other possible causes of fatigue such as anemia. If you have intense sleepiness together with negative feelings, hopelessness or sadness, inform your doctor to rule out depression.

7) Food cravings, food aversions

Pregnancy symptoms cravingWhy it happens: the sudden hormonal increase changes your food tastes; therefore, you may get food cravings -a sudden and intense urge to eat something in particular, which may eventually be quite unusual- or food aversion -repulsion for certain foods, even with the thought of them.

It is believed that during pregnancy our body asks for what it needs -hence cravings- and makes us reject things we don’t need or may be harmful, such as aversion to cigarette in smokers (unfortunately, this is not always the case).

What can you do about it:

Cravings:

  • Go ahead and indulge yourself with what you crave, provided that you generally follow a balanced and healthy diet,
  • when you crave for unhealthy foods, try to avoid excess: eat one scoop of ice cream, not the whole 1-kilo carton!
  • if cravings are too frequent, try to do activities to distract yourself so that you don’t think about food all the time: go for a walk, talk to a friend, read a book, go to the movies…

Aversions:

  • Most food aversions will go away after the first trimester, so most likely you will be able to eat meat or drink milk again thereafter,
  • if you keep having aversion to certain foods, try to find healthy substitutes for what you can’t tolerate, e.g., have calcium-fortified cereals if you can’t drink milk.

When to call your doctor: If you crave for clay, ashes or dirt -a condition called pica– as this can be really dangerous for you and your baby; if your food aversions are too intense and followed by frequent vomiting (see Nausea and vomiting).

8) Frequent urination

Pregnancy symptoms frequent urinationWhy it happens: you may notice from very early in pregnancy that you need to pee more often. As your body blood flow increases with pregnancy, more blood goes to the kidneys in order to flush more waste products out of your body; this leads to increased urine production. Urination is more frequent during the night because the fluid you had retained in your legs during the day will get reabsorbed when you lie down. In addition, as the uterus grows it starts putting pressure on the bladder.

What can you do about it:

  • don’t hold you urine, as this can predispose you to urinary infections,
  • avoid too much caffeine (coffee, tea, cola drinks) since they have diuretic effect,
  • don’t drink too much before going to bed.

When to call your doctor: If, besides frequent urination, you feel burning or pain when you pee, or you see blood when wiping: these can be signs of a urinary tract infection.

9) Headaches

Pregnancy symptoms headacheWhy it happens: headaches occur frequently early in pregnancy mostly due to the increased hormone levels; but low blood pressure, low sugar, anemia or dehydration can all worsen headaches. Women who had migraines before getting pregnant may experience worsening in the first trimester, but usually improvement as the pregnancy progresses.

What can you do about it:

  • drink plenty of fluids,
  • eat frequent meals,
  • get some rest when possible.

When to call your doctor: If headaches persist, check with your doctor whether you can take acetaminophen (Tylenol), which is usually allowed throughout pregnancy. Contact you doctor if your headaches are too intense, do not subside with Tylenol or are accompanied by visual disturbances or other symptoms.

10) Heartburn, heavy stomach

Pregnancy symptoms heartburn 2Why it happens: Again, progesterone is responsible for relaxing the sphincter (ring of muscle) that separates the stomach from the esophagus; this leads to acid reflux.

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.

When to call your doctor: if you can’t cope with heartburn, ask your doctor to prescribe you an antiacid medication that is safe for pregnancy.

11) Mood swings

Pregnancy symptoms mood swingsWhy it happens: mostly because of your hormones, but eventually increased by your dizziness, nausea or other pregnancy symptoms, you may feel at times irritated or depressed, anxious or out of energy, overjoyed or panicked! Is not only hormones,  though. Pregnancy will bring major changes to your life, so it’s natural to worry about many things: whether your will make it through labor and delivery, if you baby will be fine, whether you will be a good mother, if the relationship with your partner will be affected, etc, etc… Most women will also become more forgetful; while this is normal, it may be quite frustrating…

What can you do about it:

  • talk about it, find someone who can listen to you: your partner, a family member, a friend, or other mums-to-be,
  • ask for understanding and support, not only psychological but also physical: if you can’t do certain activities at work or a home, let someone help you,
  • get some rest: you may feel worse if you are tired or sleep-deprived,
  • engage in activities that calm you down and relax you; mild exercise can also help.

When to call your doctor: if you feel constantly down or overwhelmed, if you have negative or suicidal thoughts, if you can’t go ahead with your daily life; in these situations you may need professional help.

12) Nausea and vomits

Pregnancy symptoms nauseaWhy it happens: nausea is one of the commonest pregnancy symptoms (occurs in about 85% of pregnancies). It is not fully understood why it happens, but it seems to be related to β-HCG levels: the higher levels, the more nauseous you may feel (e.g., women carrying twins).

Nausea and vomits usually start around the 6th week of pregnancy and persist until week 13, although they may last up to the 16th – 20th week, or more rarely beyond 20 weeks. They can be of variable intensity, for some women very mild, for others very severe, leading to continuous vomiting. Nausea may be more intense during the morning -that’s why it’s called morning sickness– although this is not always the case.

What can you do about it:

  • nausea gets worse when you have empty stomach, therefore, have frequent and small meals,
  • foods with high starch content may relieve nausea (crackers, potatoes, rice, pasta), but each woman find which foods can tolerate and which not,
  • avoid food with strong smell or taste,
  • ginger can help (either raw ginger, ginger ale or ginger pills),
  • accupressure, motion sickness wristbands and vitamin B6 can also be effective,
  • stress and tiredness can worsen nausea, therefore try to get plenty of rest,
  • keep drinking to avoid dehydration, but drink small amounts of fluids at a time, since large amounts can make nausea worse.

When to call your doctor: if nausea doesn’t allow you to eat or drink anything, or if you can’t stop vomiting, your doctor can prescribe you certain medications that may be helpful. Sometimes intense vomiting may lead to dehydration, a condition called hyperemesis gravidarum, which requires admission to a hospital for rehydration and intravenous treatment.

13) Nosebleed, stuffy nose, gum bleeding

Pregnancy symptoms stuffy noseWhy it happens: blood flow increases in pregnancy, and your gums and nasal lining are very fragile and bleed easily. Gums may bleed when you brush your teeth. Nosebleeds may appear when you blow your nose; you may also notice that your nose gets more easily congested, also as a result of the increased blow flow to the nose’s mucous membranes.

What can you do about it:

  • keep seeing regularly your dentist to rule out certain gums problems, which are common in pregnancy and may increase bleeding,
  • switch to a softer toothbrush,
  • to stop nose bleeding pinching your nose for a few minutes should help,
  • for your nose congestion you may use a humidifier, or try a saline nasal spray,
  • don’t use nose spays or other decongestants without checking with your doctor.

When to call your doctor: if your gum or nose bleeding are heavy or too frequent. If your nose congestion gets too intense and you can’t breathe.

14) Smell intolerance, increased sense of smell

Pregnancy symptoms smellsWhy it happens: many women won’t stand certain strong smells, either from food, cosmetics or others sources, triggering nausea or vomits. This sensitivity to smells is hormone-related; it is said that nature prepares you to “sense” dangerous threats in order to protect your baby.

What can you do about it:

  • avoid foods with intense smell,
  • you may need to stop cooking for a while -if possible,
  • don’t use scented cosmetics if the smell bothers you; this is also true for laundry soap, softeners, air fresheners, etc.

When to call your doctor: in case your smell intolerance leads you to intense vomiting (see Nausea and vomits).

15) Vaginal bleeding

Pregnancy symptoms vaginal bleeding 2Why it happens: Bleeding during the first trimester is extremely common (it happens in about 25% of pregnancies) and is usually of no concern. A slight bleeding may be due to the implantation of the embryo in the uterus; sometimes a small detachment of the sac from the uterine cavity -or subchorionic bleeding- may be the reason; an inflammation of the cervix may occasionally cause slight bleeding (mainly with intercourse). Sometimes though, bleeding can be worrisome, i.e., when related to threatened miscarriage or ectopic pregnancy (a pregnancy outside the uterus).

What can you do about it:

  • keep track of the amount and characteristics of the blood,
  • don’t have intercourse, don’t use tampons,
  • according to the cause of the bleeding, you may be asked to get some bedrest, and refrain from heavy work or heavy lifting.

When to call your doctor: If you see blood, you should inform your doctor, even if you have light bleeding, as it may not be always easy to understand when bleeding is to worry about. But you should call your doctor right away (or go to the emergency room) if you have heavy bleeding, cramps (like intense period pain), or sharp pain in your abdomen, as these can be signs of miscarriage or ectopic pregnancy.

16) Vaginal discharge

Pregnancy symptoms vaginal discarge 2Why it happens: Your high hormones are responsible for an increase in vaginal discharge, that should be white or clear, and thin.

What can you do about it:

  • you can wear panty liners, but you should not wear tampons,
  • prefer cotton underwear,
  • avoid string or thong underwear that may cause intense rubbing, which together with the increased discharge can favor yeast or other infections.

When to call your doctor: if you have discharge that is yellow, green or foul-smelling, or if you have intense itching or burning.

 

Stay tuned! More posts with symptoms to expect during the second and third trimester of pregnancy will follow…

 

References

  • NICE: Antenatal Care- Routine Care for the Healthy Pregnant Woman. March 2008, UK
  • HAS: Comment mieux informer les femmes enceintes? Avril 2005, France
  • American College of Obstetrician and Gynecologists: Nausea and vomits, Vaginal bleeding

Photo credits

Cover: Getty images; 1) dornascostasnuncamais.com.br; 2) babycenter.com; 3) adriseaplanes.eu; 4) thealphaparent.com; 5) pregnancymagazine.com; 6) womenshealthcaretopics.com; 7) motherandbaby.co.uk; 8) ladycarehealth.com; 9) momjunction.com; 10) ladycarehealth.com; 11) fitbottomedmamas.com; 12) not-equal.eu; 13) womenshealthcaretopics.com; 14) health-and-parenting.com; 15) zliving.com; 16) privatepregnancy.co.uk

THE HPV VACCINE: WHY IS IT CONTROVERSIAL?

The HPV vaccine has been around for almost 10 years and more than 175 millions doses have been distributed in 63 countries, with several studies confirming its safety and efficacy. In spite of that, the vaccine still remains a subject of controversy. Although recommended by most scientific societies worldwide, some recent reports questioning its safety fuelled even more the debate, dividing both general public and medical community.

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In this article we will analyse the existing evidence regarding the HPV vaccine, with particular focus on its efficacy and safety. In order to organise the available information, the article will be divided into the following sections:

  1. Getting to know HPV
  2. Why a vaccine? The burden of HPV-related diseases
  3. The three available HPV vaccines
  4. Vaccination schedule and timing 
  5. Efficacy of the HPV vaccine
  6. Safety of the HPV vaccine
  7. Recent safety concerns: the chronicle of events
  8. Other debatable issues
  9. Unanswered questions…
  10. Conclusion

1. Getting to know HPV

HPV vaccine cure cancer awarenessHPV (human papillomavirus) is a virus and is transmitted from person to person through skin-to-skin contact.

  • HPV infection is extremely common, and most of the times it will be cleared by the immune system.
  • Of the over 100 types of HPV, about 12 subtypes of the HPV (mostly subtypes 6 and 11) may cause genital warts (also known as condylomas). These so-called “low-risk types” can also cause a rare condition called recurrent respiratory papillomatosis, in which warts grow in the throat.
  • Approximately 15 types of HPV (most commonly types 16 and 18) are related to cancer. While cervical cancer is the most common HPV-related cancer, this virus can also cause other cancers: vulvar, vaginal, anal and oropharyngeal (mouth and throat),  as well as penile cancer in men.

You can read more detailed information on HPV here.

 

2. Why a vaccine? The burden of HPV-related diseases

HPV vaccine every 2 minutes a woman diesThese figures will give you and idea of the magnitude of the problems caused by HPV:

-Worldwide, over 500,000 new cervical cancer cases are diagnosed annually. Cervical cancer ranks as the 4th cause of female cancer in the world and is the 2nd most common female cancer in women aged 15 to 44 years (1).

In the United States, an estimated 26,000 new cancers are attributable to HPV each year, about 17,000 in women and 9,000 in men (2) .

In Europe, about 58,000 new cases of HPV-related cancers are estimated to occur every year (3).

-Regarding  precancerous lesions, the estimated annual burden of high-grade precancerous lesions ranges between 280,000 and 550,000 new cases per year in Europe (4).

-In addition to cancers and precancerous lesions, the problem of genital warts should also be taken into consideration. Genital warts are very common: 1 out of 10 persons will have condylomas at some point in their lives (the frequency varies according to different countries between 0,3 and 12 %) (5). About 800,000 new annual genital warts cases are estimated to occur in women and men in Europe (4). Although not life-threatening, the costs derived from their treatment and their psychological burden should not be neglected.

 

3. The three available HPV vaccines

HPV vaccine collageFrom 2006, 2 vaccines have been available: One bivalent (Cervarix®), directed against HPV types 16 and 18, responsible for about 70% of cervical cancers  and other HPV-associated cancers; the other quadrivalent (Gardasil® of Silgard® in different countries) containing 4 HPV types:16 and 18, together with HPV 6 and 11 which are responsible for more than 90% of genital warts.

In December 2014, the American Food and Drug Administration (FDA) approved a nine-valent vaccine, Gardasil 9® (6), which, besides the 4 strains contained in Gardasil (i.e., 6,11,16,18), includes types 31, 33, 45, 52, and 58, responsible for an additional 20% of HPV-related cancers (4). Gardasil 9 has also been recently approved for commercialisation in Europe (7).

 

4. Vaccination schedule and timing 

HPV vaccine who should get it ACIPinfographic

  • Vaccines are given as a 3-dose series, Gardasil at 0, 2 and 6 months, Cervarix at 0, 1 and 6 months (8).
  • In the States, The Advisory Committee on Immunization Practices (ACIP) and  the American College of Obstetrician and Gynecologists (ACOG) recommend that girls be routinely vaccinated at age 11 or 12 years.
  • Since 2010 boys have been included in the vaccination schedule in the USA, with the same schedule as girls.
  • If not vaccinated when they were younger, girls/young women and boys/young men should be vaccinated through age 26 (9).
  • Vaccine may be given starting at age 9 years (9, 10).
  • A reduced, 2-dose schedule is recommended by the World Health Organization (WHO) for those aged 9-13 years; this schedule is not recommended by the ACIP but it has been adopted by many countries.HPV vaccine Protect your children
  • Earlier vaccination (before age 14) results in higher immune response. Another argument in favor of early vaccination is the fact that vaccines are more effective before the onset of sexual activity (8).
  • Vaccination is recommended regardless of sexual activity or known HPV infection. Although vaccines seem to be less effective in sexually active people, some benefit is expected to be attained since exposure to all types of HPV included in the vaccines is very unlikely. Testing for HPV is NOT recommended before vaccination.
  • The vaccines are prophylactic, that is, they do not prevent progression of existing infection to disease or treat existing disease. (2)
  • The HPV vaccine is covered by most private health insurance and government insurance programs worldwide. Vaccinations schedules may vary in different countries.
  • There seems to be additional protection by the vaccine in women through age 45, as showed by certain studies (11). However, there is no recommendation for vaccination in individuals aged 26 to 45.
  • The same schedule applies for Gardasil 9 (0, 2 and 6 months). Revaccination with the nine-valent vaccine is not recommended in persons who previously completed the three-dose series with the bivalent or or quadrivalent HPV vaccine (8).

5. Efficacy of the HPV vaccine

HPV Vaccine Charlene-Choi1The ultimate goal of the HPV vaccine is to reduce the incidence of HPV-related cancers. For obvious ethical reasons, the endpoint set to evaluate the HPV vaccine efficacy in different studies was precancerous lesions, namely CIN 2 and 3 (high risk lesions of the cervix, with potential to evolve to cancer). Other efficacy endpoints evaluated were incidence of HPV infection and incidence of condylomas.

Studies conducted before licensure showed that both vaccines achieved a high level of protection: 98-100% for the HPV types included in the vaccine in a naive population (that is, women who did not have HPV 16 or 18 at the time of  vaccination),  although the protection against precancerous lesions was 30-40% in the total vaccinated cohort (which included women who did not finish their immunization plan, or that were already infected with the virus before vaccination) (12, 13, 14, 15). There was also cross-protection for other types of HPV (i.e., HPV 45 and 31), which was more intense with Cervarix (16).

HPV vaccine AustraliaThe impact of vaccination on the general population has also been analysed in some studies. Australia was the first country to introduce an organised HPV vaccination program, achieving one of the world’s highest vaccination compliance rates.  Since 2007, when the National HPV vaccination program started with the quadrivalent vaccine, HPV infections from the types included in the vaccine decreased from 29% to 7% (17); a 93% reduction in the diagnosis of genital warts was also observed (18). Moreover, other recent studies showed an almost 50% reduction of  high-grade cervical precancerous lesions in women who had received all required doses of the vaccine (19).

Denmark also counts with an organised vaccination program. Six years after licensure of the quadrivalent HPV vaccine, a reduction of cervical precancerous lesions was observed, which was 80% in younger patients (20).

Recently, a study was conducted to evaluate the efficacy of the nine-valent vaccine. Gardasil 9 prevented 97% of high-grade precancerous lesions of the cervix, vulva, and vagina caused by the five new high-risk HPV types (HPV31/33/45/52/58) (21). The nine-valent vaccine also generated immune responses to HPV6/11/16/18 that were as good as or better than those generated by the quadrivalent vaccine. (4, 22)

 

6. Safety of the HPV vaccine

Many studies have evaluated HPV vaccine safety, both before their commercialisation and post-release, which demonstrated no differences in side effects as compared to control groups, irrespective of age and ethnicity (23).

HPV vaccine armed against cancerAccording to the CDC, the most commonly reported side effects of the vaccines are:

  • Pain, redness, or swelling in the arm where the shot was given
  • Fever
  • Headache or feeling tired
  • Nausea
  • Muscle or joint pain

Fainting (also known as syncope) and related symptoms (such as jerking movements) is not uncommon (24), especially in teenagers. For that reason, it is recommended that people receiving the HPV vaccine sit or lie down during vaccination, and remain seated for 15 minutes after the shot. (23)

Considering the target age of vaccination (which includes women in reproductive age), pregnancy outcomes received special attention. No increase in miscarriage rates has been reported for either of the vaccines (25). In addition, pregnant women that were recorded and observed in registrative trials did not have increased rate of congenital abnormalities (26, 27, 24).

Studies have also demonstrated efficacy and safety of the vaccines in men, both in heterosexual and men who have sex with men (28).

Serious side effects are very rare (less than 0.5%) (29), the most common being persistent headache, hypertension, gastroenteritis, bronchospasm and anaphylaxis. Their reported incidence is similar to that of other compulsory vaccines types (30).

HPV vaccine third pokeCertain side effects have been a matter of concern since the introduction of the vaccine, namely autoimmune diseases (AD) (i.e., hypothyroidism, rheumatoid arthritis, Behçet’s syndrome, Raynaud’s disease, type 1 diabetes, and vitiligo), neurological disorders (such as epilepsy, paralysis, Guillain–Barré syndrome, central demyelination, and multiple sclerosis) and venous thromboembolism (a blood clot that plugs a vein). It should be mentioned that ADs are not rare in adolescents and young adults, particularly in women. Therefore, it is a real challenge to distinguish causal from temporal association. A recent study gathered the results of 9 large studies (of which one was an analysis of 42 trials together, or metanalysis) in order to investigate severe adverse reactions after the HPV vaccine. None of the included studies found evidence of increased risk of autoimmune disease, neurological disorder, or venous thromboembolism (31).

The Global Advisory Committee on Vaccine Safety (GACVS), established by the World Health Organization (WHO) provides independent, scientifically rigorous advice on vaccine-safety issues. In December 2013, the committee reviewed different topics and considered all available evidence on the safety of HPV vaccines, and concluded that both commercially available vaccines are safe (32). Likewise, the International Federation of Gynecology and Obstetrics (FIGO) Gynecologic Oncologic Committee and Subcommittee for Cervical Cancer Prevention support the continued administration of the HPV vaccines in appropriate populations (33).

7. Recent safety concerns: the chronicle of events 

HPV vaccine Japanese_SchoolgirlsAlthough some isolated cases of side effects had been described in UK and Australia (34), Japan was the first country reporting on several girls suffering from severe pain and disability; these cases were heavily publicised in newspapers, TV news and social media, but they also alarmed the medical community. Japanese physicians published later on a series of 44 girls who were diagnosed with complex regional pain syndrome (CRPS) (35). Due to these concerns, in June 2013 the Japanese Ministry of Health, Labour, and Welfare (MHLW) decided to suspend its active recommendation of HPV vaccination. This decision created intense debate among scientists and general public, which continues until nowadays (34).

In March 2015, Denmark‘s TV channel TV2 aired a documentary entitled The Vaccinated Girls – Sick and Betrayed. The journalists gathered about 60 girls from all over Denmark who became sick shortly after receiving the HPV vaccine. Among the doctors interviewed is Louise Brinth, who examined approximately 80 girls with similar symptoms potentially caused by the HPV vaccine. Dr. Brinth noted that the girls experience symptoms such as dizziness, passing out, and severe headaches. She said, “They have abdominal pain and nausea. They have weird muscle movements they cannot control. And they’re very tired… We see a pattern that screams to heaven, and that should be examined by some solid research.”

HPV vaccine Danish documentaryIn April 2015, Dr. Brinth reported in a scientific journal on 53 patients complaining of orthostatic intolerance, severe headache, excessive fatigue, cognitive dysfunction, gastrointestinal discomfort and widespread pain. Most of them were diagnosed with a rare syndrome known as postural orthostatic tachycardia syndrome (POTS), and all of them were in close temporal association with the HPV vaccine (36a, 36b).

Denmark’s documentary has had a huge impact worldwide, both in the general public and the medical community. A closed Facebook page set up for suspected victims of adverse reactions to Gardasil in Denmark tripled its -careful verified- members; similar Facebook groups were created in other countries.

At the request of Denmark, The European Medicines Agency (EMA) is currently conducting a safety review of HPV vaccines. However, the agency emphasizes that this review “does not question that the benefits of HPV vaccines outweigh their risks.”The agency also notes that while the review is being carried out, no change in the use of these products is recommended. See the EMA’s review conclusions here.

HPV vaccine reactions independent UKIn May 2015, UK’s newspaper The Independent published an article entitled: Thousands of teenage girls report feeling seriously ill after routine school cancer vaccination. The article focuses on the story of Emily Ryalls, 17, who started feeling intense pains and difficulty breathing soon after receiving the HPV vaccine.

Mrs Ryalls reported Emily’s symptoms to the Medicines and Healthcare Products Regulatory Agency (MHRA), and she was not alone: adverse reactions after HPV vaccination numbered 8,228, of which 2,587 were classified as “serious”; that’s substantially more that those reported with other compulsory vaccines (see graph). The MHRA, though, said it had no concerns on the numbers of adverse reactions related to the HPV vaccine and that the “expected benefits in preventing illness and death from HPV infection outweigh the known risks”.

Emily’s mother, together with other 80 families in similar situation across the UK have formed the Association for HPV Vaccine Injured Daughters (AHVID).

As stated by the newspaper “This article created significant debate among medical professionals, journalists and members of the public…”.

HPV vaccine France fiasco SV-1136-vaccin-HPVIn France, the National Security Agency of Medicines and Health Products (ANSM) just published (September 2015) the results of the follow-up of more than 2 million girls aged 13-16 years, vaccinated between 2008 and 2013 to evaluate the occurrence of side effects, mainly autoimmune diseases. When analysed all the diseases together, their results showed no overall increased risk of occurrence of serious events. However, when each disease was analysed individually, a four-fold increase in the occurrence of Guillain Barre syndrome was observed. The study also found an increased risk of Inflammatory Bowel disease, but the association was weak.

The authors conclude: “…the results of the study… prove reassuring regarding the risk of autoimmune disease associated with the HPV vaccines. The expected benefits of this vaccination in terms of public health are far greater than the eventual risks the girls may be exposed to” (37). In spite of these “reassuring” results, the vaccination rate in France continue to be low (less than 30%).

HPV vaccine POTSIn September 2015, another report provided details on 45 individuals from 13 countries who developed a chronic ailment soon after receiving the HPV vaccine. “A disabling syndrome of chronic neuropathic pain, vexing fatigue, and profound autonomic dysfunction may appear after HPV vaccination,” say the authors, headed by Manuel Martínez-Lavín, MD, a specialist in chronic pain conditions from Mexico City. After a mean period of 4 years following HPV vaccination, 93% of individuals “continue to have incapacitating symptoms and remain unable to attend school or work,” write the authors (38).

POTS after HPV vaccination has also been reported in the United States.  Dr. Blitshteyn, a neurologist from New York, described six patients who developed POTS between 6 days and 2 months after HPV vaccination. All patients reported improvement over 3 years, but residual symptoms persisted (39).

The US Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) emphasised that controlled clinical trials in tens of thousands of individuals plus postlicensure monitoring of millions of individuals have found no causal association between HPV vaccination and atypical pain syndromes or autonomic dysfunction.

HPV vaccine Diane HarperDr. Diane Harper, an american obstetrician & gynecologist, is one of the HPV experts called in to design the clinical trials of Gardasil and Cervarix.  Although initially in favour of the vaccine, in recent years she has questioned Gardasil safety. She stated that “Gardasil has been associated with at least as many serious adverse events as there are deaths from cervical cancer developing each year”. Moreover, in an article published in December 2009 she concluded that, given the various limitations and risks of the vaccines, the benefits and risks of HPV vaccination must be weighed with the benefits and risks of HPV screening (Pap smears) to reduce cervical cancer in a cost-effective manner (40).

Dr. Harper does not support mandatory HPV vaccination for schoolchildren, because she believes that the duration of protection may be too short (see below). She has also criticised the short period of time vaccines were tried before its licensure,  and the misleading publicity carried out by the pharmaceutical companies. Learn more here.

8. Other debatable issues

Vaccination in boys

HPV vaccine is cancer prevention.

The rationale of vaccinating boys is to reduce the transmission of the HPV virus to women and to protect them against oral and anal cancers (41). Since these cancers are very rare, it has been questioned by some scientists whether is it worth to expose millions of boys to potential vaccine side effects in order to protect girls, or to prevent a so rare type of cancer (responsible for just 300 deaths in the USA); whether the benefit outweighs the risk and if men vaccination is cost effective. While countries such as Australia and the USA include boys in their vaccine recommendations, other countries (i.e., UK and France) have not yet adopted this measure.

Men who have sex with men are a special category, since they are at higher risk of anal cancer. Thus, some experts believe these men (and not every boy) should be offered the vaccine. However, this measure may be difficult to implement: in order get covered by their insurance or social security, young men may be required to declare their sexual preferences.

Immunogenicity of Gardasil vs. Cervarix

HPV vaccine ArgentinaImmunogenicity means the ability of the vaccine to provoke an immune response; in other words, the “strength” of the vaccine.

Most countries adopted vaccination with Gardasil instead of Cervarix assuming equal protection for cancer, with the “bonus” protection against genital warts. But is it really like this?

Several studies have demonstrated that Cervarix elicits stronger and longer-lasting immune response than Gardasil (42, 43).

These laboratory findings have also been confirmed by some clinical studies: Over the years, the efficacy of the Cervarix to protect vaccinated women from precancerous lesions (total vaccinated cohort-naive) was 93%, while Gardasil’s dropped to 43% (44)

Age of vaccination

HPV vaccine school girlThis subject has also raised intense debate and concern. As stated above, immune response provoked by the vaccines may be of limited duration, especially for Gardasil. This can be a serious limitation of the vaccine because, as Dr. Harper noted “… if the HPV vaccine does not last for at least 15 years, no cancers will ever be prevented; women will just get the cancers at a later time in life after the vaccine has worn off“.

If this short protection span is confirmed by clinical studies, a boost dose would solve this limitation. However, this would increase considerably the cost of the vaccine; moreover, women who don’t comply with this recommendation will become unprotected over time.

Increase of promiscuity?

Many people feared that the the HPV vaccine would lead girls to promiscuous behavior. This was actually investigated by some studies, and have proved not to be true: no increase in sexually transmitted diseases was observed among vaccinated girls (45), showing that vaccination is unlikely to promote unsafe sexual activity.

9. Unanswered questions…

  • HPV cancer vaccine flyer - 8-1/2 x 11Will the HPV vaccine reduce cervical cancer deaths in real-world conditions?
  • In light of the latest publications, should vaccination programs be halted until the situations is clarified?
  • Due to these latest concerns, will more women opt for no vaccination, missing the opportunity to be protected against cancer?
  • Since the syndromes potentially related to vaccines are difficult to diagnose, is it possible that they have been underreported in the past? Could they possibly become over reported in the future?
  • Will the vaccine create a false sense of full protection against cervical cancer, resulting in less women attending screening programs?
  • Will the vaccine lead to a reduction of the HPV types included in the vaccine, but to an increase of those not included in the vaccine?

10. Conclusion

HPV vaccine End-cervical-cancer-posterIt is indeed exciting to have a vaccine that protects against cancer. After seeing women dying from cervical cancer, I truly wish that cervical cancer will be eradicated in the future. But we MUST be sure that we don’t create more harm than good in the process.

HPV vaccine smear for a smear campaignI am in favor of vaccines. Vaccines have done a lot of good to humanity (just imagine if we would still have small pox, or poliomyelitis…). It is true that every single medical practice may come with side effects, and this include vaccines. But we MUST know exactly what are the vaccine risks, and whether the benefits outweigh the risks.

I firmly believe that governments, scientific societies and pharmaceutical companies MUST do an effort to inform people in a responsible and honest manner, so that all of us -young people, parents and physicians- continue to believe in good science, and vaccines don’t lose their credibility.

It will take 10 to 20 years to figure out the true benefit of the HPV vaccine. In the meantime, keep in mind that Pap tests never killed anyone, on the contrary, they have saved millions of lives. Therefore, don’t forget your Pap smear!

 

Read on the latest events related to the HPV vaccine here.

 

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Photo Credits

Intro: Getty images; 1: curecancer.org; 2: m2.behance.net; 3: (collage) wikimedia commons; 4: cityofchicago.org; nkytribune.com; 5: english.cri.cnhpv.health.gov.au; 6: marketingmag.cascontent.cdninstagram.com; 7: Japan: wikimedia commons; Denmark: vaccineimpact.com; UK: independent.co.uk; France: science-et-vie.com; POTS: pinterest.com; Harper: initiativecitoyenne.be; 8: bphc.orgmigueljara.files.wordpress.comlh3.googleusercontent.com; 9: healthvermont.gov; 10: compasscayman.comi.dailymail.co.uk