Pregnancy After Infertility in Hawaii

Over the next 2 to 4 weeks, you will be monitored with ultrasounds and blood tests. All of the ultrasounds will be done transvaginally. There are no known risks of ultrasound in pregnancy.

In most cases, after the initial pregnancy test, the HCG level is repeated 2 days later. For most normal pregnancies, the initial level will roughly double during that time period. Your progesterone level may also be checked twice to make sure that it is adequate and supplementation will be ordered if it is not.

Pregnancy dating can be confusing.  This is because pregnancies are dated from the date of the theoretical last menstrual period which would have been roughly 3-weeks prior to the embryo transfer if this were a spontaneous conception.   The first ultrasound appointment is typically around 6-weeks of gestation.   A pregnancy at this stage will appear as a gestational sac on the ultrasound scan.  The purpose of this visit is to identify the number of sacs and verify that it/they are in the uterus.

Usually, sometime between 6 to 7 weeks of gestation, the heartbeat of the embryo can be detected.  The “crown-rump length” of the embryo will be measured and compared to the expected size.

At 7 to 8 weeks of gestation, the embryo will be measured again in order to verify normal growth and the heart rate will be checked again. Less than 10% of pregnancies that have progressed to this point will end in miscarriage.

If all is well at this point, usually you will be transferred to your OB-GYN for ongoing prenatal care.

Many of our pregnant patients (including all of our IVF patients, egg-donor recipients and cryopreserved embryo recipients) may be on progesterone and estrogen during the early portion of the pregnancy.  If you are not on progesterone (or estrogen) it is because it has been determined by blood tests that you do not need it. The progesterone and estrogen that are taken are natural progesterone and estrogen. Progesterone can be given by intramuscular injection, vaginal suppository, vaginal gel, or vaginal capsule. Estrogen can be given orally, vaginally, by intramuscular injection or by transdermal patch.

The FDA has placed warnings on all reproductive hormones that they should not be used in pregnancy. This is because some synthetic hormones have definitely been associated with birth defects. However, no harmful effects to the mother or the fetus are presently known to medical science from the use of natural progesterone or estrogen. Failure to take the progesterone (or estrogen) as directed could result in miscarriage. As your pregnancy progresses, your dose may be modified in response to how well the placenta is making the hormones. Do not stop the hormones unless told to do so by your doctor or nurse.

Miscarriages are the loss of an early intrauterine pregnancy. They represent about 15-25% of all of the pregnancies that occur. There is an increased pregnancy loss rate with increasing age. Most of these early losses are due to abnormalities of the embryo’s chromosomes. Treatment includes D&C (dilation and curettage of the uterus) or allowing the pregnancy to be passed naturally. In general, for women 35 or younger, about 15-20% of pregnancies will end in miscarriage. For women 35-40, about 20-25%. For women over 40, the risk is greater than 30%.

During the first few weeks of pregnancy, about 80% of normal pregnancies will show doubling of the HCG levels each 48 hours. If your numbers do not increase normally, there are 3 possibilities: you could have a normal pregnancy that is in the “slowest” 20%; the pregnancy could be abnormal and in the uterus; the pregnancy could be in the fallopian tube (ectopic). In this case, we will follow your levels quite closely until we can determine which of these is true.

Ectopic pregnancies are pregnancies that implant outside the uterus. About 95-97% of them occur in the fallopian tubes. Ectopic pregnancies represent 2-5% of the pregnancies. Ectopic pregnancies can be treated medically or surgically, depending upon the situation. If untreated, they can rupture and become a life-threatening condition. Our monitoring is designed to make the diagnosis before this could happen.

First of all, do not panic. About 25-30% of women will experience an episode of bleeding or spotting during the first trimester. Most of the time, it is due to the implantation of the embryo. As the embryo’s blood supply is being established, it is not uncommon to see some bleeding or staining due to the growth of the placenta into the uterine tissue. If you notice bleeding, please notify us. You will probably be instructed to come in to the office so that we can examine you and perform an ultrasound. Once we have verified that the pregnancy is ongoing, you may be placed on bed rest or restricted activity until the bleeding stops. Although there is no scientific evidence to show that bed rest improves the chances of a good outcome, this may be prescribed for you depending on the specifics of your case.

You should eat a well-balanced diet supplemented with the prenatal vitamins prescribed by your physician. Sensible eating habits, combined with your prenatal vitamins, are sufficient to maintain your pregnancy. The United States Department of Agriculture recommends that a healthy diet consists of two to three servings of milk and meat products, three to five servings of vegetables, two to four servings of fruit and six to eleven servings of grain daily. They also recommend that fats, sweets and oils be used sparingly. The average weight gain during the first trimester is 3-5 lbs. However some women gain more and some women lose weight. The body stores fat for even most slim women who are adequate to sustain a pregnancy in the absence of weight gain.

Avoid all beverages containing either caffeine or alcohol as well as all herbal remedies &/or supplements except those approved by your physician. You should also avoid foods made with unpasteurized milk products or raw shellfish.

Sugar substitutes: Unfortunately, not much human research has been done on saccharine use in pregnancy. Animal studies, however, show an increase in cancer in the offspring when pregnant mothers ingest the chemical. Added to the evidence that the sweetener crosses the placenta in humans and is eliminated very slowly from fetal tissues, these studies suggest that it is sensible not to use saccharine during pregnancy.

On the other hand, studies have not found any harmful effects from the use of typical amounts of the sweetener aspartame (Equal, NutraSweet) by most women during pregnancy.

Because of the risk of mercury contamination which can affect the developing fetal nervous system the FDA suggest pregnant women avoid swordfish, tilefish, shark, mackerel. You should also limit your consumption of other fish including tuna to less than 12 oz per week. Because of the risk of hepatitis or parasitic infection, any uncooked seafood should be avoided including oysters, clams and raw sushi or sashimi.

If you are experiencing nausea and vomiting commonly associated with pregnancy, remember it is important to stay hydrated by drinking small amounts frequently and eating small frequent meals. Nausea tends to be worst when you are quite hungry or full and you will need to experiment to see which foods are best tolerated. For many women, bland starchy foods such as crackers, noodles, soup, etc are well tolerated. It may also be helpful to try an acupressure band – these are commonly sold in drug stores for treatment of seasickness. Some women find ginger (in ginger ale or sold as ginger capsules) to be helpful. Many women find prenatal vitamins hard to swallow due to the nausea of early pregnancy. In this case, it is acceptable to break the tablets and take part of one at each meal or to switch to a chewable tablet.

Depending on the specifics of your case, your physician may advise you to refrain from intercourse until after the first documentation of the fetal heartbeat. If you are having any vaginal bleeding or cramping, please refrain from intercourse.

We also advise refraining from any strenuous physical exercise such as high-impact aerobics, running, etc. The following guidelines for exercise in pregnancy are provided by the American College of Obstetricians and Gynecologists:

1. Regular exercise (at least 3 times per week) is preferable to sporadic activity. Competitive activities should be avoided.
2. Vigorous exercise should not be performed in hot, humid weather or during illness.
3. Strenuous exercise should not exceed 15 minutes. Additionally, exercise should be preceded by a 5 minute muscle warm-up and followed with a cool down period.
4. Activities that require jumping or rapid changes in direction should be avoided because of joint instability. Swimming, biking and walking are ideal during pregnancy.
5. A pregnant woman’s heart rate should not exceed 120 beats per minute.
6. Women should drink fluids before, during and after exercise to prevent dehydration.
7. High impact activities should be avoided.
8. Activities such as sitting in a hot tub or sauna should be avoided.

Women who have a history of miscarriage, premature labor, multiple pregnancies, vaginal bleeding or heart disease should consult with their physician about exercise during pregnancy. A woman with a sedentary lifestyle should not begin a fitness program during pregnancy. If a woman is physically fit, she may be able to tolerate the same level of exercise during pregnancy with only minor modifications. Many women who have conceived during an IVF cycle may be on activity restrictions for the first few weeks of the pregnancy.

You should avoid very long, hot baths or Jacuzzis as there is a theoretical risk of slightly increasing the chance of neural tube defects with prolonged elevations of the core body temperature.

Most of the development of the major organ systems occurs during the first trimester. For this reason, we suggest that you avoid hair coloring, x-rays, or exposure to pesticides and chemicals if possible.

Airline travel is safe, however, if you should experience complications, it may be difficult to arrange for medical care. If you are experiencing pregnancy complications and you must travel, please check with us first. Whether driving or flying, it is advisable to walk around every few hours to avoid the formation of clots in the legs. It is important to wear shoulder and lap belts. You may also want to carry extra fluids and food for snacks.

Toxoplasmosis, a bacterial infection associated with eating undercooked meat and exposure to cat feces, can cause birth defects if acquired during the first 12 weeks of pregnancy. If you are pregnant, you should not change your cat’s litter box. Food should be handled carefully and always cooked appropriately. Gardening chores should be performed with gloves.

Our patients have many questions regarding medications that are safe to take during pregnancy. Unfortunately, that list is too long to mention. The following is a list of the prescription and over the counter drugs about which we are most commonly asked and are safe for use in pregnancy. If you have any concerns or questions about anything not listed, please call the office or your local pharmacist. If you are seeing a physician for a condition unrelated to pregnancy, be sure to inform him or her that you are pregnant. We will not prescribe medications for anything other than conditions related to your pregnancy.

1. Pain: Tylenol, Tylenol #3, Percocet. Do not take Motrin, Advil or Nuprin
2. Coughs, cold, flu: Sudafed, Robitussin (not Robitussin DM)
3. Allergies: Benadryl
4. Constipation: Colace, Metamucil, Fibercon, Miralax
5. Antacid: Tums
6. Inhalers: If you are asthmatic and need to use inhalers, you may take these.
7. Vaginal/Yeast infections: Over the counter preparations (monistat, mycelex) are safe.
8. Antibiotics: Penicillin, Amoxicillin, Erythromycin

Whether or not exposure to microwaves is harmful is still controversial. It is believed that two types of human tissue—the developing fetus and the eye—are particularly vulnerable to the effects of microwaves because they have a poor capacity to dissipate the heat the waves generate. The following precautions should take place:

1. Be sure your oven does not leak.
2. Do not stand in front of the oven when it is in operation.
3. Follow the manufacturer’s directions to the letter.

If your dentist wishes to perform dental x-rays, please let him know that you are pregnant. Dental x-rays are directed far away from your uterus. Lead aprons shield your uterus and your baby effectively from any radiation. Determining the safety of other types of x-rays during pregnancy are more complicated, but it is clear that diagnostic x-rays rarely pose a threat to the embryo or fetus. It is usually recommended that elective x-rays be postponed until after delivery.

Electric blankets can raise body temperature excessively, and although their use hasn’t been clearly associated with fetal damage, the theory is there. Be cautious too when using a heating pad. If treatment with one has been recommended by a doctor, wrap it in a towel to reduce the heat it passes along, and limit application to 15 minutes. Don’t sleep with it.

Household Cleaning Products. No correlation has ever been noted that using household cleaning products causes birth defects. No studies have proven that the occasional incidental inhalation of ordinary household cleansers has any detrimental effect on the developing fetus; on the other hand, no studies have proven frequent inhalation completely safe. The following are guidelines in screening out potentially hazardous chemicals:

1. If the product has a strong odor or fumes, don’t breathe it in directly.
2. Use pump sprays instead of aerosols.
3. Never mix ammonia with chlorine-based products.
4. Try to avoid using products such as oven cleaners and dry-cleaning fluids.
5. Wear rubber gloves when you’re cleaning.

Insecticides. Some chemical insecticides have been linked to birth defects. Whenever possible, take the natural approach to pest control. If your neighborhood is being sprayed, avoid being outdoors as much as possible until the odor has dissipated—about 2 to 3 days. When indoors keep the windows closed. The chemicals are only dangerous as long as the fumes linger. Inside the house, use “motel” or Combat-type traps to get rid of roaches and ants; use cedar blocks instead of mothballs in clothes closets.

Paint Fumes. It has been reported that latex paints contain unsafe amounts of mercury. Federal regulations now require that paints be reformulated so they don’t contain mercury. But because you don’t know what hazard may turn up in paint next, painting should be avoided during pregnancy. While painting is being done, try to arrange to be out of the house. Make sure there is adequate ventilation. Completely avoid exposure to paint removers.

Most obstetricians will book prenatal care appointments 4 weeks or more into the future. For this reason, you should call your OBGYN immediately after the initial heartbeat is identified to schedule your first visit about 3-4 weeks later. Please let us know as soon as possible who your OBGYN will be, so that we may get your records to them in a timely fashion. We will also write a letter to your obstetrician to update her/him on your progress. You must sign a form for the release of your medical records. If you do not have an obstetrician, please notify us of this so that we can recommend one for you. After you have delivered, please provide us with the following information: Delivery date, sex and weight of baby(s), pregnancy complications, and any problems with the children.