Your Maternity Journey Vol. 5

When Conception Gets Complicated: Infertility and Miscarriage

In the U.S., an estimated 10-15% of couples struggle with infertility. Medically, infertility is diagnosed after a couple has been unable to conceive for a year, despite having frequent sex without the use of birth control. Infertility can have a variety of causes involving one or both partners. One-third of the time, the issue is with the woman and one-third of the time, with the man. In the remaining cases, there may be issues with both partners, or the cause of the infertility may be impossible to determine.

When to See a Doctor

While most couples do eventually manage to conceive, don’t wait to consult your doctor if any of these conditions apply:

• You are younger than 35 and have been trying to conceive for a year
• You are 35 or older and have been trying to conceive for at least six months
• You are over the age 40
• You have very painful/irregular periods or are not menstruating at all
• You have endometriosis or pelvic inflammatory disease
• You have had two or more miscarriages
• You have undergone treatment for cancer

Your partner should also consult a doctor if he:

• Has a low sperm count or other problems with sperm
• Has a history of testicular, prostate, or sexual problems
• Has undergone treatment for cancer
• Has small testicles
• Has a swelling in his scrotum
• Has family members with fertility problems

Causes of Female Infertility

Many conditions, or combination of conditions, can make it difficult to conceive or carry a baby:

• Ovulation disorders such as polycystic ovarian syndrome, or hormonal imbalances involving either thyroid hormones or the hormone prolactin, which can prevent or disrupt ovulation.
• Uterine or cervical abnormalities, such as an abnormally shaped uterus or polyps or benign tumors in the uterine wall, can interfere with implantation of a fertilized egg.
• Salpingitis, a condition in which the fallopian tube is damaged or blocked, prevents the release of an egg into the uterus.
• Endometriosis is the abnormal growth of uterine tissue outside of the uterus itself, which may impact the function of the ovaries, uterus, and fallopian tubes.
• Ovarian insufficiency (early menopause) is when the ovaries stop working and menstruation ends before age 40.
• Pelvic adhesions are bands of scar tissue that can form after pelvic infection, appendicitis, endometriosis or abdominal or pelvic surgery, which can then affect fallopian tube and ovary functions.
• Certain cancers as well as the chemotherapy and radiation commonly used to treat cancer can also impact fertility and increase the risk of miscarriage.

Treating Infertility in Women

Once the cause of a woman’s infertility has been identified, there are several categories of treatment:

Medication
A variety of prescription medications are available to treat infertility. Some stimulate egg maturation while others cause the ovaries to release more eggs. Medication is also available to suppress abnormal prolactin levels, which can interfere with ovulation.

Surgery
Surgery can be used to repair blocked or damaged fallopian tubes or remove fibroids, polyps, and patches of endometriosis.

Assisted Reproductive Technology (ART)
If you’ve undergone infertility treatments without getting pregnant or are trying to conceive without a male partner, you may choose to consult a fertility specialist about Assisted Reproductive Technology, or ART.

• Intrauterine Insemination (IUI) is a procedure in which your partner’s sperm is injected directly into your uterus via a catheter. IUI may be prescribed in conjunction with medications that stimulate ovulation.
• In Vitro Fertilization (IVF) is a procedure in which a couple’s egg and sperm are incubated together in a lab to produce an embryo. The embryo is then placed in the woman’s uterus in the hopes that it will implant. IVF is a 4-step process:

1. For 8-14 days, a woman is given daily injections to stimulate the production of many mature eggs at a time. When the eggs are mature, ovulation is induced via an injection of the hormone hCG.
2. Using ultrasound to guide the retrieval procedure, the doctor inserts a hollow needle through the walls of the vagina and into the ovaries to suction out the mature eggs.
3. A semen sample is placed in a dish with the egg(s) and left overnight in an incubator. Fertilization usually occurs on its own.
4. Performed in the doctor’s office, embryo transfer occurs 1 to 6 days after retrieval. Using a long, thin tube, the healthcare provider injects the embryo into the uterus through the vagina. If the procedure is successful, the embryo will implant into the lining of the uterus 6 to 10 days after retrieval.

When conception doesn’t happen as quickly or easily as you’d like, it can be frustrating and emotionally challenging. But with proper treatment, 85-90% of all infertility issues can be resolved, so it’s important to have hope and get help as soon as you suspect there is an issue.

Miscarriage

Miscarriages are common, occurring in 15-20% of pregnancies, usually in the first trimester. A miscarriage can happen any time after fertilization and can easily be mistaken for a period if it occurs during the first 8 weeks of pregnancy. Recurrent miscarriages that occur within the first trimester are usually due to genetic or chromosomal problems of the embryo. Structural problems of the uterus can also play a role in early miscarriage. When recurrent miscarriages occur in the second or third trimester, the cause could be uterine abnormalities, autoimmune problems, an incompetent cervix, or premature labor.

A miscarriage is a traumatic and usually unexpected event, and grieving is both normal and healthy. It’s important to remember that even after losing two pregnancies in a row, more than 50% of couples will go on to have healthy babies without fertility treatment. However, it is still a good idea to consult a fertility specialist after two consecutive miscarriages, especially if you are 35 or older.

The Emotional Toll of Infertility and Miscarriage: Tips for Taking Care of Yourself During a Challenging Time

In a recent study of 200 couples undergoing fertility treatment, 50% of women (and 15% of men) described infertility as the most upsetting experience of their lives. You may feel depressed, anxious, angry, or socially isolated. Your self-esteem may be affected. You and your partner may be experiencing sexual dysfunction or marital problems. All this is compounded by the high doses of estrogen used for IVF, which can cause mood swings, sleep disturbances, and hot flashes.

After a miscarriage, the emotional repercussion can continue for months. No two women will react the same way. Some are overwhelmed by shock and disbelief. Others feel depressed or angry or have trouble concentrating. Some women have a sense of guilt, even though they did nothing to cause the miscarriage. Others simply feel emotionally numb. Crying jags are quite common and you may feel triggered emotionally when you see a pregnant woman or a cute baby. Moreover, as with IVF, miscarriage involves sudden hormone changes that impact the emotions.

Getting the Help You Need

• Be good to your body. If you’ve suffered a miscarriage or are undergoing fertility treatments, your body has been through a lot. Moreover, you are likely experiencing ongoing stress and anxiety. Stress is how the body reacts to threatening or anxiety-causing situations. The stress response, or "fight-or-flight” reaction, raises your heart rate, speeds up your breathing, causes your muscles to tighten, and increases your blood pressure. Ongoing stress causes physical, emotional, and cognitive issues and depresses the immune system. That’s why it’s so important to eat healthy, exercise, and get plenty of sleep. Stress also causes all kinds of bodily aches and pains, so you may want to get a massage, visit the chiropractor, or take a yoga class.
• Pay attention to your partner’s needs. Whether you are grieving a first miscarriage or dealing with an ongoing struggle with infertility, try to take care of each other. Be respectful of each other’s emotions and coping styles. Some people need to talk, others withdraw. If your coping styles are getting in the way of feeling close to each other, consider marriage/relationship counseling.
• Be “in the moment.” Focusing on a miscarriage or failed in vitro attempt and worrying about whether you will ever have that longed-for child keeps you in laser-focused on the source of your grief. Take refuge in what is happening right now. A dish of ice cream, a butterfly, a spectacular sunset—life’s simple pleasures can distract and relax you. If you have a meditation practice, keep it up. Or try a free, online guided meditation from MarinHealth.
• Spend time in nature. Take walks on the beach or in a park. Notice the beauty that surrounds you and breathe the fresh air. Nature really does have a “healing power.” A recent Japanese study found that people who spent 40 minutes walking in the forest had lower levels of the stress hormone cortisol compared to people who spent 40 minutes walking in a lab. Try these Marin and Sonoma County Healing Places.
• Be open to joy. It’s OK to laugh with friends and family, and enjoy the moment you are in. Joy and laughter are healing.
• Know who NOT to talk to. We all have friends (and family) who are good listeners, and friends we can count on to say the wrong thing. For example, when you’re expressing sadness about losing a baby, Sarcastic Susan might say “You can borrow mine anytime.” She thinks she’s lightening your mood, but you may find her approach insensitive and glib. Philosophical Phoebe might hit you with an empty phrase like “Everything happens for a reason.” Then there’s Rita the Rationalizer, who points out that “Hey, at least you know you CAN get pregnant.” Or Tone-deaf Tabitha whose idea of consoling you is telling you to “Relax! Trying is the fun part." If a confidante has not been helpful during other trying times in your life, don’t count on them being helpful now.
• Seek Professional Support. Only you know how much and what kind of support you need, so be honest with yourself. You are under no obligation to be “tough.” Your emotions may be raw, but they are also perfectly normal. In fact, fertility clinics increasingly recommend mental health screenings before a patient begins treatment. Consider seeing a counselor or therapist, or find an online support group and other resources from The National Infertility Association or Infertility Unfiltered.