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Fertility, Pregnancy, and Childbirth
A Gynecologist Answers Your Most Embarrassing Questions
By Lissa Rankin
St. Martin's PressCopyright © 2010 Lissa Rankin, M.D.
All rights reserved.
From the time I was young, I cursed my uterus. Cramps plagued me when I was trying to do rounds at the hospital, and blood would leak out of my tampons and onto my scrubs in the middle of a surgery. Seeking a way to escape my own womanhood, I discovered that I could take birth control pills daily and never get a period. Why hadn't anyone ever told me this? After I uncovered this secret, I sent my uterus to a dark recess of some basement closet and didn't bleed again for a decade. Every now and then, my uterus (I affectionately call her Yoni) would cry out for me, but I pretty much ignored her. I wasn't a very good friend.
Around the time I turned thirty-four, I heard Yoni calling more consistently, beckoning like a siren bellowing out to sea.
She'd cry, "Lissa! Lissa! Don't forget about me."
And I'd shrug her off: "No, Yoni. I'm busy."
She kept asking, "Aren't we ever going to have a baby?"
I responded with my standard brush-off answer: "Not now, maybe tomorrow."
As my thirty-fifth birthday loomed, I decided to bring it up with Matt, the commitment-phobic perpetual bachelor I had been dating for almost two years. But I wasn't quite sure how to broach the topic. Do you say, "So I've been chatting with my uterus lately"? Or do you couch it in the awkward terms of biological clocks and such?
Now, mind you, I was never one of those women who had to be a mother. I was always a bit on the fence. I love children, and with the right guy I could see myself having oodles of love to offer a child. But I didn't see myself trying to wrangle some guy into fathering my child if he didn't want to be a fifty-fifty parent. So it seemed a strange turn of events to find myself bringing it up. I guess I knew deep down that my beloved Matt would be a wonderful father, and I feared he'd realize this when I was forty-two and past my prime.
So I swallowed my pride and, heart beating fast, I broached the baby conversation. I have to give him credit. In spite of how shocked and blindsided he felt, he heard me, validated me, and promised to give it some thought. I didn't blame him for being surprised. After all, we had joked that we were the perfect couple. I was the twice-divorced girl who never needed to marry again, and he was the perpetual bachelor. But alas, things change.
I asked him to consider my question over the course of the next year — no pressure. I wasn't attached to any answer, and I wouldn't take it personally if he said no. But if, at the end of the year, he said no to having a baby with me, I wanted permission to take it off the table permanently. Not to judge anyone else's choice, but personally, I just didn't want to be a forty-something-year-old woman making a test tube baby because I had delayed childbearing too long.
Almost exactly a year to the date after that fateful day, Matt said yes.
I felt this rush of something — adrenaline, I guess — move through me, and I broke into a cold sweat.
I said, "Well okay then." Matt's face registered panic. Turns out he thought he'd have to do more convincing.
Almost as an afterthought, Matt asked awkwardly, "So, uh, should we get married, then?" No ring. No grand gestures. I agreed. We wanted our baby to know she was chosen.
Soon afterward, I took my last birth control pill and invited Yoni out of the closet.
The next month, Matt and I said our vows in a private ceremony in Big Sur. We fantasized about creating a honeymoon baby, but thirteen days after our wedding my period arrived, splendid in her red dress, leaving me curled up like the fetus I'd hoped I could create. In the throes of terrible cramps and faucets of blood pouring on my sheets, I cried, "Yoni! What are you doing?"
She said, "Ahhh ... I'm back."
To Yoni, I yelled, "No wonder I locked you up!" and to Matt, "Get me pregnant, now!"
Let's just say it was a confusing, exhilarating, and surreal time. I know I'm not the only woman who feels this way about her fertility. For many of us, fertility can be a hot-button trigger. Sure, our bodies signal fertility readiness when we're in eighth grade, but many of us aren't emotionally ready until we're pushing forty.
More and more, we delay even thinking about childbirth until our ticking biological clocks turn up the volume. In my opinion, something is seriously wrong with evolution. With advances in women's rights, greater professional opportunities for women, and an epidemic of commitment-phobic guys, many of us simply aren't ready to reproduce in our twenties, when we're most fertile. And if you're one of those women in your late thirties or forties who is still waiting for Mr. Right, you may be in tears by now. It's just not fair. Why must women fit fertility into such a tight schedule? I mean, seriously. Not to question the Divine, but couldn't we work on fixing this little kink in the system?
If your fertility elicits strong feelings, you're not alone. Maybe you found yourself a young mom, long before you were ready, and now it's time for you to spread your own wings. Maybe you put off childbearing in order to pursue your career and now it's too late. Maybe you got pregnant when you weren't ready and chose to terminate the pregnancy. Maybe you got pregnant but lost your baby. Maybe you popped out your babies right on schedule, but you're so caught up in being a mother that you've forgotten who you really are.
Regardless of your relationship with your own fertility, spend some time with yourself to get in touch with the quiet inner voice of your heart. Instead of second-guessing your fertility decisions and yourself, listen to the guru that lies within you. Keep in mind that every decision we make informs who we are today. It's easy to slide into feelings of regret, but how can we regret what made us who we are?
Is there a test that can tell me whether I'm fertile?
If you've put off pregnancy to pursue your career, waited decades for the right partner, or delayed childbearing to get ready emotionally, you're just like many of my patients. Then one fateful day, you meet the perfect lover, your career is on autopilot, and you realize you're ready. But wait! Is it too late? Wouldn't it be great if you could simply take a blood test that would predict whether you're still fertile?
Unfortunately, it's not that simple. While a blood test called FSH (follicle-stimulating hormone) can be ordered by your doctor and FSH can also be measured more crudely by the over-the-counter First Response fertility test, these tests are far from perfect. While a high FSH level can suggest that your eggs are less fertile, a low FSH does not in any way guarantee that you will get pregnant. And I've seen women with menopausal-level FSH tests conceive. So you just never know until you try. If you conceive and give birth to a child, you're fertile. While you can undergo an extensive battery of tests to evaluate why you might be infertile, normal testing does not prove that you are fertile. And even those tests are imperfect. I've seen many women with abnormal testing go on to conceive naturally after years of expensive fertility treatment. When it comes to a woman's ability to conceive, I've learned to never say never.
We've been trying to get pregnant and I'm so impatient. Waiting is the hardest part. On average, how long does it take for a couple to get pregnant?
I know how frustrating it can be to wait. Once you've finally decided to take the plunge and stop your birth control, you're ready to start decorating the nursery already. When you're trying to plan for a baby, you end up putting your entire life on hold. Can you plan that ski trip over Christmas break? Well, it depends whether you're pregnant by then. Should you buy that fitted blouse that will certainly be out of season by next year? Hard to say — you might be wearing maternity clothes. Should you take that account that will culminate in a big presentation next October? Who knows? You might be on maternity leave by then. Waiting is so hard. And each month that goes by without a pregnancy signals yet another failure — and even more uncertainty. I feel you, sister.
In truth, it takes mere seconds to get pregnant. When just the right egg meets the perfectly suited sperm, they merge in moments. But how long does it take for those ideal conditions to align? It varies widely from couple to couple. If you're having sex at the right time, the chance of getting pregnant the first cycle you try is 30 percent. The second month, you have another 30 percent shot. Most couples who are having sex around the time of ovulation conceive within six months. After that, the pregnancy rates per cycle seem to go down. Studies show that 85 percent of couples get pregnant within a year. By definition, we label the 15 percent of couples who do not conceive in the first year as "infertile," although I hate that term. It feels so defeatist. I prefer the term fertilely challenged.
Over the next thirty-six months, about 50 percent of the remaining couples will conceive spontaneously. The 5 to 7 percent of couples who do not conceive spontaneously within two years are statistically unlikely to do so without fertility treatment. But again, you just never know. I've seen it happen....
Keep in mind that the last thing you want to do when you're trying to get pregnant is stress about it. Stress impairs your fertility. (I know, I know. Now we need to stress about stress!) While waiting is hard, the best thing you can do for your fertility is have sex, have fun, and just go with the flow. If you're desperate to conceive, you're under thirty-five, and a year has passed, or if you're over thirty-five and you've waited six months, you might want to consider seeing a fertility specialist.
If I'm trying to conceive, does having an orgasm help?
Mary Roach, author of Bonk, reports that in the early 1900s doctors recommended orgasm as a treatment for infertility. She says, "The upsuck theory holds that the contractions of a woman's orgasm serve to suck the semen up through the cervix and deliver it quickly to the egg, thus upping the odds of conception. There is evidence that this is true with certain animal species. (Pigs, for instance. In Denmark, pig inseminators actually stimulate the sows while inseminating them for just this reason.) Noted sex researchers Masters and Johnson were 'upsuck' skeptics and designed a study to test this theory. By mixing simulated semen with radiopaque dye and placing it in a cervical cap, they could x-ray women during orgasm to see whether it was being sucked in by the uterus. They found no evidence that it was. Roy Levin, a retired sexual physiologist in the UK, points out that sperm take some time to capacitate, and thus you wouldn't want to deliver the sperm too quickly to the egg, because they're not up to the task yet. So the jury's still out. Unless you are a sow. Then yes, it seems to help."
On the other hand, another study found that women who have orgasms during intercourse after the prospective daddy ejaculates retained more sperm than either those who didn't orgasm or those who orgasmed before their partner. And those who retain sperm in the vagina for ten to fifteen minutes may be associated with higher rates of fertilization.
So it's hard to say. There's certainly no airtight evidence either way, so I say orgasm if you feel like it, but don't make it yet another thing to add to your fertility to-do list. Trying to conceive can be stressful enough, without heaping on additional expectations.
Can abortion cause infertility?
Not usually. But I've been asked that question by hundreds of tearful women. Those who choose to abort babies often have open wounds in their psyche related to their decision. It's an emotionally charged issue already, but if you add infertility to the mix, it's like salt on a wound.
Although I haven't had an abortion, I have stood beside so many women going through the procedure that I almost feel like I've experienced it personally. You find yourself pregnant from the wrong guy at the wrong time, and you do the best you can to make the right choice. You cry your way through the abortion, knowing you don't have any other choice at that moment in time. You heal and move on with your life. Then, ten years later, you've met the perfect partner, you've aligned your life to receive the gift of a child, but you can't get pregnant. Next thing you know, you're kicking yourself, wondering if that long-ago pregnancy was your one-and-only chance to be a mother.
Having trouble getting pregnant often triggers intense guilt, self-hatred, and doubt in women who have previously chosen to terminate a pregnancy. If you're one of those women, please, give yourself a hug. What's done is done. It doesn't benefit you to beat yourself up about a decision you can't undo. While you may be tempted to slide into a free fall of "what ifs," this won't help you one bit. You can only truly live in the present moment. But I'll get off my gynechiatrist soapbox now.
Rest assured that your fertility challenges are likely unrelated to your past choices. Unless you suffer serious-but-rare complications from your abortion, such as pelvic infection or scar tissue inside the uterus, abortion usually does not affect future fertility.
My patient Elaine had two abortions as a teen, and when she tried to get pregnant at thirty-seven, she couldn't. She blamed her abortions and felt that God was punishing her for giving up her pregnancies. In actuality, Elaine suffered premature ovarian failure, meaning that her eggs behaved as if she were in menopause, a condition completely unrelated to her abortions. Personally, I believe in a loving God who feels compassion for the pain Elaine is experiencing, not a vindictive deity who strips women of their fertility out of spite. But that's just me....
So please. Be kind to yourself. It's in the past, and there's no point regretting something from your past. Instead, explore the life lessons you might learn and appreciate the fact that all of our experiences, even the painful ones, help us evolve and grow into the people we are meant to become.
I've heard that abortion increases the risk of breast cancer. Is this true?
As you can imagine, this is a highly charged question. Both abortion and breast cancer are hot-button topics, and when you link them, sheesh! If you Google search this topic, you come across some very passionate folks out there. Because abortion disrupts the maturation process of the breast, it has been hypothesized that it might increase the risk of breast cancer. However, multiple studies do not support an association between abortion and breast cancer. The American Cancer Society's Web site says: "The scientific evidence does not support the notion that abortion of any kind raises the risk of breast cancer." The American College of Obstetricians and Gynecologists issued a committee opinion saying essentially the same thing. While certain political factions would prefer to scare you into never getting an abortion by raising the specter of breast cancer, their allegations have no basis in science and are merely that — scare tactics.
I'm using birth control, and I don't plan to get pregnant. But I'm terrified that I will get pregnant and have to abort the baby. Can you tell me what I might expect if I wind up with a pregnancy I can't keep?
Obviously, it's always better when you can plan a pregnancy, make sure your body is in optimal condition, choose the perfect partner, and time it brilliantly so that pregnancy and parenting fit into your life. But alas, life doesn't always work this way.
Kudos to you for asking before you find yourself with an unwanted pregnancy. Since you're thinking ahead, please don't forget that the morning-after pill (Plan B) exists, and you can purchase it over-the-counter in some states or by prescription in others. It can be a godsend for those broken condoms, skipped pills, or lusty, unplanned sexual encounters that happen when a passionate moment strikes. The sooner, the better, but Plan B is effective up to seventy-two hours after the accident.
Assuming birth control efforts fail and you find yourself faced with a painful choice, remember that it's your body, your life, your pregnancy. 'Nuff said. Of course, there's always adoption (and since my sister is adopted, I'm a big fan). But should you choose to abort a pregnancy, tell someone you love, make sure you have good support, and consider seeing a counselor. It's the hardest thing some women ever do.
Excerpted from Fertility, Pregnancy, and Childbirth by Lissa Rankin. Copyright © 2010 Lissa Rankin, M.D.. Excerpted by permission of St. Martin's Press.
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