Early Pregnancy After Infertility

By Jessica R. Brown, M.D.

The bleeding had grown heavier, the cramps were almost unbearable, and gazing down into the toilet bowl, Jane was certain that she had passed placental tissuea sure sign of miscarriage shed been told. Even more unbearable than the physical pain was the pain in her heart as she contemplated the loss of yet another desperately wanted pregnancy. After 8 years of infertility, 2 GIFT cycles, one miscarriage and one ectopic pregnancy, she had finally conceived tripletswith IVF. The staining began three weeks after the embryo transfer, despite the progesterone and baby aspirin, and had now progressed to a heavy painful flow. An hour later, Jane wept tears of joy when a sonogram revealed two healthy babies still within her womb.  Not long ago, Janes story would have been within the realm of fiction.

Today, with the advent of powerful fertility medications and assisted reproductive technology, stories such as these are not unusual among women who have experienced infertility. But while these women may be outwardly indistinguishable from the average pregnant woman, they may approach pregnancy very differently. The typical pregnant womans concerns:
- Can I still do aerobics?
- I hope I dont gain too much weight.
- Thank heavens I can still have sex.
contrast with those of the typical woman who conceives after infertility:
- Can I still climb stairs?
- I hope this time Ill make it to the point where Ill have a nice big tummy.
- Im scared to have sexare you sure it wont hurt the baby or cause me to miscarry?

For most women, pregnancy is considered a natural, normal process, one which has perhaps been overly medicalized through infertility treatment.

Actually, common-sense advice given to all pregnant women also applies to the majority of women who conceive after infertility: eat sensibly, get plenty of rest and plenty of fluids, avoid alcohol and cigarette smoke, minimize caffeine, and ensure adequate intake of folic acid (0.4 mg/day). If you think you may need medication consult your Obstetrician-Gynecologist. Dont assume that you are prohibited from taking it just because you are pregnant. And yes, you can continue to have sex. Still, the harsh reality is that women who conceive after infertility do appear to experience a higher than average risk of miscarriage and ectopic pregnancy than others. While the miscarriage rate in the normal population has been estimated at 12 to 15%, approximately 20% of IVF pregnancies and 20 to 30% of pregnancies after fertility drugs end in miscarriage.

Furthermore, the fact that very early miscarriages often go unrecognized among the normal population may contribute to the overestimation of pregnancy loss among infertile women, who are apt to know that theyre pregnant the instant they miss a period. In other cases, a miscarriage after infertility may be associated with the condition that caused difficulty conceiving in the first place: polycystic ovarian syndrome, a common cause of irregular menstrual cycles and infertility is associated with an increased rate of miscarriageup to 30%, even in younger women.  And a variety of other conditions, such as disorders of ovulation, anatomic disorders of the uterus, or infection, can be associated with both infertility and miscarriage. Multiple pregnancies, a common side-effect of fertility treatment, are also more likely to miscarry.  Whats more, women of advance reproductive age are at especially high risk for miscarriage: the rate increases from 10% in younger women to 18% for women ages 35 to 39, 34% for ages 40 to 44 and 53% for ages 45 and older.

On another front, the complex relationships between immunological disorders and pregnancy loss are currently the subject of intense research and debate. For example, the antiphospholipid antibody syndrome is a well recognized cause of thrombosis (abnormal blood clotting) and pregnancy loss.   Women with this syndrome test positive for abnormal antibodies,which may include anticardiolipin antibody, antiphosphatidylserine antibody and lupus anticoagulant. Some women with infertility or recurrent miscarriage, as well as some normal women, also test positive for these antibodies. Treatments such as heparin (an anticoagulant or blood thinner) and low dose baby aspirin have been shown to be beneficial for women with the antiphospholipid antibody syndrome. But for most infertile women, the benefit of testing for these antibodies and possibly instituting treatment remains controversial.

Antithyroid antibodies have also been shown by some groups to be associated with decreased success in IVF cycles. Yet among women of childbearing age, the problem these antibodies are most commonly associated with is postpartum thyroidiris (a flare-up of thyroid inflammation after giving birth). Women with antithyroid antibodies are at high risk for hypothyroidism (thyroid underactivity) and should undergo thyroid function testing. The significance of these antibodies in relation to a womans fertility is uncertain. While all women who test positive for antithyroid antibodies appear to be at increased risk of thyroid disease, it is likely that only a subset are at increased risk for miscarriage.

To help minimize the risk of miscarriage, many women who are pregnant after infertility will find themselves being treated with such relatively safe medications as baby aspirin, progesterone supplements, or antibiotics early during pregnancy. For some women, especially those with a history of multiple miscarriages, treatments such as heparin or IVIG (intravenous immune globulin) may be recommended. However, these treatments carry a greater risk of potentially dangerous side effects (such as internal bleeding or anaphylaxis) and should not be given indiscriminately.

Close surveillance during early pregnancy helps identify those women at increased risk for ectopic pregnancy or miscarriages. The average pregnant woman sees her obstetrician at 8 weeks gestation (4 weeks after her missed period) and has a urine pregnancy test and pelvic exam. She may even go through her entire pregnancy without encountering an ultrasound machine. In contrast, previously infertile women undergo serial testing for BhCG levels followed by serial transvaginal sonograms during the first trimester.

The first sonogram is generally performed at 7 weeks when fetal heart activity should generally be present. Heart activity is very reassuring since even in an infertile population only 7% of pregnancies are lost once a fetal heart beat has been confirmed. Compare this to 2% in the general population. Sometimes the sonogram is performed earlier to determine if more than one fetus is present or to investigate bleeding pain in early pregnancy.

Early pregnancy bleeding may be a sign of miscarriage, ectopic pregnancy or placental separation, but it is frequently unexplained. It is reassuring that even in the face of heavy bleeding, a pregnancy that still demonstrates fetal heart activity will continue on toward delivery in greater than 90% of cases.

Jessica R. Brown, M.D., Reproductive Medicine Associates of Brooklyn, Asst. Prof. of Clinical Obstetrics and Gynecology, NYU Medical Center


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