Planning for Pregnancy
How does the typical family plan for a vacation? They discuss the idea for a while and then start to do research. Where should we go? What time of year? How much will it cost? What possible concerns might there be? This process of planning and deciding could take weeks or months…all for a one or two week trip. How about buying a new car? The same types of concerns, selection, how much, different options to weigh, research to do.
How do people usually plan for a pregnancy?
Well then, how does the typical couple plan on deciding it's time to have a child? (assuming that it's planned at all!) Typically one partner will suggest that it's time to have a baby and the other one will agree (or not, which is another story), and then they go for it. Maybe there is a brief discussion of the financial aspect, but that's about it.
As an ob/gyn, I can tell you that a scenario I see very often is a woman who is worried because when she was early in the pregnancy, before finding out that she was pregnant, she partied hard over the weekend, drank a lot, smoked, took some prescription medication, or something along those lines. Now, she's concerned if she has somehow hurt the baby. Why didn't she think about this when she was partying? Most people know that the important critical days for a baby to develop are in the first couple of months, and yet they so often take incredible risks because they don't stop to consider whether or not they might be pregnant.
Change your lifestyle before you conceive
This is ironic in a way, because if you ask most women, they will admit to making all kinds of changes once they learn that they are pregnant. No alcohol. Quit smoking. Stop drinking coffee and coke. Getting more rest, more exercise, eating better. These are all important things to do once you are pregnant, but these types of changes ideally should begin BEFORE pregnancy! Those first few weeks are incredibly important.
I would like to strongly suggest the approach that I call Planning for Pregnancy (this article will focus on the woman since she will be the one getting pregnant, although there are things the man can do also). This means doing some homework before becoming pregnant. Learn your family history. Start taking certain vitamins and supplements. Stop taking harmful substances. Change your lifestyle. See an obstetrician to review your health. Have some blood or other tests done to make sure there isn't something wrong that you don't know about. Check your medical insurance. Learn about fertile timing.
Benefits of Planning for Pregnancy
What are the benefits of planning for pregnancy? The main one is to try and prevent the birth of a baby with a birth defect. Other benefits include learning about fertile timing so pregnancy can be achieved sooner, learning about ways to lower the risk of miscarriage, and lastly, learn how to "maximize" fetal potential by being as healthy as possible both before as well as during pregnancy.
Let's talk about this in more detail.
MAKE AN APPOINTMENT WITH AN OB DOCTOR
This is called a preconception visit. The doctor should obtain a detailed medical history of you, your partner and your close relatives. The doctor's job is to analyze your situation as carefully and as thoroughly as possible, looking for any medical situations that might indicate a need for specific tests. Before this appointment, you can start by collecting information and making some changes.
KNOW YOUR FAMILY HISTORY
You should learn as much as you can about your and your partner's close relatives. This includes brothers and sisters, parents and aunts and uncles. Try to identify if any of the following have occurred:
- Any babies born with birth defects
- Any children who were born who died at birth or a young age
- Any relatives or their children with mental retardation or a learning disability
- Any children who had to have surgery at a young age (for example, cleft lip, urinary surgery, heart surgery)
- Any relatives who were told later in life that some condition they have may have been present since birth
- Any relatives that were unable to have children or had many miscarriages
- Anyone with a blood clotting disorder (Hemophilia or unusual tendency to form blood clots)
- Relatives diagnosed with toxemia, pre-eclampsia or HELLP syndrome while pregnant
- Bring this information to the OB doctor who can help interpret it.
GENETIC DISEASES – ARE YOU A CARRIER?
A huge amount of new information and testing is available to us regarding genetic diseases. These are conditions where a person can be a carrier for a serious disease and yet there is nothing wrong with them at all. If they are married to another carrier of the same disease, there is a high probability that their child can be born with a devastating illness. Conditions such as sickle-cell anemia, cystic fibrosis and Tay-Sachs disease are all inherited this way. These are just 3 of more than 10,000 other genetic conditions inherited in this manner.
For example, the newest testing protocol for anyone of Ashkenazi Jewish heritage is to test for the carrier state of 11 different conditions, all more common in people of this background. There is a 1 in 5 chance that any Ashkenazi Jew is a carrier for one of these 11 disorders, all very serious or even fatal conditions. (See the Genetic Disease Foundation web site for more information). All preventable if the genetic testing is done before pregnancy or early in pregnancy. One in 30 Caucasians is a carrier of Cystic Fibrosis, a devastating lung and intestinal disease. One in 10 blacks are carriers of the gene for sickle-cell anemia.
LIFESTYLE CHANGES TO MAKE
Even before becoming pregnant, there are activities that should be avoided. The main reason is that you may not know when you actually conceive since by the time you are later for your period, you are already 4-5 weeks pregnant.
Avoid the following activities:
- High altitudes, above 8,000 feet.
- Risky sports such as sky diving, hang gliding, skiing, horseback riding (anything where you are at risk of falling or having a collision)
- Scuba Diving
- Extremely hot baths or hot tubs (warm is okay)
- Power Boats, Jet skis, roller coasters, off-road vehicles (extremely bumpy and bouncy)
- Intense exercise, "boot camp," sprinting, prolonged endurance activities
- No alcohol, smoking, drug use
- Don't have medical diagnostic X-Rays during the second half of your cycle, as you may already be pregnant.
- All prescription medicines must be discussed with the OB doctor but do not suddenly stop taking important medication. Many drugs can cause birth defects if taken in early pregnancy. These include Accutane, "statin" drugs (cholesterol lowering), certain blood pressure drugs, seizure medications, Lithium and others.
- Stop taking most if not all vitamins, herbs and supplements, at least until talking with the OB doctor. One prenatal vitamin a day is good to take (see ahead). For example, excess Vitamin A (above 5,000 units a day) has been shown to cause birth defects.
- Do not handle your partner's medications. Certain anti-baldness drugs (Propecia) or prostate meds (Proscar) can be VERY dangerous even in minute amounts if accidentally ingested during early pregnancy.
- Do not eat certain fish such as swordfish or mackerel due to the risk of mercury toxicity. Tuna should be limited to once a week. (FDA Reference)
- Do not eat undercooked red meat or lamb due to the risk of toxoplasmosis. Wash all raw fruits and vegetables very well before food preparation. Stop changing cat litter. Consider a blood test to see if you are immune to Toxo.
- Do not eat packaged sliced deli meats due to the rare risk of Listeria, a very dangerous food-borne infection that can cause miscarriage and fetal death (See the CDC handout on Listeria). Also, do not eat raw white cheeses such as bleu cheese, feta or goat cheese. Only eat hot dogs that have been boiled or cooked very hot.
- Do not tell everyone that you are trying to get pregnant. You do not know how long it will take, and if it does not happen right away, you are likely to get all sorts of unwanted comments and suggestions.
- Men: Avoid prolonged immersion in hot water which may lower sperm count. Cyclists should have a special bike seat to prevent pudendal nerve pressure. Do not use marijuana, it can lower the sperm count and impair sexual potency (as can excessive alcohol).
These activities are okay while trying to become pregnant:
- Travel by airplane is okay
- Moderate exercise as long as your breathing is not severely labored (be able to carry on a conversation). The best approach is to continue the same exercise program as before attempting conception. It is better not to begin an intense training program when deciding to become pregnant.
- Some coffee or caffeine is okay, about 1 cup of coffee per day or two sodas. Decaf is very safe as is most tea (black teas can be close to coffee in caffeine content, herbal teas are very low).
- Diet soda is okay also (this includes Equal, NutraSweet, Splenda and Sweet'N'Low)
- Many over-the-counter medicines such as cold and allergy medicine, Tylenol (better to avoid aspirin, Advil, Motrin and Alleve), heartburn medicine, stool softeners and fiber supplements
- Water-based lubricants during sex (such as Astroglide, K-Y Silk-e or Today personal lubricant) are okay but avoid any vegetable or petroleum based products such as Vaseline, hand lotion, mineral oil, etc.
- It is okay to eat chocolate. Dr. Jick's rule: never tell a pregnant (or almost-pregnant) woman that she can't eat chocolate! Moderation is best, of course.
Positive steps to take when trying to become pregnant:
- See the OB doctor for a preconception visit
- Take a prenatal vitamin daily. This contains folic acid, a B-vitamin that has been proven to reduce the risk of a rare birth defect called spina bifida (neural tube defect involves damage to the brain or spinal cord).
- See your dentist. Untreated cavities can harbor bacteria, and this has been linked to an increased risk of miscarriage and premature birth.
- If you are more than 50 lbs. overweight, trying to lose some weight can help your fertility and can help reduce the risk of pregnancy complications such as diabetes, high blood pressure and Cesarean Section (bigger women have bigger babies which leads to increased rate of C/S).
- If you are more than 10 to 20 pounds below your recommended weight for your height, you should try to gain some weight before conceiving. Very thin women have a rough time in the first trimester, and are at increased risk of severe morning sickness which can result in malnutrition, dehydration and hospitalization for intravenous fluids. Also, some thin women have irregular periods which can reduce their fertility.
- Have a basic idea about your fertile timing. See the section ahead on the "fertile window."
- Check with your medical insurance provider. Is pregnancy a covered benefit? What are the disability or maternity leave policies where you work? It could be VERY helpful to learn this information prior to becoming pregnant in case you need to make some changes.
- Check out your workplace for any possible toxic exposures. Chemicals, x-rays, and infectious diseases can occur in the workplace. Talk to the OB doctor about this.
- Drink only purified water.
- Improve your diet. Lots of fruits, vegetables, fiber, whole grains and dairy. Cut down on red meats, high fat items like butter, cheese, fried foods, salad dressings and sauces, and watch the sweets.
- Think about the timing of conception. You may not have control over this, but just in case, you might look ahead 9 months. If you live in the northeast, do you want your due date in January or February? If you live in southern California, August and September are very hot and extremely hard to handle when you are full term. My advice: try to get pregnant during the months you really don't want to deliver!
MEDICAL ISSUES AND TESTING THAT MIGHT BE HELPFUL
- Basic lab tests can rule out diabetes, anemia, thyroid disease, kidney or liver disease, all conditions that you might not know about but that could have a tremendous negative impact should you become pregnant.
- Tests for immunity to certain conditions such as Toxoplasmosis (toxo), German Measles (rubella) and Chicken Pox. All of these can cause birth defects if acquired during the first or second trimester. Vaccinations are available for chicken pox and rubella, not for toxo.
- STD tests might be needed if you are concerned. If there is any chance of HIV, this should be determined before conception so medication can be started right away.
- If periods are irregular, tests should be done for PCO (polycystic ovary syndrome). This hormonal disorder is associated with a high risk of miscarriage (up to 70%!), and is treatable with simple medication (metformin).
- Pelvic ultrasound might be helpful if there is any concern about defects of the uterus or ovarian conditions such as PCO.
- Family history of miscarriages or preterm birth might warrant this.
- Blood tests to check for abnormalities of the immune system or blood clotting disorders might be needed if there is a history of blood clots in you or your close relatives.
- Genetic counselling might be necessary if there significant conditions identifioed in any family member or relative of you or your partner.
- If you take any birth control hormones such as the Pill or the Patch, we advise stopping these and then waiting for one normal menstrual period before attempting conception.
THE FERTILE WINDOW
It is useful to know when during the menstrual cycle a woman is most fertile. The "textbook" menstrual cycle is 28 days long. Day 1 is the first day of bleeding (the first day of the period). Faint spotting should not be counted as day 1. Based on this, the MOST fertile day is day 14, the day of ovulation. The next best days are days 13 and 15. Days 11 and 12 are pretty good but day 16 is a much lower fertility day. Sperm live about 48-72 hours in the genital tract, and the egg takes about 48 hours to go through the tube (which is where conception occurs).
The best day for conceiving a boy is to have intercourse only on day 14. The best day for a girl is to have sex only on day 11 or 12. However, having sex only one day may lower the overall chance for conception.
Therefore, the best days are days 11 to 16. This is your "fertile window." During these 6 days, try to have sex at least twice, but not 2 days in a row. Sex every day is okay, but does not greatly improve your chance of conception.
If the cycle is regular, but not 28 days, the above numbers can be adjusted. For example, if the cycle is 35 days and regular, add 7 to all of the above numbers. Ovulation will be on day 21, and the fertile window will be from days 18 to 22.
For couple who do not have regular cycles or who do not want to look at the calendar, if you are having sex at least 3 times per week, the chances are very good you will not miss ovulation. Some couples work very long hours, or travel a lot, in which case it is very possible to miss the fertile window entirely.
Ovulation kits can help, but often won't test positive until the day before ovulation. Meaning the kit will tell you when day 13 has happened, but you have "missed" the opportunity on days 11 and 12.
If the cycles are completely unpredictable, or longer than 45 days, then you should see an OB doctor right away as there may be a significant fertility issue which is readily treatable.
STATISTICS ON CONCEPTION
- 50% of couples will conceive within 6 months of having unprotected intercourse. 80% will conceive within 1 year, and 90% within 18 months.
- The chance that pregnancy will occur during a single cycle is about 20%.
- If pregnancy has not occurred after 6 months of trying, it might be time to visit an ob/gyn or fertility doctor to discuss the situation.
- Even for healthy young couples there is still about a 15% chance of miscarriage with each pregnancy, even the first one.
- For woman older than 35, it may take longer to become pregnant, the risk of a fertility problem increases, the rate of miscarriage increases to 20% and the chance of a chromosomally abnormal baby is about 1 in 200.
- By age 40, there is only a 25% chance of getting pregnant within 1 year of trying, the rate of miscarriage is above 25% and the chance for a chromosomally abnormal baby is about 1 in 50.
OBSTETRIC TERMINOLGY and DUE DATES
OB doctors always talk about pregnancy starting from the first day of the last period. This means that that day you conceive you are already 2 weeks pregnant, and the day you are late for your period, you are 4 weeks pregnant. Using this method, a full term pregnancy is 40 weeks. Menaing, the due date is 40 weeks from the first day of the last menstrual period. Biologically, the due date is 38 weeks from conception, so these two descriptions are equivalent.
An easy was to estimate your due date if you have 28-day cycles is to take the first day of your last menstrual period, subtract 3 months and then add one week. That will be very close to your actual due date.
Many women do not know when their last period was, or they do not have 28 day cycles. In this case, an early ultrasound can establish the due date, and the number of "weeks" pregnant determined by the ultrasound is based on the 40 week pregnancy counting method. So, in many situations, we know your due date even though we do not actually know the first day of your last period. In these cases, forgot about when your period was and leave it off any paperwork you fill out. It will just lead to two different due dates, something we want to avoid.
By the way, the due date is referred to as the EDC, which stands for Estimated Date of Confinement. Silly, huh? That's medical terminology for you. We prefer to use EDD, Estimated Delivery Date.
Home pregnancy tests are very sensitive, and sometimes the results can be a bit misleading. Testing theoretically can detect pregnancy up to 11 days after conception, which is 3 days before you are even late for your period. However, at this time the body can also have a false positive pregnancy test (called a chemical pregnancy). Thus, the test is weakly positive, but the menstrual period begins a few days later. This can be disappointing if you are not prepared fir it.
It is better to wait until about 1 week late for your period. By this time, the test should be strongly positive, and then we would say that you are 5 weeks pregnant. Early pregnancy symptoms can occur at 5-6 weeks. These include unexplained fatigue, loss of taste for things such as alcohol and coffee, sensitivity to odors, breast tenderness and frequent urination.
IS THERE A TEST TO DETERMINE IF I AM FERTILE?
Unfortunately there is no such test. The only way to know is to try. Assuming that you are otherwise healthy, you should be able to get pregnant. If not, there are lots of OB doctors and fertility specialists available to help you.