51% #1705: Infertility and High-Risk Pregnancy
On this week’s 51%, Albany OB GYN Dr. Katherine Cartwright offers her guidance for those struggling with infertility, and we speak with Albany Medical Center’s Dr. Erica Nicasio about her work monitoring high-risk pregnancies.
You’re listening to 51%, a WAMC production dedicated to women’s issues and experiences. Thanks for tuning in, I’m Jesse King.
We’ve got another roundup of health-related conversations for you today. Last week, we took an in-depth look at endometriosis, a disease that, in addition to causing a lot of pain, can also contribute to issues like infertility. But as our first guest today will tell us, there’s actually a lot of reasons why someone may have trouble getting pregnant. It’s an issue that can feel very personal and heartbreaking, so to dispel some myths right up front: infertility doesn’t necessarily mean there’s anything wrong with your body, and it’s actually more common than you might think. According to the Centers for Disease Control and Prevention, roughly one in five American, heterosexual women up to age 49 (with no prior births) will have trouble conceiving after their first year of trying. So if you think you might fall in that group, hopefully today’s episode has some basic information to get you thinking and put you at ease.
Dr. Katherine Cartwright is an OB GYN with Albany Obstetrics & Gynecology. She got her medical degree from Nova Southeastern University and completed her residency at SUNY’s University at Buffalo. Dr. Cartwright says she provides comprehensive women’s health care for patients at various stages in their lives, but as part of that, she provides an awful lot of guidance to women (and couples) struggling to conceive.
The way that we medically define infertility is 12 months of inability to conceive, despite regular intercourse and regular cycles. Within 12 months, somewhere between 80-90 percent of couples will be able to achieve a pregnancy on their own. So once they've reached a year, that's when we have a medical diagnosis of infertility. It's a little bit different in patients with different risk factors. So patients who are a little bit older, patients over 35, we use more of a six-month cut off. That has a little bit less to do with a difference in them suddenly being infertile after six months, and more to do with known declining fertility with age and wanting to get those people into medical care and into a workup [sooner].
When we have a patient that's concerned about infertility, there's a wide range of things that we really need to talk to them about. Their medical history is one of the most important things, and then talking to their partner and having a patient come in and be evaluated with their partner – or at least have good information about their partner – is really important. This is really a two-person issue, if there is a concern about ability to conceive, and about a third of infertility issues actually are male-factor issues. So I think it often is looked at as a solely female problem if someone's not conceiving, and it's something that we have to talk about very early on and make sure that we are looking at all angles.
The basic workup is looking at the very basic building blocks of “How do we make a baby here?” And are all of those parts here? So, is this person making eggs? And are they releasing an egg every month? That's obviously something that's necessary. Is there sperm, and is the sperm normal? Is it present? And then the third thing that we really need to look at is, are they able to meet? So is there a structural thing that's preventing the egg from meeting with the sperm, and those are things we call “tubal factors,” where the actual fallopian tube where they're supposed to meet could be impacted by a variety of different disease processes that could inhibit the ability for an otherwise normal egg and sperm to meet. And that's really where the workup is focused. So we look at all three of those different things in a different way. Usually, we do blood testing, and just talk about a patient's medical history and cycles to see if it sounds like ovulation could potentially be an issue. We generally will get a semen analysis, so that is actual testing of the semen in the sperm from the male partner. And there are tests that we can do, either with dye or with saline that we put through the uterus to actually watch the tubes and see that they are open and able to have a sperm and an egg pass through them.
Once you identify with what the issue is, is it usually an easy fix?
So, it really depends what the causes are. One of the difficult things with infertility is the number one cause of infertility is “unexplained infertility” – that’s an actual, medical diagnosis. And that is where most infertility workups land us, is with what we call “unexplained infertility.” So we do this whole workup, we do lab work, and we say everything looks normal. You know, it's always sort of a double-edged sword of good and bad, because for a patient, there's nothing wrong with you – but we don't have an answer as to why this is happening. [With] unexplained infertility, there are things we just sort of empirically do, which means we're just trying things, helping to time intercourse a little bit better. Sometimes we monitor their cycles and actually help make sure that they ovulate by giving them medications and monitoring their cycles. And even patients with unexplained infertility have relatively high rates of eventually being able to conceive. And sometimes we don't find an answer. But for a patient, what they really want is to have a baby, and so lots of times fertility doctors may say, “We don't have a good answer as to why this hasn't happened, but here are all of the options and things that we can try.” And that's everything from IUI, which is insemination, to IVF, which a lot of people are kind of familiar tangentially with IVF and how that works. And so sometimes patients ultimately go on to have these more invasive infertility interventions and treatments without ever having a definitive answer as to why they weren't able to get pregnant on their own.
Do you have any thoughts on IVF or IUI? Like, is there one that I guess is easier?
It depends, it depends on the patient. And I think there's different factors to consider. There are people who just don't want to go the route of creating embryos and re-implanting them – that’s what IVF is. So IVF is where they actually take eggs out of someone's ovary, they fertilize them with sperm, they grow them, make sure that they're growing, and then they essentially put them back in the uterus to grow. And so it's definitely a lot of technology that's used. And that's medically amazing that we have [that], but for some people, it's just too much, and they don't want to do it. For other people, anything they could possibly do is something that they want to pursue. Financially, I think it's a concern for patients. Historically, many infertility treatments have not been well covered by insurance. In New York state, companies now are required to offer some fertility coverage. I don't know all of the details in it, it really depends on the size of the company, and there are some exemptions to that, but we do have better coverage than we used to. So hopefully, there's less of a financial constraint for people that are trying to use these services to grow a family.
Would I be able to ask you about miscarriages?
Yeah, yeah. So early pregnancy loss, or miscarriage, is very common. It's something that, you know, the numbers are mixed, because we know that there are very early pregnancies that are just not clinically recognized, meaning sperm meets the egg, it starts to implant, and the pregnancy fails before a patient even knows that she's pregnant, let alone is actually seen and has labs or an ultrasound or something done. Numbers vary anywhere between 25-30 percent in most documented research on this. So that means there's a quarter to a third of a chance, with every successful fertilized egg that is implanting or trying to implant in the uterus, that that could not result in a successful pregnancy with a baby at the end. Early on in pregnancy, it’s something people worry about a lot. And, you know, we usually will bring them in for initial visits to meet with a doctor and evaluate in early pregnancy, somewhere around eight weeks or so. But in patients who are feeling well, they have a positive pregnancy test, they haven't had pain or bleeding, and they're feeling well, there's no real reason to rule out an early pregnancy loss unless they're having symptoms in most cases. So symptoms of an early pregnancy loss would be things like bleeding, or painful cramping. Those are really the two things that people present with most often. There can be cases of both pain and bleeding that don't result in miscarriage, and it can be a really scary time for patients, because if it's really early, we can't see a pregnancy on ultrasound, we don't have a really good way to confirm that things are moving forward normally, and so there's, unfortunately, a multiple-week period often of just waiting and seeing what will happen for patients. So that can be certainly anxiety-provoking for them. Reasons for miscarriage vary, and similar to infertility, we often just don't have a good answer as to why a miscarriage has happened. A single miscarriage with rates anywhere from 25-30 percent often is just kind of bad luck. Most of those miscarriages have to do with what we would consider a non-viable embryo, an embryo that, as it was dividing, had some kind of chromosomal abnormality that's not compatible with life. And so that's sort of the body's way of not continuing a pregnancy that would not be able to be successful. In patients who have had recurrent pregnancy loss, so multiple miscarriages, the workup becomes a little bit different, and there are other things that we need to look into. This is not infertility, necessarily, in that they haven't been able to get pregnant – that’s what people think of as infertility – but recurrent pregnancy loss, where someone has been unable to have a baby, is still a form of infertility, and is something that needs to be to be looked at.
What do you see as the future of treatment and research for infertility?
It is a much newer field than I think people realize. The first baby ever born from IVF, I believe, is 40 or 41 now. And so if you think of that in the grand scheme of medical science, and what we know, it's really a very, very young field. I think continuing to find treatments and ways to predict fertility is one of the things that I hope we get better and better at. We have patients come in all the time that say, “I would love to have my fertility tested,” and it's just not something that you can do. We can't say, “Here's a test, this means for sure that you are fertile and you will not have any issues with infertility.” Continuing to look at what are some of the factors, especially in this unexplained infertility area where there are huge numbers of patients that have unexplained infertility, I think really focusing on ultimately, can we find a cause for that? What exactly is that cause? And how can we address that in the future is probably one of the biggest things that we need to do.
If someone is struggling with their fertility, what advice do you have for them?
It's always a good idea, before someone even starts to try to conceive, to have a conversation with their provider, whether they see a physician or a midwife, or whoever it is that they see for reproductive health care. Having a conversation, from the beginning, is a way to probably alleviate a lot of the unknowns and the anxieties related around conceiving, and how it will work if there's a problem. So that initial conversation we have with patients a lot, it's called a “preconception visit.” And we talked to them about things that potentially could influence their fertility: Do they have regular cycles? Do they have a history of infections, or pelvic infections? Do they have a history of endometriosis? Looking at the age of patients is something that we always think about in a preconception visit. If I have a patient who's coming to me and is 42, and just got married, and says, “I would like to try to conceive in this next year,” that's a patient that I often will immediately get some baseline labs on and actually recommend that they see a fertility specialist. Over 40 is a specific population of patients who have declining fertility at a rate that we really want to make sure that we're not wasting any time if they have decided that this is something that's important to them, and they want to move forward. These are not patients who I would wait 12 months or even six months to wait and see what happens. We often do what's called “concurrent management,” where they will actively be seeing an infertility specialist to start a workup while they're trying to start to conceive, because we really don't want to have delays in something that we know, biologically, does have some limitations.
So looking at age, looking at all those risk factors, family history is something that we talk about a lot. And then other risk factors that could make a pregnancy more dangerous if they were to be pregnant. So something that would be a high-risk factor for a patient in a future pregnancy is important for us to talk about before they're pregnant. Do they have a cardiac condition? Is it well managed? Do we need to optimize their medical health and talk about medications that are safe in pregnancy, prior to them even conceiving? So that that's really where that conversation should start.
If a patient has a concern that they are not pregnant as fast as they think they should, to me, that is enough to start a workup. So by definition, 12 months under 35, and six months over 35 is the definition of infertility, if you haven't been able to conceive. But if I have a patient who walks in and says, “I only get my period every three months,” it's not realistic to wait 12 months, because they haven't really had 12 months of chances if they're not ovulating every month, or they're not having regular cycles. Or if a patient says, “I conceived all of my other kids within one to two cycles, and it's been eight months so I'm really concerned,” that's a patient that I would also really start and initiate a workup. So I think the patient's concerns are important, and that's important to bring to any physician that you talk to, because that often is enough to at least start an initial workup for a patient.
As Dr. Cartwright pointed out, conception is just the start — there’s plenty to navigate going forward, and issues to look out for. Our next guest is a maternal fetal medicine specialist at Albany Medical Center. Dr. Erica Nicasio earned her medical degree from Tufts University School of Medicine in Boston, and completed her residency at the University of Massachusetts Medical School. She specializes in the diagnosis and management of fetal anomalies, preterm delivery, hypertensive disease and diabetes in pregnancy, multiple gestation, and more.
What kinds of issues do you see people coming in for?
Some of the more common things that we see are things that are becoming a lot more common for women just in general and in health care, in the population. We see a lot of women that have things like hypertensive diseases, so high blood pressure. The other really common medical issue that a lot of women have or developed during pregnancy is diabetes. So we take care of women both that have either Type I or Type II diabetes prior to pregnancy, to help them with insulin control and their pregnancy management, because it can change what happens with their blood sugars during pregnancy. And then also gestational diabetes, which is a specific form of the disease that develops because of the pregnancy, and can change as the pregnancy progresses. So those are some of the more common things that we deal with from a mom side. We also have complex pregnancies from the baby side, so we deal with those sorts of issues such as women that have had preterm labor, for example, going into labor early and delivering a baby. Or fetal anomalies, so a baby that developed some sort of congenital abnormality or a developmental abnormality that we can diagnose by ultrasound and sort of managing what we do with that going forward.
At what point do people usually identify the fact that they might have a high-risk pregnancy? I'm guessing there's gonna be some people who are going into it knowing that they're going to have a high-risk pregnancy, but are there some identifying factors that they should watch out for?
Absolutely. So that definitely varies, and there's a whole spectrum of high-risk pregnancies. And I think it is hard for women to know what that actually means, and what is defined as a high-risk pregnancy. For example, women that have had complicated medical problems may know that they have a complex medical history, and that makes them high-risk just because of their diseases that they bring to a pregnancy. So someone who has diabetes, someone who has had cancer before and chemotherapy, someone who has lupus, for example. Those sorts of conditions just become a little bit more complicated, or maybe more complex, in a pregnancy. And then as the pregnancies progress, sometimes we have women that develop high-risk issues and then get transferred to us, or have a consultation with us, so that we can discuss how to best manage those pregnancies and those risks that develop. Some examples would be if we do some genetic screening, that's something we offer for women in their first trimester, so early in pregnancy, to look for abnormal chromosomes in the baby. Every woman is offered that screening, if they want to know if they have a high-risk for a baby that has a chromosome abnormality. The most common thing that we see is something like Down syndrome, which would be an extra chromosome 21. So if we do that screening, and that comes back high-risk in their first trimester, often they'll come to us for further testing and discussion of sort of what to do about those findings. Similarly, as the pregnancy progresses, sometimes when we do their anatomic screening, which is an ultrasound, where we look at all of the parts of the baby like heart, lungs, belly, all of the different congenital development of the baby to make sure that everything has formed correctly, sometimes we find abnormalities on those ultrasounds, and often women that have those diagnoses get sent to a specialist like a maternal fetal medicine doctor to have higher level ultrasounds, detailed evaluation, and then again, discussion about how that might affect their baby in utero.
How does multiple gestation complicate a pregnancy? What should people expect if they're planning to have twins or triplets?
That's a good question. So that's definitely one of those high-risk pregnancy issues that get sent to us as well. So multiples have become much more commonplace because of infertility treatment and older women getting pregnant. And oftentimes, we get to diagnose that – so we get to tell a woman who’s had a pregnancy test at home that's positive and comes to an ultrasound and, surprise, we see two babies in there. That can be very exciting. We also have to talk to them about the complications that are increased in those multiple gestations. Pretty much as an overarching rule, most of the complications that we see in pregnancy, like high blood pressure diseases, early labor, gestational diabetes, those sorts of things, are just more commonly seen in a twin pregnancy compared to a singleton pregnancy. You're twice as likely to have a genetic abnormality, for example, because of the additional fetus being there. So these pregnancies are definitely more high-risk than a typical single gestation, so we watch them much more closely than the typical, uncomplicated single baby. And then interestingly, there's different types of multiple gestations, including how the twins formed and how they live inside the uterus. So they can be in their own sac and have their own placentas – completely separate pregnancies, like two babies in there, doing their own thing. And that's generally the lowest risk type of twins. Or they can be sharing placenta, or they can even be sharing gestational sacs, so they're living in the same fluid-filled sac, and those become much more complicated as well. We have to monitor to make sure that they're each getting the nutrients and blood flow and oxygenation that they need to develop appropriately, and if they don't, it can be much more complicated.
I've read that you've also done research on things like preeclampsia, fetal growth restriction and fetal testing and maternal obesity. Could you tell me a little bit about your research there?
Absolutely. So I was looking at preeclampsia, which is basically a high blood pressure disease that develops during pregnancy. Usually after 20 weeks of pregnancy, so it can happen sort of any time. Women develop high blood pressure as well as protein in their urine, and then it can also affect their kidney function, their liver function and their blood counts, like their platelets. And the biggest risk is, you know, a neurologic risk woman can eventually have if not controlled. It can develop neurologic complications like strokes, and seizures, and really scary things that would be dangerous to pregnancy. So we often end up delivering babies on the earlier side, to protect mom's health, because of the risk of the severity of the disease to mom. And in other countries, they see a lot more eclampsia, which is actually the seizures that can develop. And unfortunately, though we see it relatively commonly, especially at a center where we have high-risk doctors, and we get referrals for it, we still don't exactly know even why it happens. So that's sort of what interests me, is sort of trying to help to understand why some women develop preeclampsia and other women don't. We know that there are risk factors from a health perspective – like having high blood pressure, or lupus, or things that affect your kidneys, for example, put you at risk for preeclampsia. But then otherwise, you know, healthy first-time moms [develop issues] – first pregnancies are actually more likely to get preeclampsia than women that have had multiple pregnancies before. And we don't exactly understand the reason for which women will develop this disease and which women will develop even more severe disease, but we think that it has to do with the placenta and how the placenta forms and invades into the uterus and communicates with the blood vessels in mom. That's sort of what I was looking at, was taking women that have preeclampsia and comparing them with women who don't, and looking at their placenta after they deliver, to see if there was a protein that was expressed differently from one pregnancy to the other. But to be honest, you know, people have been researching this topic for many, many years, and we still have lots of question marks. So it's a very, very complicated disease process that, if we were able to figure out the mechanism of why it happens, then we will be able to treat it better. But unfortunately, right now, the only solution is to deliver the baby early to help remove the placenta. And commonly, the disease actually gets much better after delivery.
So this is of course, aside from the usual things people experience with pregnancy, the ways the body changes. I once had a nurse who told me her vision temporarily deteriorated during her pregnancy – is that a thing? What other things might women experience that we just don't talk as much about, or know as much about?
There are a ton of changes just due to having a pregnancy in general. And so women's bodies are going through so many different changes, and then the changes change, as the pregnancy progresses. Pregnancy’s 10 months long, and so it's definitely a journey. The big things that we see are, you know, some physiologic changes, meaning changes that just happened because of the pregnancy: increased blood volume, so you actually have more blood flowing through your body during pregnancy than you do normally, to feed the pregnancy, and then also in preparation for delivery, when the body loses blood. Many women get anemic during pregnancy. And many women can be anemic before pregnancy, but the way the blood is concentrated, actually causes some anemia. So some low blood counts, we monitor for that, for example. Your respiratory system changes, both the way that you're getting oxygen to your body and then also as the uterus grows, it can affect how you breathe, because the uterus gets big enough to affect the diaphragm and its ability to go up and down. And so many women will describe shortness of breath during pregnancy. Another really common one is reflux, acid reflux. A lot of people are prone to that baseline, but in pregnancy, the sphincter that closes your esophagus to your stomach off so that the acid in your stomach doesn't go back up into your esophagus and chest and cause that acid feeling gets looser, because of the hormones of pregnancy. And so a lot of women have issues with reflux getting worse during pregnancy. And then as the uterus grows, it also causes compression of all of your abdominal contents as the uterus kind of fills up the belly and makes that reflux worse. So we see a lot of that as well.
Is the way that we're having babies changing at all in the U.S.?
That’s a good question. In terms of delivery type, our cesarean rates probably have increased over the years, but so has our high-risk pregnancy [rate], and high-risk pregnancies put you at risk for having a cesarean delivery. So I think a little bit of that has probably played into it. I think there's a lot of social pressures that come with the idea women have as to how their delivery should go. And with social media and Pinterest and things like this, people get the idea that it should be one thing for everybody, or that, you know, having a “natural birth” is the only way to successfully have a baby. But there's a lot of ways that babies come into this world. One of the things is, you never know how it's gonna go. And I think people have an idea that they should have a birth plan, and have everything set up and be ready. And having done this for long enough now, what we really know is that generally nothing goes according to plan. And so having a little bit of flexibility and being ready for whatever comes your way during the labor processes is usually a good way to go into it.
Before we go, we’re celebrating Women’s History Month by taking some time each week to recognize prominent women in history. Last week Natalie Rudd joined us from the National Women’s Hall of Fame in Seneca Falls, New York, and she’s back with us to share some more of the “women of the hall.”
Dolores was born in New Mexico, however, she spent most of her life in Stockton, California. Her primary inspiration was her mother: she owned a 70-room hotel where she would often welcome low-wage workers and oftentimes waive the fee for them. She was an active participant in her community and really encouraged cultural diversity, which was really common in Stockton, which was a heavily agricultural-based community. So they had an agricultural community that was made up of Mexican, Filipino, American Japanese, and Chinese working families.
Dolores found for inspiration as an organizer while serving in the leadership for the Stockton community service organization, or CSO. During this time, she set up voter registrations, and pressed local government for barrio improvements. And then in 1955, she was introduced to the CSO director, Cesar Chavez, and the two soon discovered that they had this shared vision of organizing farmworkers. Together, they launched the National Farm Workers Association in 1962. The two were partners in lobbying and really unionizing farm workers in America, and she really came to prominence when she helped organize the 1965 Delano strike of 5,000 grape workers. The strike lasted for five years, and drew national attention for its nonviolent resistance.
During this time, during the national boycott of the California table grapes, she was in New York and she came in contact with Gloria Steinem, who was doing a huge part of the burgeoning feminist movement. And she realized that they have a lot in common, so she was advocating for farm workers while also advocating for women and how they are discriminated within the farm working movement. At the age of 58, she suffered a life-threatening assault while protesting against the policies of then-presidential candidate George Bush. A police officer with the baton ended up breaking for her ribs and shattering her spleen. And then during her really intensive recovery period, she took a leave of absence from the union and focused on women's rights. During this time she traveled the country on behalf of the feminist majority's “Feminization of Power,” which is a campaign that resulted in a significant increase in the number of women representatives at the local, state, and federal levels. So she began her career working with agricultural farm workers and has worked continuously for union rights as well as lobbying to get women into government. Even now, today, at 89 years old, she continues to work tirelessly to help leaders advocate for the working poor, women, and children. She founded the Dolores Huerta Foundation, where she travels across the country engaging in campaigns, all that supports equality defending civil rights, and she often speak to students and organizations about issues of social justice and public policy.
Nellie was a pioneer in investigative journalism in the late 1800s. She was one of the first reporters who truly went behind the scenes to get the real story. She had herself committed to a mental institution in an effort to expose the abuse that occurred there, and the results of this story were reforms that were actually made to living and care conditions at Blackwell's Island Mental Institute in New York City. When this story broke, she became like an overnight sensation, she became an extremely popular reporter. She ultimately ended up shining a light on everything from the improper treatment of prisoners in New York City jails, to the poor working conditions in factories, to corruption politics – she wrote about it all. She ended up gaining a ton of fame in 1899 when she traveled around the world in 72 days, which drew inspiration from the fiction novel Around the World in 80 Days, which is written by Jules Verne. She married a successful businessman, Robert Seaman. And then after he died in 1904, Nellie took control of his company and put into practice all of the workplace reforms that she had envisioned while working as a journalist, such as health care, and adding fitness centers into his company. She ended up unfortunately dying of pneumonia at a very young age of 57, but she had done so much in her lifetime. She really ushered in this whole new era of investigative journalism in such a short life, she really accomplished a lot. And that's like the quick version. I could spend hours talking about Nellie Bly. The small stories about her travels and her journals are really, really incredible.
Natalie Rudd is the learning and engagement manager at the National Women’s Hall of Fame in Seneca Falls, New York. The Hall will be inducting its next class, including Indra Nooyi, Mia Hamm, Octavia Butler, Michelle Obama, and more, this September.
51% is a national production of WAMC Northeast Public Radio. It’s produced by Jesse King. Our executive producer is Dr. Alan Chartock, and our theme is “Lolita” by the Albany-based artist Girl Blue.