Chapter 13 Preparing for pregnancy
Actively preparing for pregnancy is a constructive step towards achieving a positive pregnancy outcome and provides prospective parents with the opportunity to make conscious decisions about their health and lifestyle, options that may not be available once a pregnancy is confirmed. The challenge to health professionals is that pregnancies are often unplanned or women seek care too late for any effective interventions. As part of a primary care team the midwife is in a position to promote and be involved in this aspect of preventive medicine and aid a couple to be physically, psychologically and socially prepared for conception and parenthood.
Preconception care
There has been increasing recognition that a woman’s health status, lifestyle and history prior to conception strongly influence the achievement of a healthy pregnancy outcome. Once a pregnancy is confirmed interventions which could have influenced pregnancy outcome are either lost or ineffectual. Preconception care can be defined as ‘a set of interventions that identify and modify biomedical, behavioural and social risks to a woman’s health and future pregnancies’ which are aimed at both partners achieving optimum health prior to conception (Centers for Disease Control and Prevention 2006, Korenbrot et al 2002).
Preconception advice is readily available in the mass media and the internet. However, the provision of preconception care is still not universal with the majority of services being provided by primary care practitioners most of them opportunistic (Wallace & Hurwitz 1998). Heyes et al (2004) in a study of preconception services found that while agreement of the importance of preconception care was evident, factors that hindered the delivery of such provision were lack of training, resources and practice policies. The Department of Health recognize that half of all pregnancies are unplanned but have made recommendations regarding the availability of pre-conception information for parents including what becoming a parent might be like (National Service Framework, [NSF] 2004).
The preconception period refers to a time span of anything from 3 months to 1 year before conception (Bussell 2000) but ideally should include the time when both the oocyte and sperm mature, which is approximately 100 days before conception (Bradley & Bennett 1995).
A preconception programme takes time to complete; therefore adequate time needs to be allowed for the initial consultation and the subsequent follow-ups where results, advice and treatment may be given. Box 13.1 outlines the information and investigations that may be included.
Box 13.1 Information and investigations in a preconception programme
General health factors
Body weight
Assessment of body type is done by the Quetelet or body mass index (BMI) and is calculated by dividing the weight in kg by the height in m2. It is a reflection of weight for height and therefore a high BMI identifies those people who are relatively overweight irrespective of their height.
Example: For someone who weighs 60 kg and is 1.65 m tall, the BMI is calculated as follows:
BMI charts and calculators are readily available. The desirable or healthy range is between 18.5 and 24.9. The underweight, overweight and obese categories can lead to long-term health hazards (Table 13.1).
Table 13.1 Classification of body mass index (BMI)
| BMI (kg/m2) | NICE classification | BMI classification |
|---|---|---|
| Under 18.5 | – | Underweight |
| 18.5–24.9 | Healthy weight | Normal |
| 25.0–29.9 | Overweight | Overweight |
| 30.0–34.9 | Obesity I | Obese |
| 35.0–39.9 | Obesity II | – |
| ≥40 | Obesity III | Morbidly obese |
Source: Lewis 2007.
By the time a pregnancy is confirmed, much of the cell organization, differentiation and organogenesis has already taken place. Suboptimal conditions at this time can result in fetal damage and stunted growth. An optimum BMI for maximum fertility and for producing a healthy baby of normal birth weight appears to be around 23 (Wynn & Wynn 1983, 1990). Low maternal weight before conception is associated with an increased risk in low birth weight babies and symmetrical growth restriction (Bussell 2000).
The prevalence of obesity has developed into one of the most serious public health challenges in Europe. The last two decades has seen a three-fold rate increase and overweight and obesity are known to shorten life expectancy and increase health risks (WHO 2006). Kanagalingham et al (2005) observed over a decade an increase in the proportion of obese women and the mean booking body mass index (BMI) in a UK maternity hospital. The risk of pregnancy complications and adverse pregnancy outcomes in overweight and obese women are increased. Even moderate overweight is a risk factor for gestational diabetes and hypertensive disorders of pregnancy, whereas overt obesity also includes a higher incidence of caesarean delivery (Bergholt et al 2007). It is most likely that midwives will encounter women who are either overweight or obese prior to and during pregnancy and that obesity related complications will continue to increase. It is now recommended that BMI should be calculated at the beginning of pregnancy (NICE 2003, 2008). The aim of preconception care is to help such women achieve an appropriate BMI prior to conception to enhance pregnancy outcome.
Principles of a healthy diet
Information and advice about a healthy diet is easily obtained from the Food Standards Agency (FSA) website http://www.eatwell.gov.uk/healthydiet. The principles of a healthy diet are to eat more starchy foods such as cereals, bread and wholegrain, at least five portions of fruit and vegetables daily, less fat, salt and sugar and some protein foods such as meat, fish, eggs and pulses. It is important to eat a variety of foods to ensure sufficient vitamins and minerals are included. According to the National Diet and Nutrition Survey (2004) intakes of salt, saturated fat and sugar were above the daily recommended values although total fat was lower. Mean intakes of some vitamins and minerals were low and adults living in households in receipt of benefits also had lower average intakes of energy and some nutrients compared with adults in non benefit households. A large proportion of men and women exceeded recommendations for alcohol consumption. From this brief synopsis it becomes apparent that dietary advice should be offered at every opportunity in an effort to enhance nutritional status. The challenge is to try and alter people’s nutritional attitudes and eating habits.
Folate, folic acid and neural tube defects
Folic acid is a water-soluble vitamin belonging to the B complex. The term ‘folates’ is used to describe the folic acid derivatives that are found naturally in food and the term ‘folic acid’ is used to refer to the synthetic form used in vitamin supplements and fortification of foods. The main sources of folate in the UK diet are dark green vegetables, potatoes, fruit and fruit juices, beans and yeast extract. Folates are vulnerable to heat and readily dissolve in water; therefore considerable losses can occur as a result of cooking or prolonged storage. Folic acid is more stable and better absorbed than folate and is added to many brands of bread and breakfast cereals. All women are recommended to increase their daily folate and folic acid intake by an additional 400 μg prior to conception and during the first 12 weeks of pregnancy to reduce the risk of first occurrence of neural tube defects (NTD) (DH 1992).This can be achieved by:
Women with a history of a previous child with NTD should be prescribed 5 mg of folic acid daily to reduce the risk of recurrence.
It is acknowledged that approximately half of all pregnancies are unplanned and that compliance with the recommendations is difficult. An increasing number of countries have introduced mandatory fortification such as the USA, Canada and South Africa where significant reductions in NTD-affected pregnancies have been reported (Bille et al 2007). Mandatory fortification does have its concerns particularly in relation to older people with vitamin B12 deficiency and the possibility of adverse neurological function, however mandatory fortification has been recommended along with a requirement to reduce folic acid intakes from voluntarily fortified foods and to monitor the effects of long-term exposure above the set limits. Even if mandatory fortification becomes a reality the recommendations of a 400 μg/5 mg supplement are still applicable (Scientific Advisory Committee on Nutrition (SACN) 2006).
Vitamin A
Vitamin A is essential for embryogenesis, growth and epithelial differentiation, but a high intake of the retinol form of vitamin A is known to be teratogenic. Rothman et al (1995) found a high dietary intake of vitamin A produced an increased frequency of craniofacial and heart defects among the babies born to women who had consumed high levels of vitamin A before the 7th week of pregnancy.
Vitamin A comes in two forms – retinol from animal sources and plant carotenoids which are vitamin A precursors. It is the preformed retinol which is of concern. In livestock production the diet is supplemented with retinol and concentrations reflected in animal products with levels being the highest in calf liver and lowest in chicken liver at 25 200 and 10 500 μg/100 mg. There is evidence to suggest that the retinol content of liver has decreased over time. However, women who are pregnant or planning a pregnancy are still advised to avoid eating liver, liver products or supplements including fish liver oils containing retinol. The lowest supplemental dose associated with teratogenic risk is 3000 μg/day (DHSS 1990, SACN 2005).
Mercury
High levels of mercury are found in fish such as shark, swordfish and marlin which can be harmful to the neurological development of the fetus. Women should be advised to avoid eating these kinds of fish and to restrict the consumption of tuna to no more than two fresh tuna steaks or four medium-size cans a week (FSA 2007).
Listeria
Listeria monocytogenes is a bacterium that can cause spontaneous abortion, pre-term labour or stillbirth. Although the incidence during pregnancy is rare, pregnant women or women planning a pregnancy should be advised to avoid eating mould-ripened cheeses such as Brie or Camembert, blue veined cheeses or pate and to ensure that meat or reheated foods are thoroughly cooked (FSA 2007).
Pre-existing medical conditions and drugs
Diabetes
Diabetes mellitus is the most common pre-existing medical condition in pregnancy and the prevalence of both type 1 and type 2 diabetes is increasing. Infants of insulin-dependent diabetics are at an increased risk of congenital abnormalities and perinatal morbidity and mortality (Macintosh et al 2006).
Preconception care is associated with a significantly lower risk of major and minor congenital abnormalities yet many women neither plan their pregnancies nor achieve adequate glycaemic control before conception (Ray et al 2001). In England, Wales and Northern Ireland in 2002–2003, less than half of pregnant women with pre-existing diabetes had preconception counselling, testing for glycaemic control or folic acid supplementation. The most important aim of preconception care is to achieve the best possible glycaemic control before pregnancy as the teratogenic effects of hyperglycaemia occur during organogenesis. Diabetic complications such as retinopathy and nephropathy may worsen during pregnancy. Tight control however is associated with asymptomatic hypoglycaemia and women need to be specifically counselled about prevention and management strategies (Taylor & Davison 2007). Varughese et al (2007) found that diabetic women of childbearing age attending general diabetic clinics were not provided with appropriate counselling regarding the reproductive issues associated with their condition and that some patients were on potentially teratogenic medications. The standards of preconception and pregnancy care need to be improved (CEMACH 2007). The Diabetes NSF recommends that service provision should include all members of the multidisciplinary team (NSF 2001).
Epilepsy
Women with epilepsy need accurate information and counselling throughout the life stages, including conception in order to make informed choices. It is not known whether pregnancy increases the risk of sudden death in epilepsy (SUDEP), however six out of the 11 deaths in the confidential enquiry into maternal deaths met the criteria (Lewis 2007). The aim of preconception care is to help the woman plan her pregnancies carefully and to keep her seizure free on the lowest possible dose of anti-epileptic drugs (AEDs). Folic acid supplements of 5 mg/day should be offered. The risks and benefits of treatment with individual drugs need to be discussed in relation to major malformations as well as longer term neurological and cognitive outcomes (Adab et al 2004). Such assessment is difficult in relation to the newer AEDs as clinical data are limited (NICE 2004a). In a systematic review Adab et al (2004) acknowledged the difficulties highlighted above and cautiously concluded that the consensus of clinical advice was to continue medication during pregnancy using monotherapy at the lowest dose required to achieve seizure control and to avoid polytherapy.
Phenylketonuria
Phenylketonuria (PKU) is an inborn error of metabolism resulting from a deficiency of phenylalanine hydroxylase and characterized by mental retardation (see Ch.48). It is treatable by a low phenylalanine diet although some women with PKU discontinue treatment during childhood. Unless careful dietary control is resumed pre or peri-conception, the toxic effect of phenylalanine (Phe) on the developing embryo/fetus results in a high incidence of microcephaly, mental retardation and congenital heart defects (Rouse et al 2000). An international collaborative study has demonstrated that careful monitoring and controlled dietary phenylalanine restriction during pregnancy decreases the incidence of these morbidities. Optimum fetal outcomes occurred when maternal blood Phe levels of 120–360 μmol/L were achieved by 8–10 weeks of gestation and maintained throughout pregnancy (Koch et al 2003). Maternal dietary control and compliance with therapy is not easy for some women therefore they need help and support (Clarke 2003). Lee et al (2003) argue that this preventable situation is as a result of a lack of appropriate resources for these high risk women. The cognitive and behavioural development of the offspring of these women is also of concern and needs further research (Waisbren & Azen 2003).
Oral contraception
Oral contraception should be stopped at least 3 months and preferably 6 months prior to planning a pregnancy to allow for the resumption of natural hormone regulation and ovulation. The oral contraceptive pill is associated with vitamin and mineral imbalances that may need correcting. Copper levels are raised while zinc levels are reduced and can result in a deficiency of the latter mineral. Vitamin metabolism is also affected, which may lead to deficiencies of folate, B complex and vitamin C and an increase in vitamin A (Bradley & Bennett 1995). Other forms of contraception such as barrier methods will need to be advised during this time.
Drug abuse
The prevalence of taking drugs has decreased slightly in England in the 16–24 age groups with cannabis being the most frequently reported drug used. This was followed by ecstasy, cocaine and amphetamines (DH 2004). Disruption of the menstrual cycle is common among women using drugs like ecstasy, amphetamines, opiates and anabolic steroids, and heavy drug use during pregnancy is associated with miscarriage, preterm labour, low birth weight, stillbirth and abnormalities. Drug users are unlikely to present for preconception care as a high proportion of these women conceal their drug use (Illman 2001).
Environmental factors
Smoking
Smoking can affect women’s sexual and reproductive health as well as the longer-term health status of themselves and their children. Studies suggest that women who smoke may suffer menstrual problems and an early menopause. In terms of fertility, women who smoke are twice as likely to be infertile or take longer to conceive than non-smokers. In men, smoking affects sperm morphology and can cause lower sperm counts. Couples who smoke are also known to have a poorer response to fertility treatments. The adverse effects of smoking during pregnancy are well known with increased risks of ectopic pregnancy, spontaneous abortion, low birth weight, fetal malformations and pre-term labour. Passive smoking is also associated with low birth weight and preterm labour. Other health risks include an increased risk of heart disease and stroke in women who use the oral contraceptive pill and malignant cancer of the cervix. Stopping smoking can reduce or reverse these risks. It is known that smoking is associated with social disadvantage and is more prevalent in the lower social classes and younger age groups. Women whose partners smoke are less likely to succeed in stopping smoking during pregnancy and are more likely to return to smoking after the baby is born (British Medical Association 2004). Lumley et al (2002) in a review of interventions for promoting smoking cessation during pregnancy programmes found that smoking cessation rates were increased and the incidence of low birth weight babies and pre-term labour reduced. Stanton et al (2004) also demonstrated that targeting men for smoking cessation at the time that their partners were pregnant appeared to be an effective strategy. Women should be offered smoking cessation interventions as part of antenatal care (NICE 2008).
Alcohol
Consuming large quantities of alcohol can reduce appetite and affect nutritional status (Goldberg 2000). High alcohol intakes in women have been associated with menstrual disorders and decreased fertility (Jensen et al 1998). Alcohol is a teratogen and fetal alcohol syndrome (FAS) is used to describe the congenital malformations associated with maternal alcohol intake during pregnancy. Fetal alcohol spectrum disorder (FASD) is used to describe the condition associated with alcohol exposure during pregnancy but where the full characteristics of FAS are not fully manifested (see Ch. 46). In view of the fact that the exact dose of alcohol that is safe in pregnancy is as yet inconclusive the safest approach is to abstain from drinking alcohol while trying to conceive and during pregnancy. For those women who wish to continue drinking alcohol the advice is to drink small amounts of no more than two units not more than once or twice a week as this has not been shown to be harmful (Mukherjee et al 2005, RCOG 2006).
Counting units of alcohol is an effective way of calculating alcohol consumption although consideration should be given to the amount and type of alcohol consumed as home measures tend to be larger (Box 13.2). Women who have difficulty in reducing their alcohol intake should be referred to local counselling or support services.
Exercise
Moderate exercise is known to be beneficial for health and the benefits of regular exercise for the healthy pregnant woman appear to outweigh the risks (see Ch.16). Clapp (2006) advises that healthy women who exercised regularly in the preconception period should be encouraged to continue either at an equivalent level or at least half of that level and sedentary women should be encouraged to increase their recreational activity. A randomized comparative trial of the efficacy and safety of exercise during pregnancy is currently being conducted for women at risk of gestational hypertension or preeclampsia (Yeo 2006). The outcomes of this study will be of interest to midwives and obstetricians.
Workplace hazards and noxious substances
Humans are exposed to many environmental agents that may be hazardous to their reproductive capacity and much of this exposure may occur in the workplace. Some occupational exposure to hazards can reduce male or female fertility (RCOG 2004) although the Health and Safety Executive (2006) require employers to ensure that exposure to substances that can cause occupational asthma, cancer, or damage to genes that can be passed from one generation to another, is reduced as low as is reasonably practicable. Reports of miscarriages or birth defects among workers using visual display units (VDUs) have not been borne out.
Genetic counselling
Any couple who has a family history of genetic disorders or who has had a previous baby affected with a congenital abnormality will inevitably want to discuss the reasons why it happened or the implications of such conditions for any future offspring they may have. Turnpenny & Ellard (2005) describe genetic counselling as a process of communication and education where the overarching principles are to:
The concept of risk is not always easy to understand for some people and risk figures are often quoted as either odds or percentages (see Ch. 18). It is important therefore that a consistent and clear approach is adopted to avoid any confusion and the couple’s perspective of the problem ascertained so that they are able to decide for themselves what constitutes a ‘high’ or ‘low’ risk (Turnpenny & Ellard 2005).
Chromosome abnormalities
Chromosome aberrations include the trisomies, such as trisomy 21 (Down syndrome) and the rarer trisomy 13 and 18. Age factors are significant particularly in Down syndrome, for which the risk is 1% for a woman around 40 years of age. Monosomies are usually lethal and non-viable autosomal trisomies are extremely common in spontaneous abortions. Sex chromosome abnormalities, such as Turner’s syndrome (XO) and Klinefelter’s syndrome (XXY) have a rare recurrence rate in families. Translocation is where genetic material is transferred from one chromosome to another and is regarded as reciprocal where there is exchange of chromosome material but no change in chromosome number. The incidence of reciprocal translocations is approximately 1 in 500 in the general population (Turnpenny & Ellard 2005).
Mendelian inheritance
Genetic disorders can occur as a result of Mendelian inheritance and are either dominant or recessive. An autosomal dominant disorder manifests when the condition is present in the heterozygous state (i.e. only one gene of a pair of chromosomes need be affected). The risks associated with this inheritance pattern are relatively straightforward – there is a 1 in 2, or 50%, risk in a couple where one of them is affected with the condition. An autosomal recessive disorder manifests only in the homozygous state (i.e. both chromosomes of a pair must be affected), which means that any offspring of an affected individual are obligatory carriers given that the other partner is unaffected.
Consanguinity is an important consideration in relation to autosomal recessive disorders. The incidence of congenital malformations in the children of first cousins is approximately twice that seen in the children of unrelated parents. Rates of consanguinity vary from <1% in Northern Europe to >50% in some Arab states (Turnpenny & Ellard 2005).
Multifactorial inheritance
The commoner congenital malformations, such as cleft lip and congenital heart disease do not follow any recognized pattern of Mendelian inheritance. These conditions arise as a result of a combination or interaction of environmental and genetic factors and are referred to as showing multifactorial inheritance even though they show a definite familial tendency and an increased incidence in close relatives (Turnpenny & Ellard 2005).
Prenatal diagnosis
Prenatal diagnosis is an option for couples who are at high risk of having a child with a serious genetic condition. For some couples such an option inevitably includes the difficult decision of whether to terminate the pregnancy or not. Ideally, for a couple to truly benefit from this option they should be identified and assessed before a pregnancy is planned so that they can be counselled and given the time to consider the risk and come to a decision based on the options available to them. Preimplantation genetic diagnosis is also an option particularly for couples undergoing assisted conception (Turnpenny & Ellard 2005).
Infertility/subfertility
The National Institute for Clinical Excellence (NICE 2004b, p 10) define infertility as ‘failure to conceive after regular unprotected sexual intercourse for two years in the absence of known reproductive pathology’. Approximately one in seven couples in the UK has difficulty conceiving. It is further estimated that of 100 couples trying to conceive naturally, 85 will conceive within 1 year and 95 within 2 years (Human Fertilization and Embryology Authority HFEA (2007)). Couples who have been unable to achieve a conception after 1 year are referred to as being subfertile. Infertility is categorized as primary if there has been no prior conception and secondary if there has been a previous conception. There have been no major changes in the prevalence of fertility problems although more people now seek help than did so previously. The trend is for women to have fewer children and to delay childbearing until a later age when there is an associated decline in fertility (RCOG 2004). Natural human fertility is low compared with other species and the chance in the most fertile of couples conceiving within one menstrual cycle is no higher than 33% therefore to expect a higher chance of pregnancy than this from any fertility treatment is unrealistic (Cahill & Wardle 2002).
The factors responsible for infertility are many and varied, with an incidence in men up to 30% (Box 13.3) and in women up to 40% (Box 13.4). Of these, approximately 39% of cases of infertility involve problems with both partners. In 30% of couples the causes of infertility remain unexplained (RCOG 2004).
Initial management of the infertile couple
Much of the initial management of the infertile couple is via primary care, therefore the preliminary investigation of both partners and subsequent referral to specialist care will be through the general practitioner. Early referral is indicated where the female partner is over 38 years, has a history of infertility of more than 3 years, has indicative tubal disorder, ovulation disorder or where the male partner has an abnormal semen analysis. The investigative process is aimed at achieving an accurate diagnosis and definition of any cause, an accurate estimation of the chance of conceiving with and without treatment and a full appraisal of treatment options. Providing information, counselling and support are also an integral part of the management to help the couple cope with the stress of treatment and the possibility of failure (Cahill & Wardle, 2002).
It is important that both partners are involved in the management of their infertility and that full explanations are given to the couple at each stage in the investigation and treatment. This should be backed up with written information including a list of addresses of relevant organizations and fertility support groups. Rubella status should be confirmed and folic acid supplementation commenced for the female partner. A detailed drug history should be taken from both partners including any history of drug abuse and any occupational factors. General advice regarding lifestyle factors such smoking and alcohol should be given to both partners and weight control advice for the female partner if appropriate. The couple should be advised that sexual intercourse every 2–3 days optimizes the chance of pregnancy. The male partner should have semen analysis undertaken as part of the initial assessment (Box 13.5). Women with regular menstrual cycles are likely to be ovulating but women with regular cycles and a history of more than 2 years infertility should have measurement of serum progesterone levels to confirm ovulation. Women with irregular or prolonged irregular cycles should have serum progesterone and serum gonadotrophin levels measured (RCOG 2004). Most investigations are relatively simple but more specialized investigations need to be undertaken in a dedicated, infertility clinic where there is access to a specialist team as this is likely to improve effectiveness, efficiency and patient satisfaction. The most important predictors of a successful conception in infertile couples undergoing investigation and treatment are the female partner’s age, the duration of infertility, previous pregnancy history and the quality of the sperm. The success rate for in vitro fertilization treatment declines with increasing age and previous IVF failure (RCOG 2004).
WHO Normal semen analysis values (WHO 1999):
Regulation
Any centre that provides techniques that involves fertilization outside the body has to be regulated by the Human Fertilization and Embryology Authority (HFEA), a statutory body that was created in 1991 following the passing of the Human Fertilization and Embryology Act in 1990. Its primary responsibility is to license and monitor clinics in the UK that offer in vitro fertilization (IVF) and donor insemination (DI) treatments, human embryo research and to regulate the storage of eggs, sperm and embryos. The HFEA Code of Practice (2003) imposes obligations upon centres to take account of the welfare of the relevant children, to give and record information and to provide counselling.
Assisted conception techniques
The aim of all assisted conception techniques is to promote the chances of fertilization and subsequent pregnancy by bringing the sperm and egg close to each other. A range of assisted reproduction techniques is available to treat the infertile couple and it is important that the appropriate treatment option is offered (Rowell & Braude 2003).
Ovulation induction
The principles of management of ovulation disorders include diagnosis and treatment of underlying causes and once an adequate sperm count and tubal patency have been confirmed ovulation induction can be commenced.
The World Health Organization classifies ovulation disorder into three groups:
Clomifene citrate and tamoxifen are referred to as anti-oestrogens and are a first-line treatment for Group II ovulation disorders. Clomifene citrate works by blocking oestrogen receptors in the hypothalamus inducing negative feedback, gonadotrophin secretion and follicular growth stimulation. Adverse effects of such therapy include multiple pregnancy, ovarian hyperstimulation, abdominal discomfort and hot flushes. Treatment should be for up to 12 months and women should be informed of the risks of treatment and offered ultrasound monitoring at least during the first cycle of treatment (RCOG 2004).
Women with clomifene-resistant polycystic ovarian syndrome can be treated with gonadotrophins, either human menopausal gonadotrophin, urinary follicle-stimulating hormone or recombinant follicle-stimulating hormone. Ultrasound monitoring is undertaken throughout the treatment to measure follicular size and number to reduce the risks of multiple pregnancy and ovarian hyperstimulation syndrome (RCOG 2004).
Dopamine agonists such as bromocriptine and cabergoline are safe and effective treatments for women with ovulatory disorders due to hyperprolactinaemia (Cahill & Wardle 2002).
Intrauterine insemination (IUI)
IUI is indicated as a first-line management where there are problems such as hostile cervical mucus, antisperm antibodies or male fertility problems such as a low sperm count or premature ejaculation although tubal patency of the female partner must be assured. It is also useful for cases of unexplained infertility. In order to increase the chances of success, ovulation is monitored and often induced and the sperm prepared to maximize its fertilizing ability before being inserted high into the uterus. If the sperm used for the procedure is freshly produced from the male partner then a license is not required. If the sperm from the male partner has been previously frozen or if donor sperm is used then the clinic carrying out the procedure must be licensed by the HFEA for the storage of sperm. The probability of a successful conception with IUI is greater in the first four attempts with the likelihood of success being reduced thereafter (Jenkins et al 2003).
In vitro fertilization/embryo transfer (IVF/ET)
In vitro fertilization describes the laboratory technique where fertilization occurs outside the body and is one of the main types of assisted conception techniques used. IVF is indicated in cases where the female partner has uterine tube occlusion, endometriosis or cervical mucus problems, or where male factors are the main problem. It may be appropriate for cases of unexplained infertility or when less invasive methods have been unsuccessful. It also provides an opportunity to detect specific sperm abnormalities and the fertilizing ability of the sperm. Stimulation of the ovaries to produce more than one egg is required and treatment starts with pituitary desensitization followed by gonadotrophin injections. The use of gonadotrophin releasing hormone (GnRH) agonists and more recently GnRH antagonists facilitates better control of cycles by preventing the physiological surge of luteinizing hormone and oocyte release. Transvaginal ultrasound monitoring of the ovaries is recommended and an injection of HCG is given 34–38 hrs before egg collection. Transvaginal follicle aspiration is now the method of choice for oocytes retrieval and is conducted under mild sedation. The oocytes are examined for maturity and if suitable are then placed with the prepared sperm from the male partner or donor and incubated. Embryo transfer is usually performed on the 2nd or 3rd day after insemination at the four- or eight-cell stage (Balen & Jacobs 2003). No more than two embryos can be transferred to women aged <40 years and no more than three in women aged over 40 years in any one cycle regardless of the procedure used. Any remaining embryos may be frozen for later use if the clinic is able to offer this facility (HFEA 2003).
Intracytoplasmic sperm injection
Developed in 1992, intracytoplasmic sperm injection (ICSI) is a highly specialized variant of IVF treatment that involves the injection of a single sperm into the cytoplasm of an egg with a fine glass needle. It is a useful technique when sperm quality is poor and in azoospermic men sperm can be obtained surgically from the epididymis or extracted from the testis itself (Braude & Rowell 2003a). Ovulation stimulation is required as in IVF and only mature oocytes that have extruded the first polar body are suitable for use.
Gamete intrafallopian transfer and zygote intrafallopian transfer
Both gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) are laparoscopic techniques that offer little clinical advantage over in vitro fertilization and are no longer recommended (NICE 2004b).
Complications of assisted conception techniques
Ovarian hyperstimulation syndrome
One of the most serious iatrogenic problems associated with superovulation is ovarian hyperstimulation syndrome (OHSS), which can be a potentially life-threatening event. Incidence is between 0.6 and 10% of IVF cycles and 0.5% and 2% in its severe form. Associated risk factors include polycystic ovarian syndrome, young age, lean physique, HCG administration and multiple-pregnancy. Management and treatment is dependent upon the severity but should be in a specialist hospital and should include monitoring and multidisciplinary team involvement (Braude & Rowell 2003b).
Ectopic pregnancy
Ectopic pregnancy occurs in approximately 0.5–1% of all pregnancies but can rise to around 4–5% following assisted conception therapies. It is associated with significant mortality but is often detected early due to ultrasound monitoring (Balen & Jacobs 2003).
Multiple-pregnancy
Multiple-pregnancy, especially higher order multiples are associated with more complications during pregnancy and significant morbidity and mortality mainly due to the increased risk of preterm birth. The rate of triplet and other higher order births has been linked to the advent of assisted conception techniques. Ovulation induction requires careful monitoring and may result in cancelled cycles to reduce the risk. Only two embryos may be transferred in an IVF treatment cycle except in special circumstances (HFEA 2003).
Intracytoplasmic sperm injection and in vitro fertilization
There are concerns regarding the risk of major birth defects after intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF). According to Hansen et al (2002), infants conceived with the use of such techniques have twice as high a risk of a major birth defect as that of infants conceived naturally. Devroey & Van Steirteghem (2004) also state that ICSI is associated with a significant increase in de novo chromosomal aberrations. The use of ICSI has transformed the treatment of severe male infertility and has resulted in a substantial number of couples being able to have their own genetic child instead of artificial insemination with donor sperm. It is argued that the increased risk may be due to factors associated with infertility and the need for ICSI or IVF in the first place. The likelihood of chromosomal abnormalities increases as sperm counts decrease therefore males may pass on to their sons the same aberration that would render them sterile also. According to Devroey & Van Steirteghem (2004) follow-up studies in infertile couples obtaining spontaneous pregnancies and pregnancies after reduction of ovulation and after mild ovarian stimulation are needed in order to judge the congenital malformation rate after IVF or ICSI. In view of these risks couples undergoing such procedures should be offered appropriate genetic counselling and testing (RCOG 2004).
Sperm and egg donation
Any person considering donation of either sperm or eggs must undergo an assessment and screening process before any gametes are provided, and be aged over 18 and under 35 years for women and under 45 years for men. A medical and family history is taken including details of any donations that have been made elsewhere. Only 10 live birth events defined as the birth of a child or children, i.e. twins and triplets, are permissible from donors of gametes or embryos under the HFEA (2003) regulations. The screening process aims to prevent the transmission of serious genetic disorders and includes screening for human immunodeficiency virus (HIV), cytomegalovirus (CMV) and hepatitis B antibodies.
Donors are encouraged to provide as much non-identifying biographical information as possible that can be made available to prospective parents and to a donor-conceived person when they reach the age of 18. This information usually includes a physical description, ethnic group and whether the donor has any children, and now includes the donor’s parents’ ethnic group, whether the donor was adopted, the donor’s marital status and where applicable, the gender of any children. Since April 2005, a donor-conceived person can ask for the donor’s name now and name at birth if different, the date and place of the donor’s birth and their last known address or the address that was recorded at the time of registration. Donors who made donations prior to April 2005 can remain anonymous if they wish but can decide to re-register as an identifiable donor and consent for identifying information to be given to donor-conceived people created using their donation once they reach the age of 18. Although the donor will be the genetic parent, in law they have no legal relationship, legal rights or obligations to any child created from their donations.
The HFEA’s role as the UK’s Fertility Regulator is to ensure that the fertility services people receive are safe, appropriate and sensitive to their needs. The last 5 years have seen a 2.5-fold increase in the number of single women having IVF and a four-fold increase in lesbian couples having IVF (HFEA 2006).
Surrogacy
Legal arrangements for surrogacy require the commissioning couple to both be over the age of 18, married to each other and the child genetically related to at least one of them. Civil ceremonies are not recognized and neither is any contractual arrangement legally binding (Surrogacy UK 2007). This means that either a fertile woman can be artificially inseminated with the sperm of the husband of the commissioning couple or the commissioning couple can undergo an IVF procedure and produce an embryo. The surrogate mother then acts as a host as the embryo is placed in her uterus. The commissioning couple can then apply for a parental order within 6 months of the birth as long as the child is living with them. The surrogate mother must still register the birth, as consent to the parental order cannot be given until 6 weeks after the birth of the child and no money other than reasonable expenses must have been paid. When a court has granted the parental order, the Registrar General will make an entry in a separate Parental Order Register re-registering the child. Adults who are the subject of parental orders are able to gain access to their original birth certificates after being offered counselling.
Psychosocial and psychological aspects of infertility
The inability to conceive children is a stressful situation for couples and individuals alike and can have deleterious social and psychological consequences. Commonly reported feelings are of guilt, anger, depression, anxiety, inadequacy, grief, loss of control and low self-esteem (Read 2004). Many of these symptoms persist over extended periods of time. The psychological distress appears to be more common in the partner with the fertility problem and infertile women are reported to have significantly higher levels of depressive symptoms relative to fertile women although men can also experience considerable distress. Most infertility patients, especially women consider the evaluation and treatment of infertility to be the most upsetting experience of their lives and the negative psychological impact of infertility by many health providers and mental health clinicians is underestimated. Women often have to undergo the bulk of the invasive procedures and are responsible for the daily monitoring activities required of treatment regimes and its subsequent disruption of their lives. Even when the reproductive impairment lies with the partner, women tend to carry the psychological burden although men appear to negotiate the transition to a childless lifestyle more easily than their wives (Cousineau & Domar 2007). However, infertility can also have positive effects with couples feeling closer by improved communication, having increased sensitivity to partner’s feelings and a sense of closeness (Leiblum 1997).
Fertility clinics should aim to address the psychosocial and emotional needs of their patients, as well as their medical needs. The availability of appropriately trained counsellors is essential in the management of the infertile couple, as there are fundamental differences in their requirements from those of other disease-oriented consultations. The first is that the central focus is the couple’s inability to fulfil their desire to have children. The second issue is that the interests of the child that may be conceived must be considered. Third, the treatment process often involves repeated therapies that if unsuccessful, create further stress and disappointment, and finally the couple are obliged to share intimate details of their sexual behaviour (Boivin et al 2001). In a systematic review, Boivin (2003) found that psychosocial interventions in infertility were more effective in reducing negative effects than in changing interpersonal functioning and although pregnancy rates were unlikely to be affected by such interventions, group interventions such as relaxation training were more effective across a range of outcomes than counselling interventions. Both men and women were found to benefit equally from such interventions.
One of the most difficult aspects of infertility treatment for a couple is deciding when to stop. Integral to the process is a realistic appraisal of the couple’s problems before they start and an honest view of the cumulative chance of conception and live birth after a certain number of cycles. Most couples find stopping treatment extremely traumatic and they need help with preparing for this decision. After unsuccessful treatment cycles the number of further treatment cycles need to be discussed and then treatment terminated after that agreed limit (Balen & Jacobs 2003). The couple must then decide whether to remain childless or consider adoption.
Psychosexual aspects of infertility
The stress of infertility and its treatments may cause or exacerbate sexual difficulties for both men and women. For men, this may include erectile or ejaculatory failure, particularly when repeated semen samples are required and for women, the distress or anxiety may lead to arousal difficulties. Couples may also begin to avoid intercourse so as not to remind one or other partner of the fertility problem and feelings of only being wanted, when there is a chance of conception can lead to psychological issues of power and control. Such stresses conspire to alienate couples from the recreational aspects of sexual relations, resulting in an obsessive focus on the procreative aspects instead. Infertility examinations should include an evaluation of a couple’s sexual behaviour including overt and clear questioning about their sexual activity with special reference to frequency and timing of intercourse and whether penetrative sex is actually occurring (Read 2004).
Ethical issues associated with infertility
The advancing reproductive technologies, while achieving the goal for many infertile couples are fraught with ethical dilemmas for all concerned. Resourcing and financial issues result in decisions being made as to who can be treated and who cannot. Issues arise relating to the welfare of the child, the ages of the prospective parents, the loss of anonymity of donors, the child’s rights to know about its genetic origins, surrogacy and the creation of surplus embryos are to name but a few. Although these issues cannot be discussed in this chapter, everyone involved with infertility treatments and assisted conception techniques must be aware of them.
The role of the midwife
The psychological and psychosocial distresses associated with fertility treatments are not only complex and individual to the couples concerned but their effects can be persistent, leaving both partners with feelings of anxiety and low self-esteem. It is important that the midwife is aware of the types and implications of fertility treatments that are currently available and is able to provide care which is empathetic and sensitive to their needs not only throughout the pregnancy but also into the postnatal period as couples who have experienced infertility can also experience difficulties adjusting to parenthood (Balen & Jacobs 2003).
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This is an excellent text that covers all aspects of women’s health
Action on Smoking and Health (ASH): http://www.ash.org.uk
British Agencies for Adoption and Fostering (BAAF): http://www.baaf.org.uk/index.shtml
British Epilepsy Association: http://www.epilepsy.org.uk
British Infertility Counselling Association (BICA): http://74.220.203.213/bica/index.php
British Pregnancy Advisory Service (BPAS): http://www.bpas.org
Diabetes UK: http://www.diabetes.org.uk
Endometriosis UK: http://www.endo.org.uk
Foresight Foresight: http://www.foresight-preconception.org.uk
Human Fertilization and Embryology Authority: http://www.hfea.gov.uk
Miscarriage Association: http://www.miscarriageassociation.org.uk
NHS Pregnancy smoking helpline, Tel: 0800 169 9169
Quit Quit: http://www.quit.org.uk
Resolve: The National Fertility Association: http://www.resolve.org/site/PageServer