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FAQs

Welcome to F.I.R.M. Blogs

I hope to post blog entries on a regular basis to help to answer some of the common questions that we have been asked by patients regarding various subjects in the field of Reproductive Endocrinology & Infertility. This is in an effort to help to provide clear explanations of various conditions, and to counter a lot of mis-information that patients can sometimes receive from other sources such as the internet, friends, or other health professionals. It should be recognized that each patient is in a separate situation which can justify various treatment options. There is not a single right or wrong way to treat each person. The information in these postings is a general educated view that is supported by factual medical literature. I strive to keep this as well as my own knowledge as up to date in the field as possible. Though these opinions are generally held by all of the physicians at the FIRM, understand that slight differences of management may occur depending on a patient’s individual situation. I welcome new questions that can serve as future blog topics.

Smoking and Fertility

Most patients know not to smoke, don’t they? Maybe so, but that doesn’t mean that they (and their partners) don’t smoke, or that they tell the truth to their doc, or that they aren’t exposed to significant amounts of secondhand smoke.

Approximately 30% of reproductive age women and 35% of reproductive age men in the United States smoke cigarettes, as do an increasing percentage of adolescent and teenage girls. This is despite costly and long-standing national campaigns to limit their use.

Given the high prevalence of smoking and the documented variety of deleterious health effects, C. Everette Koop, MD, the former U.S. Surgeon General had appropriately labeled smoking “the chief single avoidable cause of death in our society and the single most important health issue of our time.” Specifically addressing the adverse effects of smoking on reproductive health in the introduction to a Seminars in Reproductive Medicine issue devoted to a review of the this subject , Dr. Koop summarized the available data in stark terms: “Women who smoke have decreased fertility. The risk of spontaneous abortion is higher for pregnant women who smoke… Babies born to smokers weigh, on average, 200 grams less than babies born to comparable women who do not smoke, with low birth weight being an important predictor of infant mortality”

In addition to smokers who inhale the toxic, carcinogenic and mutagenic substances known to be prevalent in cigarette smoke, many nonsmokers are regularly exposed by inhalation of “sidestream” smoke from burning cigarettes and / or from “passive” smoke exhaled by smokers. A recent study documented cotinine, a major metabolite of nicotine, to be found in dose dependent concentrations relative to the number of cigarettes smoked in 100% of the follicular fluids of infertility patients undergoing in vitro fertilization oocyte retrieval. One hundred percent (100%) of women known to be exposed to passive smoke in the home also had follicular fluid cotinine detected, albeit at lower concentrations. What was as alarming was that 84% of women reporting themselves as non-smokers and with a non-smoking partner also had detectable levels of cotinine in their follicular fluids. These women were exposed environmentally, with all but one working outside the home. As the authors, who had previously reported the ovarian toxin heavy metal cadmium in the follicular fluid of smoking infertile patients, state regarding these women, “this constitutes an unsolicited hazard to their health and is an argument for smoke free public areas and workplaces.”

A number of comprehensive reviews of the literature have been published summarizing the cumulative data supporting an association between cigarette smoking and diminished female fecundity. The impact of cigarette smoking on early spontaneous abortion has been an important addition to these reviews on fertility, with the increase in pregnancy loss and ectopic pregnancies attributable to smoking adding to the overall adverse reproductive impact of this habit. It has led Joffe to describe smoking as the foremost reproductive poison of the 20th Century – and, might we add, perhaps the 21st.

Augood estimates that up to 13% of female infertility is caused by cigarette smoking.

The available biologic, experimental and epidemiological data support a substantial increase in female infertility attributable to cigarette smoking.  Stopping smoking in many women not already in earlier menopause and not permanently effected with tubal factor infertility returns the potential for fertility. Ex-smokers have fecundity similar to that of women who have never smoked, often when they quit even within a year of starting to try to conceive. The adverse effects of sidestream and passive smoking are notable and add to the urgency of addressing not only those who smoke in campaigns aimed at prevention of infertility, but those with whom they live and work or share the environment.

Those couples already suffering from infertility need to know that continuing to smoke adversely effects the success of therapy. In particular regarding Assisted Reproductive Technology (e.g. in vitro fertilization therapy), ovarian reserve, ovarian response to stimulation, the number of oocytes retrieved and fertilized, and the pregnancy rates are reduced in smokers compared to non-smokers.

The pregnancy rate in in vitro fertilization treatment cycles was thus reduced in smokers by 34%. The deleterious effect of smoking becomes more detectable in older women undergoing therapy. The percentage of women experiencing conception delay for over 12 months was 54% higher for smokers compared to non-smokers. Exposure to passive smoke further increased the odds against a woman conceiving within 6 months. Smoking by the mother, the father, or other exposure to tobacco smoke were all associated with a longer time to conception.

This information may help those seeking to conceive and carry a healthy full-term infant to do so by imploring them to stop, especially those already having difficulty conceiving or maintaining a pregnancy. And for those not currently seeking to conceive but with wishes and dreams for the future, if they are in need of yet one more health risk to add to the panoply of reasons to discontinue their habit or never start, this information and data may be most useful in the prevention of infertility.

The good news is the ready availability of evidence-based Smoking Cessation Guideline materials for health care professionals and the public, including beneficial brief interventions designed for the busy doctor’s office. First developed in 1996, the Guideline is updated regularly.

See www.surgeongeneral.gov/tobacco/default.htm.

ACOG also has material at www.acog.org/departments/dept_web.cfm?recno=13.

And the American Cancer Society has Great American Smokeout aids at www.cancer.org.

What To Expect On Your First Infertility Visit

Approximately 40% of infertility is related to the female, 30% to the male – in 20% there may be a combined problem (10% of infertility is unexplained).  For that reason patients are encouraged to come in as a couple to review both partners’ history.  The female history will focus on the menstrual cycle, which gives a good idea as to whether ovulation may be the issue, as well as surgical and infectious disease history that may point to an anatomic problem.  The male history will focus on problems that affect sperm production, i.e. surgeries, infections, adverse environmental exposures.  A good history from both partners will go a long way in identifying a probable cause(s).

Generally, a physical exam is not performed on the first visit unless there is something which clearly points to an anatomic problem, i.e. fibroids tumors, ovarian cyst, or very low sperm count.  In the case of a female anatomic problem most often a vaginal ultrasound will be performed to visualize the uterus and the ovaries.  If a male anatomic problem is suspected, an exam of the testicles and phallus will be performed.

If ovulation is a problem, most often an endocrine panel will be drawn to determine the cause.  This will help determine the most appropriate fertility medication.  If the female history points to an anatomic problem most often a hysterosalpingogram or laparoscopy will be ordered.  A hysterosalpingogram is an outpatient procedure performed in radiology whereby the physician injects a radio opaque dye through the cervix and can look at the contours of the uterine cavity as well as determine tubal patency.  A laparoscopy is an outpatient surgical procedure performed under general anesthesia.  If pathology is found laparoscopic operating instruments can be introduced to correct the problem.

If a couple has already had a complete work-up and there is a clearly identified cause(s) for infertility an immediate treatment plan will be outlined.  At the Florida Institute for Reproductive Medicine we will review costs of tests and treatments and will check with your insurance company to determine coverage.

Why Can’t I Have Another Baby?

Almost half of infertility occurs following an initial pregnancy that may have occurred soon after discontinuing contraception.  This problem, known as secondary infertility, is often overlooked or downplayed by physicians who see these patients as being fertile and are then reluctant to evaluate or treat.  Maternal age and the duration of secondary infertility are critical issues.

We know that women are born with a certain number of eggs – they never make any more eggs the rest of their life.  The number and quality of eggs declines as a function time, resulting in a significant decrease in pregnancy rates after age 35, and a drastic decrease after 38.  Infertility is defined as a lack of conception after one year of unprotected intercourse.  For individuals 35 years or older, most reproductive medicine specialists recommend initiation of a work-up after four to six months of trying.  Ultimately, again, remaining egg number and quality are the critical issues.

Evaluation for secondary infertility should be identical to that of primary infertility targeting those issues that are most suspect.  Almost 40% of all infertility is male related.  Even if a male has fathered a child, semen parameters can change drastically due to a variety of health changes including medical problems, surgeries, traumas, or infections.  A semen analysis will evaluate a male’s current fertility status.  If there has been a change in male partners, particularly if the new partner has not fathered children, certainly male factor may be the issue.  Almost 50% of infertility is female related, primarily ovulatory or anatomic problems.  While a female may have a history of regular ovulatory cycles prior to, her ovulatory pattern can change drastically following a pregnancy, especially if there has been a significant weight gain.  If prior pregnancy was delivered by cesarean section, adhesion scar formation certainly can occur and be associated with significant tube compromise.  Loss of weight will often bring about a return of regular ovulatory cycles.

If there has been a long time between the first pregnancy and initiation of a second pregnancy, certainly the issue of egg quality may be the problem, especially if mom is now over age 35.  Strategies to try and improve fertility due to an egg quality issue include superovulation (getting the patient to release multiple eggs) or in vitro fertilization (transferring more than one embryo back to the uterus).  If the initial pregnancy was delivered by cesarean section and especially if there was a history of infection, adhesions may be causing a tubal factor.  If there was retained placenta following delivery, uterine scarring can occur – hysteroscopy (outpatient surgery – scope is used to look into the uterine cavity) should be considered.  With a significant time delay before initiating a second pregnancy, conditions like endometriosis, the growth of endometrial tissue outside the uterine cavity, i.e. in the pelvis, may cause significant anatomic distortion.  Likewise, fibroid tumors that may have been small and clinically insignificant prior to pregnancy may now be large and compromising fallopian tubes or the uterine cavity.

In conclusion, secondary infertility is a very common problem.  Delaying evaluation and treatment is often associated with severely diminished chances for pregnancy.  Secondary infertility should be approached in an aggressive, targeted manner especially in the context of advanced maternal age.

Fertility Treatment and Ovarian Tumor Risk

Recent headlines have reported that IVF treatment is linked to ovarian tumors based on a recently published study. The findings are not different than was was reported over 10 years ago, and media coverage often misleads the public into making assumptions that may not be true. Many studies in the past have reported positive or no linkages with fertility treatment and ovarian stimulation and future risk of ovarian tumors. This study from the Netherlands was retrospective in nature, meaning that they started with women who had tumors, then looked to see what type of treatments they had. This type of study can possibly find causal linkages between a treatment and an outcome, but are in no way definitive as there are many biases that are introduced. You can breathe a sigh of relief that the study did find no link between IVF and ovarian cancer in a follow up of 15 years time. The only relationship was with possible “borderline” tumors, often called “low malignant potential” tumors. These are not invasive cancer and are not considered pre-cancer tumors, though they can grow like a tumor over time. The prognosis with this tumor is usually very good and tremendously different than with invasive ovarian cancer. Below is a blog from the American Fertility Association that helps to clarify a lot of this information.


Tumors of low malignant potential

Posted by Corey Whelan on Oct 27, 2011 with 1 Comments

http://www.theafa.org/blog/tumors-of-low-malignant-potential/

A new study out of the Netherlands and published in Human Reproduction is making the news today. It is entitled “Risk of borderline and invasive ovarian tumours after ovarian stimulation for in vitro fertilization in a large Dutch cohort”. Reuters picked it up as “Fertility treatment raises tumor risk in study”.

It is of course understandable that The AFA’s phones have been ringing off the hook. Women are alarmed by this report. Briefly, I wanted to share a few facts about the study and urge you to please relax while you read this.

This long term study compared women who had done in vitro fertilization (IVF) with two other groups of women; 1)the general population, and 2)sub fertile women who had not done IVF. The researchers reported an increased risk level for the IVF group of developing borderline ovarian tumors. The research also showed that the overall incidence of invasive ovarian cancer was not significantly elevated, but increased with longer follow up.

The important thing to note here is that borderline ovarian tumors are actually cysts of low malignant potential. I am not minimizing the value of this study However, the term as is being reported in Reuters and picked up by media outlets, that women are twice as likely to develop ovarian cancer after IVF, is misleading. Patient’s individual risk of getting ovarian cancer if they do IVF is not 50% higher than it would be were they not undergoing treatment. The increased risk of acquiring invasive ovarian cancer for this group is around 1.76% greater after 15 years. If you however, put together the statistics for borderline ovarian tumors along with the statistics for ovarian malignancies, the rate goes up to 4.23%. That being said, we don’t want women to wind up in either group if they can help it.

I reached out to Dan Potter, M.D. to get his opinion on the study. His comments, verbatim, were:

“This is no different than the study that was published here in the U.S. about 10 years ago. The lead author is an epidemiologist. Oftimes in studies such as this, the researcher starts with the conclusion they wish to arrive at and then they work backward to prove it. I’m not saying that’s what happened here, but these are the most problematic issues that I see in this study.

  1. They linked all of the ‘malignancies’ in the registry to patients in the two study groups (IVF and non-IVF) regardless of whether they returned the surveys or not. This creates a falsely high incidence. They compared them to ‘general population rates’ who basically have the equivalent of a survey return rate of 100%. See how they appeared to start at the conclusion and work backwards?
  2. Borderline tumors, also known as tumors of ‘low malignant potential’ or LMP are not malignancies. There is no such thing as ‘invasive cancer’ and ‘non-invasive cancer’. Cancer is invasive. Borderline tumors are not cancer and while not benign have low malignant potential. The 5 year survival rate of borderline serous tumors (the most common type) is ….…100%.
  3. They seem to speak of ‘invasive cancer’ and consider the borderline tumors ‘non-invasive’ cancer. The definition of malignancy is invasion so this simply does not make sense from a medical perspective.
  4. Their control group is women diagnosed with infertility that did not do IVF. They did not stratify these patients as to whether they became pregnant or whether they were on the birth control pill, both known protective factors. In fact, there is not control for whether the patient even had a hysterectomy or oophorectomy for endometriosis. It is hard to get ovarian cancer when you do not have ovaries. Prior use of fertility drugs in the controls may have led to pregnancy so that they did not pursue IVF. Pregnancy, BCPs, oophorectomy are all protective.
  5. There were 19,146 patients in the IVF group and 28 ‘invasive cancers’. Using their methodology they would have expected 21. Both of these number are very high compared to what we would expect in the US (about 10x higher). Not sure why they diagnose it more frequently there.”

So, to sum it up. You should absolutely discuss this study with your physician and weigh your own personal risk, based on medical and family history and genetic background. And, if you want to talk about it, please feel free to call.

Comments:
Great news about fertility treatment from the Netherlands!
The study, a large cohort of Dutch women with infertility, showed that
the incidence of invasive ovarian cancer was NOT increased in either IVF
treated women or Non-IVF subfertile women followed for up to 15 years
after treatment.

The study of 19,146 women who underwent IVF and 6,006 women treated with
lesser forms of fertility therapy over a period of 13 years, found 28
and 9 women respectively developed invasive ovarian cancer, (37 cases /
25,152 women) a rate that was the same as the general population in the
Netherlands.

9 of the 28 cases of invasive ovarian cancer found in IVF treated women
occurred beyond the initial 15 year observation period when the authors
would have expected to find approximately 3. No medical information
about other exposures that these women may have had during those
intervening years was accessible.

Borderline ovarian tumors, a non-lethal ovarian growth that may never
become cancer but may require surgery, were seen more frequently in
women who underwent IVF compared to Non-IVF subfertile women.

There are many risk factors for ovarian cancer and non-lethal borderline
ovarian tumors independent of treatment including infertility itself,
use of exogenous hormones; lifestyle factors; and family history of
cancer. The current study obtained this critical information by
questionnaire.

A limitation of the study is that while 71% of the subjects who
underwent IVF returned the 23 page questionnaire, less than half (48%)
of those who received lesser treatment responded.

Factors known to decrease the incidence of invasive ovarian cancer
including pregnancy and the use of oral contraceptives, now commonly
used in conjunction with IVF treatment, were not independently assessed.

Alan Penzias, MD

How to Evaluate an IVF Program with 5 Important Questions

Five of the Most Important Questions to Ask

1)  Ask to see the program’s official CDC pregnancy statistics.

The Wyden Bill requires that all IVF programs report their results to the CDC yearly.  While this is a law, it is not enforced by any significant penalty.  Treatment centers that do not report their data know they cannot be audited.  These clinics may be reporting erroneous data.  They may be transferring excessive numbers of embryos to achieve pregnancy.  Transferring excessive numbers of embryos leads to high rates of multiples, resulting in potentially serious morbidity and mortality to the babies and Mom.  Often programs have good fresh IVF transfer rates, but poor results with cryopreserved embryos.  Pregnancies from cryopreserved embryos can add a tremendous amount to a couple’s cumulative chance of having a baby.  Again, ask to see official CDC take home cryo IVF pregnancy rates.

2)  Ask if the clinic has regular office hours on Saturdays and Sundays.

Infertility is time specific.  If the clinic is not operating seven days a week, care, i.e. inseminations, IVF retrievals and transfers are often being compromised.

3)  Ask if the embryology lab is headed up by an embryologist certified as a highly complex lab director (HCLD).

This certification is given to embryologists who have obtained an advanced degree of training and equipment knowledge and have passed a rigorous certification exam.  Ask if the center has a secured facility for storage of your cryopreserved sperm, eggs, or embryos.  Ask how often liquid nitrogen tanks are filled and checked.  There should be documentation of these checks.  Ask if the program has a back up alarm system.

4)  Ask about cost for IVF.

Typically IVF costs range anywhere from $10,000 to $18,000 inclusive of medications.  Ask if there are additional charges for intracytoplasmic sperm injection (ICSI), typical cost $500 to $1000.  For assisted hatching, typically $500 to $1500, and whether cryopreservation, typically $500 to $1500, is included in the cost estimate.  Costs to do a subsequent cryo IVF transfer cycle range from $1000 to $3000.

5)  Ask if the physicians at the clinic are board certified or board eligible in Reproductive Endocrinology/Infertility.

Reproductive Endocrinology/Infertility subspecialists are OB/GYNs who have gone on to do two or three more years of subspecialty training in Reproductive Medicine.  To maintain board certification subspecialists must continue to keep up with important medical advances and take a re-certification exam yearly.

Answers to these five questions will go a long way in directing you to one of the better IVF programs in your area.  Do your homework – chances are your referring physician has no knowledge of these five issues.

Biological Clock

A female has the maximum number of eggs she will ever have as a fetus in utero at 20 weeks gestation, approximately 20 million.  During the last 20 weeks of in utero development, over 90% of the eggs will be lost, forming scars in the ovary.  At the time of birth, there are about a million eggs.  At puberty, when the brain-ovarian axis matures and ovulation begins, a few hundred thousand eggs remain.  The process of egg loss is known as atresia, and will continue until the last egg is released – menopause.

Each month when the menstrual cycle begins, a number of eggs start to develop – this group of eggs can vary in size from one to as many as thirty or forty eggs, depending on the number of eggs an individual is born with and her age.  With each reproductive cycle the entire group of eggs starts to develop; one egg out of this group develops to maturity and is released, i.e. ovulates, but the entire cohort of eggs is lost.  On rare occasions, more than one egg may ovulate, bringing about the opportunity for a multiple pregnancy.  This process of egg loss continues until menopause.  Typically, five to six years before menopause, cycles will become increasingly irregular as the quality of eggs that are released are often poor and may not produce enough estrogen to trigger ovulation.

Some individuals are born with much lower numbers of eggs.  These individuals are at risk for premature menopause – sometimes this occurs as early as the teenage years.  It is unknown why some women are born with fewer eggs, but likely is a function of genetics, i.e. menopause is often closely timed to maternal menopause.  The time of menopause can be influenced by a number of environmental factors, including surgeries, radiation, chemotherapy and smoking.  Starting your period early does not accelerate menopause.  Likewise, being on birth control pills, which prevents ovulation, does not delay menopause.  Again, there is a programmed loss of eggs each month.

Am I at risk for premature menopause?

It is important to identify those individuals that may be at risk for early menopause, not only for fertility concerns, but also for potential hormone replacement needs.  There are three primary means to guesstimate ovarian, i.e. egg, reserve:

Age

Age can be looked at as a rather crude guesstimate of remaining ovarian reserve, as some individuals are born with much greater numbers of eggs than others.  Certainly it is true that on average a 20-year-old is going to have far greater ovarian reserve than a 30-year-old, who would be expected to have far greater ovarian reserve than a 40-year-old.

Again, because of differences in the number of eggs someone is born with and potentially harmful environmental factors, there can be considerable variability in ovarian reserve at any age.  More accurate assessments of ovarian reserve include:

Hormonal Tests

Day 3 FSH/estradiol levels

Inhibin levels

Clomiphene citrate challenge tests

Antimullerian hormone

Ultrasound Assessment of Ovary

Counting the  number of egg/follicle units in the ovary, “antral follicle count” early in the cycle, typically days 2-4.

Combining different ovarian reserve tests is likely to give a more accurate assessment of ovarian reserve. Ovarian reserve can decrease abruptly in some individuals, likely representing an accelerated period of atresia, much like what happens in the second half of intrauterine development.  This is relatively common and can be seen in patients whose mother had an early menopause or who have been exposed to chemotherapeutic drugs, radiation, or destructive ovarian surgeries.  For others there are no obvious causes.  If an individual is at increased risk for accelerated egg loss, it is important to do regular ovarian reserve testing, especially if future fertility is a concern.

Fertility Preservation Options

Oocyte Cryopreservation

Oocyte cryopreservation is a relatively new, exciting technology for those individuals who do not have a male partner or who are uncertain as to whether they will stay with their current partner.  Worldwide, there are approximately 1500 babies born from frozen eggs.  Because of the limited number of babies born and relatively short follow up on these children, this technology should still be considered research and therefore should be carried out under an IRB (Institutional Review Board) protocol.  The institutional review board serves to review results from oocyte cryopreservation both in terms of efficacy and safety.  There are many programs throughout the country advertising egg freezing.  Many of these programs have had little or no success.  It is, therefore, important to ask some key questions when trying to identify a competent institution.  Namely, the number of babies that have been born from that particular embryology lab, not an affiliated lab or program.  Ask the number of eggs that were frozen to achieve these pregnancies, thereby getting an idea of efficacy.  The number of eggs available to an individual less than age 35 years of age or younger, on average, will vary typically between 8 and 16 each month.  For those individuals 36 and above, the cohort size is likely to be reduced, averaging between 5 and 12.  Ovarian reserve testing, again, will give a better estimate of individual egg number.  Depending on the efficiency of the program and an individual’s ovarian reserve, more than one stimulation cycle may be necessary to have a realistic chance for pregnancy.  Programs involved with oocyte cryopreservation should maintain a registry as to any birth defects or any development problems.

Florida Institute for Reproductive Medicine has been involved with oocyte cryopreservation since 1998.  To date, we have had 63 babies born from frozen eggs.  On average, we have required ten mature eggs to produce a healthy ongoing pregnancy in mothers 35 years or less.  For individuals 36-38, we are requiring on average fourteen mature eggs.  We do not offer oocyte cryopreservation for individuals over the age of 38, as the great majority of these individuals will have low ovarian reserve and a very high percentage of poor quality eggs, i.e. they are unlikely to benefit from cryopreservation.

Pre-embryo or embryo fertility preservation

This is an appropriate option for those individuals who are in a stable relationship.  In general, if there is any concern about potentially discarding an embryo, the option of cryopreserving pre-embryos should be considered.  Freezing a pre-embryo is, in essence, freezing male and female nuclear material that are close to each other but have not combined to form an individual.  Pre-embryo and embryo cryopreservation have been available since the mid-1980’s.  There have been hundreds of thousands of babies born from both pre-embryos and embryos.  There is a large body of reassuring health data, on babies born from (pre)embryos.  Fertility rates with (pre)embryos vary tremendously depending on the reproductive medicine program.  Each advanced reproductive medicine program in the United States is required by law to report their data to the CDC; therefore, before considering an individual program, check with the CDC registry (www.cdc.gov/ART/ART2011) on the program’s cryo IVF data.

Costs for oocyte cryopreservation as well as (pre)embryo cryopreservation should mimic those of a typical IVF cycle; the steps are basically the same.  Ongoing storage costs will typically vary from $100 – $400 per year.

Video- How Much Does Infertility Treatment Cost?


In this video, Dr. Michael L. Freeman from the Florida Institute for Reproductive Medicine addresses the cost of infertility treatment.

FIRM Costs for IVF can be found here.


Before proceeding with infertility treatment, in particular with IVF, ask for all the costs to be given up front. We will provide you with a written statement of all associated costs, including fees such as anesthesia or cryopreservation, before treatment so that there are no hidden fees.

Pregnant Women: Eating Well Means Eating Wisely

Taken from an article printed in Ob/Gyn News by Dr. E. ALBERT REECE, M.D., PH.D., M.B.A.
DR. REECE, who specializes in maternal-fetal medicine, is vice president for medical affairs at the University of Maryland, Baltimore, as well as the John Z. and Akiko K. Bowers Distinguished Professor and dean of its school of medicine. He said he had no relevant financial disclosures.

To help women control weight gain during pregnancy, I try to be both pragmatic and practical.

The latest Institute of Medicine guidelines on weight gain during pregnancy issued in 2009 recommend that women with a body mass index of 18.5-24.9 kg/m2, should gain between 25 and 35 pounds during pregnancy. Those who are underweight (with a BMI of less than 18.5 at the time they conceive) should gain more, between 28 and 40 pounds. However, for women who are already overweight at the beginning of pregnancy (with a BMI of 25–29.9), the weight gain recommendation is between 15 and 25 pounds.

Although I typically recommend that pregnant women gain somewhere in the 20-pound range, many women find gaining so little quite a challenge. This is natural. After all, pregnancy is a time when most women are hungrier than usual and want to eat more often than usual. These new mothers also hear all kinds of “good” advice from their friends and other women in their family such as “You’re eating for two now,” and “You’re growing a baby; this is no time to start on a diet.” It can be very hard for a woman’s physician to counteract such messages from family and friends.

The truth is, the baby is probably going to weigh around 7 pounds or so. Therefore, if a woman is gaining 30 or 40 pounds, such a gain in weight is way in excess of the weight of the baby, the placenta, and all the extra fluid combined. Gaining that much weight makes it that much harder to lose after giving birth.

The group that usually gets the most attention with regard to weight gain is the group of women with diabetes or gestational diabetes. They usually get nutritional counseling, assistance in choosing an appropriate diet, and information about glucose control. The American Diabetes Association recommends that women with gestational diabetes – and women who are just gaining more weight than you’d like – restrict carbohydrate intake to 30%–40% of their daily intake. By doing this they will at least slow the trajectory of weight gain. For those women who are diabetic, restricting carbohydrate intake also will allow them to see a lowering of their blood glucose.

Every pregnant woman needs to eat well. What they may not recognize, however, is that eating well doesn’t mean eating more – it means eating wisely. Furthermore, most women come into pregnancy without healthy eating habits. These habits are already part of their nature, so the best we can do is to try to moderate them.

On the other hand, pregnancy is a very good time to try to improve a woman’s eating habits. Indeed, there are very few other times in a woman’s life when she will be so motivated to change her health habits as when she’s pregnant. Even smokers will quit then – although they may start back up after the baby is born. But during pregnancy, not only the mother, but the entire family is invested in bringing this child into the world as healthy as possible.

When it comes to this issue, I try to be practical. You can’t expect people to change their entire lifestyle immediately. Also, I try to take a pragmatic approach that focuses on changing a few things at a time.

Food

Instead of telling women to “eliminate, eliminate, eliminate,” I encourage them to be thinking all the time about what they do eat. Decreasing carbohydrates in line with the national recommendations of no more than one-third of the daily calories is a good idea for everyone. Protein, on the other hand, is food the body can’t store. So I advise women to increase their protein intake because it has a filling effect and lowers carbohydrate intake as well.

At the same time, they can significantly increase their intake of vegetables and fruits, including salads, while watching the salad dressing. Pregnancy is also a time of slower gastrointestinal motility and constipation. Eating more vegetables – in particular raw vegetables – can cut down on intestinal transit time and help with constipation.

Liquids

Water is the best drink for a pregnant woman. They may tell you they’re consuming a lot of fruit juice. However, most of these juice drinks are full of carbohydrates in the form of sugar. Even though “naturally” unsweetened juices are a better choice, they still have a lot of calories and carbohydrates in them.

As for soft drinks – the more pregnant women avoid them, the better. They are full of sugar and are really unhealthy for anyone, especially women with diabetes.

Again, if you only counsel women to “eliminate, eliminate, eliminate,” they probably won’t do it. My pragmatic approach is to have women limit, instead of eliminate. So I say, “Try to drink more water, less soda, and unsweetened fruit juice only in moderation.”

Exercise

Exercise can be beneficial for anyone, and any woman who has been in the habit of exercising can continue. But exercise should not be a new sport you take up when you get pregnant. If pregnant women are new to exercise, it’s better to concentrate on the upper body rather than the lower, because these women don’t have an exercise-related established physiology of improved blood flow. Intense lower body exercise for these women can compromise blood flow to the fetus.

I would say that the average woman with moderate exercise habits can continue to exercise for a moderate duration at a moderate intensity and without excessive fatigue. As far as when to stop as the pregnancy advances, I use my clinical judgment. As long as the baby is growing well and there are no signs of premature labor, exercise can continue. There really is no a priori time that she must stop.

Women who have exercised vigorously much of their life – athletes and dancers, for instance – can usually continue to do so until the time of delivery. If the pregnancy is showing any signs of not progressing well, however, they should stop exercising immediately. On the other end of the spectrum are women who should not be exercising at all during pregnancy. These are the women who have a history of preterm labor or are showing signs of it, as well as those with some underlying disease.

Women with hypertension or some kind of vessel disease – like severe varicose veins or vasculitis – should not be exercising at all. With vessel disease, as the demands on the heart increase during exercise, blood will be shunted way from the fetus and could truly compromise the flow into the placenta. Sometimes these babies will experience decreased heart rates during exercise.

Some mothers have heard that certain exercises during pregnancy will make for an easier labor and delivery. There may be some truth to this, as women who are exercising before they get pregnant tend to have a lower incidence of large-for-gestational-age infants – and in that regard, they may have less difficult deliveries.

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