Knocked Up Podcast - We answer your questions
We are answering your questions
We answer your questions
We answer your questions, including:
Can I get botox whilst pregnant?
Why are my ovulation tests always negative
Timing/spacing between babies – I'm 38, have low AMH.
Fertility whilst breastfeeding
IVF and breastfeeding
If you have adeno and want a family, are you on a stricter timelines (I.e. will it get worse)
Can adenomyosis be genetic, like endometriosis
Should I remove a mirena before egg freezing to normalise hormones?
How do you manage blood thinners during pregnancy if there was unexplained PE
Pregnancy after miscarriage. So many different ‘facts’ on the internet
My first pregnancy resulted in a miscarriage, I was meant to be 11 weeks but the embryo measured 7. Is there anything I should do differently when trying again? Will I need more tracking or earlier scans?
Is it normal for sperm to fall out after intercourse, why does this happen?
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
Find us on Instagram - @knockeduppodcast
Have a question about women's health? Is there a specific topic you'd like us to cover? Email podcast@womenshealthmelbourne.com.au. We keep all requests anonymous.
TRANSCRIPT
Women's Health Melbourne is an innovative, holistic fertility and women's health practice. We are world leaders in IVF and egg freezing and provide our patients with every opportunity to achieve their goals. Our handpicked expert team provides the ultimate care experience for our patients. Reach us at women'shealthmelbourne.com.au and follow us at women's health melbourne and at Dr Raelia Lew. Welcome back to Knocked Up.
Jordi Morrison:
I'm your host, Jordi Morrison, and I'm joined as always by Dr Raelia Lew, CREI fertility specialist. Welcome, Raelia.
Dr Raelia Lew:
Hi, Jordi. It's the last episode of Knocked Up for this half of the year.
Jordi Morrison:
It is. And we are going out with a frequently asked questions that have come in through all methods from our audience. Thank you, everyone, for your great questions. In collecting our questions, a few of you asked around cosmetic injectables, such as Botox, Dysport, and other anti wrinkle treatments, which brings me the opportunity to introduce you to Monika Urbanski, cosmetic nurse at Women's Health Melbourne. Welcome, Monika.
Monika Urbanski:
Thank you. Thank you for having me.
Jordi Morrison:
Monika, I've got a couple of questions from our listeners, and you had a couple of things you wanted to speak about as well. So let's start with that. Can you have anti wrinkle treatments during pregnancy?
Monika Urbanski:
This is something that, obviously, being in the women's health clinic, I do get asked quite a lot. The answer is broad spectrum no, purely because although anti wrinkle is an extremely safe procedure and there really is no long term side effects or anything that we need to be concerned with in terms of disadvantaging or harming, you know, the mother or the baby as far as we know. The problem is that we do not know enough to say that for certain. So as a precaution, because we're not gonna start putting mothers and babies on the line for studies, we say no for pregnancy and breastfeeding. However, one of the advantages of doing fertility treatments or going through IVF is that we can work your treatments around your plans to conceive. So you can actually have your anti wrinkle treatments in between your, IVF and fertility treatments.
Jordi Morrison:
So if we can't use injectables whilst pregnant, how can we look after our skin? Because there are some ingredients we can't use whilst pregnant as well for the same reasons that you've mentioned. We've never tested on a pregnant woman. What can we do to look after our skin whilst pregnant?
Monika Urbanski:
There actually is a lot that you can do, apart from anti wrinkle to look after the health of your skin while pregnant. And a lot of it is stuff that we would do naturally anyway. So looking after your diet, your lifestyle, cutting alcohol, stopping smoking, they're all things that are always gonna beneficially impact your skin. But I'd say the best thing to focus on is your skin care. That's something that you can really proactively work on. Most important to help with making sure that you're not damaging your skin any further is to use an SPF. That's, you know, something that you should be doing every day regardless of whether it's cloudy or, you know, if you're not going outside, it's enough to get a little bit of sun exposure to start damaging the skin. And you can do other things like using your antioxidants, your vitamin c, using things like vitamin b to help hydrate the skin, they're all going to help prevent, damage from free radicals, things like pollution that are naturally degrading your skin as well. And the other thing that people are really concerned about, obviously, through pregnancy in particular, is the the the onslaught of pigmentation, essentially, especially things like melasma. So using things like a vitamin c can really help to, protect the skin from the free radicals that can cause, you know, those sorts of changes in the skin. And then coupled that with sunscreen can really help to prevent the melasma from coming on, and that's a lot easier than trying to treat it later down the track.
Jordi Morrison:
Are there any ingredients we should avoid whilst pregnant?
Monika Urbanski:
So I think the most well known ingredient that we should be avoiding is obviously vitamin a, retinol. Again, the studies aren't there to show that it's not safe, but we're not going to necessarily put, you know, a a pregnant woman at risk or her baby at risk. So we say definitely avoid retinols. There are different schools of thought as well on AHAs and BHAs. But for the most part, you know, in in small concentrations, things like lactic acid is okay to use. But if you're ever concerned, you can always come into the clinic. We do, you know, complimentary skin consultations. We have a range of skin care that is pregnancy safe, and we can talk you through your individual concerns and address those with a a bespoke skin care routine.
Jordi Morrison:
We know about anti wrinkle treatments, but the same drug can be used for all sorts of other benefits. What do you see commonly here at Women's Health Melbourne?
Monika Urbanski:
We obviously have all of the cosmetic benefits reducing, you know, frown lines, and we often treat I think the most common areas cosmetically are obviously frown, forehead, around the eyes. A lot of people don't realise you can actually use anti wrinkle for addressing asymmetry in the face as well. So if you've got a bit of a crooked smile or, you know, you've got maybe one eyebrow slightly higher than the other, those are little things that we can correct. But there are actually a lot of medical applications to anti wrinkle treatments as well. So we do get a lot of people coming in for teeth grinding, and we can obviously soften that muscle to, reduce not only the grinding, but the the tension headaches that can be associated with that.
Jordi Morrison:
Is there an ideal age that people should start anti wrinkle treatment?
Monika Urbanski:
So again, this one really just depends on the concern that you're coming in with. So if it's obviously a medical concern, no. There's not really any, age that you need to wait till to start. So that's something that you would just come in and have a chat with myself, and we would discuss what's necessary for you and and where do we start with your treatment. As far as, cosmetic purposes, if you're finding that, you are noticing more movement in your face, which generally happens as we age, ideally, prevention is better than treatment. So if you're noticing that you're squinting a lot more when you go outside but you don't necessarily have a line in your forehead when you're at rest, that's a really good time to come in and start looking at potentially treating, say, a frown line, because you'll eventually deepening. But that's not to say that if you already have those static lines that we can't treat them, we still can treat those areas with anti wrinkle and reduce the appearance of them over time. So, again, something that we can discuss with you when you come in, but, in general, prevention is better than than cure.
Jordi Morrison:
And are there any long term disadvantages or risks associated with anti wrinkle treatment?
Monika Urbanski:
Anti wrinkle is, like I said, very safe. There's very few, sort of side effects. Mainly, it's a bit of bruising, a bit of redness in the area. Sometimes you can get a little bit of a headache after your treatment, treatment, all very transient effects that go away very quickly. You know, very rare side effects, such as like a droopy brow can can occur, but that's something that we mitigate by knowing our facial anatomy and avoiding, you know, certain injection spots. I think, funnily enough, one of the things that I do get asked about is, well, if I stop getting, you know, my Botox after a number of years, is my face going to droop because we've weakened all the muscles? And the answer is no. If anything, most of the muscles that we treat on the face are muscles that are depressors to the face. So if we're relaxing those muscles, you actually get more of a long term alleviation of that depression and therefore a long term lifting of the face.
Jordi Morrison:
Raelia, this is a bit of a tough one. And I think we did an episode on this a while ago, and it's when to keep going and when to give up with IVF.
Dr Raelia Lew:
It is a really tough question for many, many reasons, and at the end of the day, it's very individual. In terms of IVF, when we consider all of the avenues we have to help someone have a baby, it's actually very unusual that we can't help a patient if they're open to every solution. I guess a problem arises when we set our own boundaries and limits on what we're willing to consider to have a family, and that's very reasonable and definitely normal to have your deal breakers in your decision making process. It's a different question as to when to stop trying with your own eggs. With egg donation, IVF, and with gestational surrogacy, and with the combination of both, it's rarely impossible to have a child if you have unlimited willpower and resources. Of course, that's not everybody. With your own eggs and sperm, it's really about having a honest, open conversation with your specialist as to what your personal prognosis for success is in the future should you continue to try. IVF definitely is not a type of technology or a type of science or medicine that works for everybody. However, the chance of getting pregnant or the probability of getting pregnant per attempt is significantly influenced by factors such as your age, your past experience, the barriers that you have to natural conception as an individual and as a couple, and also your strengths. What are your assets? What are your, I guess, advantages in an IVF context? Some people will have an IVF cycle and hate it and never want to do it again, even if they may have actually a very reasonable prognosis for success moving forward should they continue. Some people, it will be a financial barrier because IVF access is not equal, and IVF in the private sector can be expensive even though our government is very generous in subsidising IVF treatments and assisted reproductive treatments in general for those who are Medicare eligible. We also now have public fertility clinics in some places in Australia. Obviously, these have all the challenges that many areas of medicine do in the public hospital. You don't necessarily qualify for an appointment immediately. There may be substantial wait lists to treatments and limits to treatments in terms of BMI and age. But it's certainly excellent that these clinics now exist because in the past, they never did. And hopefully, there will be better equity of access around the country moving forward from this time point onwards. I think it doesn't hurt to have a second opinion if you're uncertain as as to the advice that you've received from your treating doctor. Sometimes, it's not because that advice is not the right advice. Sometimes, you do need to hear information more than once to help you make a decision and potentially in a different light and in a different fashion of communication. I think to answer the question generically is to do it a disservice because when whether to continue or whether to cease assisted reproductive treatments means different things to different people. For some people, it will mean closing one door and opening another. Closing a chapter of treatment with your own eggs, for example, to move on to egg donation is a very big psychological hurdle, but it can mean a very different prognosis for success, a very much improved prognosis, particularly for women whose age and equality is the main barrier to pregnancy. Sometimes it means because of our deal breakers, be they religious or be they just personal, it might mean closing a door and walking away from a lifelong dream of parenthood. And I think people in that situation need a good deal of support and counselling.
Jordi Morrison:
Bit of a different topic. Moving on. Why are my ovulation tests always negative?
Dr Raelia Lew:
Ovulation tests can mean different things. I think what is probably commonly meant by this is ovulation predictor kits using urine to detect an LH surge, but you could equally argue that a blood test showing a progesterone rise in the mid luteal phase is also an ovulation test. The most likely sign that you're ovulating is actually the history of a regular menstrual cycle. It's very much a given that if you have a regular menstrual cycle and you have a rhythm and you have a period and you have different phases throughout the month and you have mid cycle changes, you're definitely ovulating a 100% because it's the hormones that result in ovulation that bring on those changes and that dictate the rhythm of the menstrual cycle. Urine LH or luteinising hormone can be detected detected in the urine of people who ovulate while they're having an ovulation surge and a peak as long as the testing is done at a time when that LH hormone is concentrated in the urine. Sometimes people will have their peak surge in the middle of the night, and they might be measuring not at their peak. Sometimes people don't ovulate, and that's very common in people with PCOS, for example, that they might not ovulate often or frequently or regularly, and it can be challenging. Sometimes people with PCOS have the opposite challenge that their LH baseline levels are constantly high. And so they never get a peak level, but they always get a mild positive. That's equally frustrating. At the end of the day, if you don't release an egg, you're not gonna get pregnant and have a baby. And most people who are tracking their ovulation are doing so because they would like to become pregnant. So my first piece of advice is if you're worried you may not be ovulating, go and see a specialist because we can help you with more advanced tracking and tests, such as ultrasound monitoring and blood tests for hormonal tracking. And And if you're not, we'll be able to take measures both in diet and lifestyle and also using medications to help you ovulate. And if that's your only issue, it can be quite simple to help you get pregnant.
Jordi Morrison:
Timing and spacing between babies. So this question comes from someone who is 38 and has a low AMH.
Dr Raelia Lew:
The World Health Organisation recommends spacing children at least twelve months apart and ideally two years apart. The reason for this is to allow the mother to refill her cup and to replace the building blocks used in creating a baby, a placenta, extra litres of blood, nutrients passed on through breastfeeding. All of these amazing and wondrous experiences are very depleting for the body. And to attempt a healthy pregnancy, again, it's really good to have a nutritional focus and a really proactive recovery from pregnancy, labour, childbirth, and breastfeeding. One of the challenges we face in having babies later in life is we're very acutely aware of our fertility window, and it can be stressful when we want to, on the one hand, space our children to give them the best developmental outcomes and give ourselves a chance to recover from a pregnancy. But, also, we're worried about advancing age, reducing ovarian reserve, and declining IVF statistics. That's one of the reasons that when I see patients in my own clinical practice who are planning a family from their mid thirties onwards and sometimes even earlier, I talk to them about embryo banking and long term family planning because this is a way that we can create a resource at the time when somebody is actually realising their best personal IVF prognosis. I always say when I see you for the first time, one of the advantages or strengths that you bring to IVF is that you're the youngest you're ever gonna be, and you've got the most eggs you're ever going to have, and they're the healthiest eggs they're ever going to be. So you're going to be the best at making quality embryos that you're ever going to be in your future. And from a strategic perspective, banking embryos at that younger age will, over the course of your lifetime, improve your chances of achieving the number of children you ultimately want to complete your family. So I'm very much into strategic forward planning and embryo banking. That said, if you're in the situation where you haven't got embryos banks to plan for your next child and you have given birth and you are in your late thirties, a compromise that you may wish to consider is when your cycles do return, that you if you are not ready to be pregnant again and you may not be for physical, psychological, and personal reasons, you may wish to return to see your fertility specialist and consider embryo banking at that time.
Jordi Morrison:
We've got a couple of questions now about breastfeeding. You might want to answer them together. One of them is about fertility while breastfeeding and the other is IVF and breastfeeding.
Dr Raelia Lew:
The answer to the question obviously, the questions are different, but the answer to the question is pretty similar. So I might lump them into the one answers. When we're exclusively breastfeeding a baby and they are drawing all of their nutrition from the mother's body, quite often, it's very common to experience lactational amenorrhoea, which is when we don't actually have ovulation or a menstrual cycle happening. It's nature's contraception. It's nature's way of spacing children for us or helping us to space children. Because in the natural world, and we sometimes forget this in the modern world, pregnancy and childbirth is the most dangerous threat to a woman's life. And in terms of protecting her child, our human babies are very vulnerable. They're very needy. They need their mother to survive to help them reach a stage where they can be more independent. And it's really important for our evolution and our survival that a mother's not subjected to to risk and that she can recover from the pregnancy and birth process without becoming pregnant immediately again. That's the basis of lactational amenorrhoea. If you don't ovulate and if you're not having a regular cycle, it's very unlikely that you can fall pregnant. Now I guess the exception to that is that, you know, you may fall pregnant with your first ovulation before you've actually had a period, and that can happen for some people, but it's not common. In terms of your chance of getting pregnant, I guess the second part to that question is, well, does breastfeeding itself what if you're having an irregular cycle? What if you're having a cycle that is quite regular? Maybe you're breastfeeding occasionally instead of exclusively. Maybe you have a older child, maybe a toddler who still enjoys a couple of feeds a day and is mainly on a solid diet, but still loves a cuddle and, just a little bit of breast milk. That is very unlikely to have any adverse effects on getting pregnant naturally, and it's also unlikely to have any adverse effects on implantation in an IVF context. So I usually support my patients who wish to continue breastfeeding during IVF should they wish. And there's no real worry that the hormones we use in IVF treatment, be that in a stimulated cycle or in a transfer cycle, are going to, in any way, cause any harm to a baby if suckling occurs during treatment. We don't want to be actively stimulating the ovary in a stimulated IVF context for someone who has got hormonal suppression at the level of the pituitary gland with a very high level of prolactin as can be noted in exclusive breastfeeding because sometimes that can make us worry that the medications we use to reduce the risk of hyperstimulation syndrome in IVF may not be as effective. And so if that is the case, we would usually defer the stimulated cycle until the hormonal pattern returns to normal.
Jordi Morrison:
Now I've got some questions about adenomyosis. If you have it and you want a family, are you on a stricter timeline? Like, do you need to move faster towards getting pregnant? And then is it like endometriosis in that is it genetic?
Dr Raelia Lew:
Adenomyosis can be thought of as a cousin of endometriosis because it is a condition where the glands of the endometrium, the lining of the womb, grow in a place that's inappropriate, and that's into the muscle lining of the uterus, the myometrium. Adenomyosis is a condition that does get worse with time. It's a condition that can get worse with pregnancy. It's a really common condition, and it's a condition that has a very large spectrum. You can have very mild adenomyosis, and it has literally negligible effect on your fertility or chance of getting pregnant. It might just be an incidental finding on an ultrasound. You may not even have any symptoms like heavy periods or painful periods that you note related to it. Or you may have really severe adenomyosis where the muscle of the uterus is diffusely enlarged, periods are extremely heavy and can be very painful. And the fallopian tubes can be blocked, not because of any distal pathology at the ends of the tubes. This happens with things like chlamydia, but because the entry point of the tubes that need to traverse through the muscle, the so called isthmus of the tube, can be squished by the muscle hypertrophy and the glandular hypertrophy that happens because of the adenomyosis. There's a real spectrum. It certainly is a condition that does worsen over time, and it's a condition that no woman is born with. The younger we are when we have our children, the less likely that the burden of disease for conditions like adenomyosis and endometriosis will be so severe as that they cause us fertility problems, and they are pathologies that we can see worsen over time. So to answer that question, I would say that if you do have adenomyosis and you are in a position where you would like to be pregnant and there are other factors in your life that might be able to determine when you were thinking of optimally planning your pregnancy, you might wanna consider having your family at an earlier life stage if that's compatible with your plans and beliefs.
Jordi Morrison:
This is something we get asked quite often, actually, and it's, can I go through egg freezing with my Mirena in?
Dr Raelia Lew:
Yeah. So a Mirena is a drug name, and it's an IUD or intrauterine device that's got levonorgestrel hormone on it. And it's a really effective treatment for very heavy periods. It's a very popular method of contraception, and it's very popular for also people spacing their children. It's compatible with breastfeeding, and you still ovulate with your IUD in if you've got a progesterone IUD. There's absolutely no reason that it would interfere with egg freezing. Actually, a really common method that I use quite frequently in my practice these days because it's very effective, It significantly reduces the cost of medications in egg freezing and has excellent outcomes and good safety data is called a PPOS cycle, a progesterone primed ovarian stimulation cycle. And you can use oral progesterone medicine to prevent premature ovulation. And so the progesterone is actually a drug we use in the cycle itself. So a little bit of progesterone in the Mirena is not gonna do any harm whatsoever, and there's no problem leaving the Mirena in place for an egg free cycle.
Jordi Morrison:
How do you manage blood thinners during pregnancy? Explained PE.
Dr Raelia Lew:
So PE means pulmonary embolism, which is a blood clot that can travel to the lung from a vein. It's a really dangerous situation. What I would say is that anybody who's had a serious blood clot, be it a deep vein thrombosis or a pulmonary embolus or any other kind of blood clot or a family history of a clotting disorder that they believe they have a personal risk of, it's really important to involve a haematologist in pregnancy planning and fertility planning. Have a look at all of your clotting cascade blood tests and risk factors, and determine an individualised plan for what we call thromboprophylaxis or prevention of blood clots in treatment. IVF and actually pregnancy itself is what we call a prothrombotic state, which means the hormones in our bodies at that time increase your chance of having a blood clot. And so we like to, for some people who are at higher risk than our population of this happening, use some special blood thinners or antiplatelet agent to minimise the risk of that happening and of the the person having a blood clot that could cause a dangerous event. Most of the time in those situations, we use injectable antiplatelet agent. A popular one that people may have heard of is enoxaparin. And it's given daily as a subcuticular injection. Patients self inject. It's quite stingy. And we cease that medication. It is short acting around procedures that could cause excess bleeding. So we don't want patients to be on blood thinners at the time of an egg collection because it could precipitate excess bleeding. And certainly, in the pregnancy and delivery space around the time of giving birth or around the time of having an epidural or a spinal anaesthetic, because we wouldn't want anyone to have bleeding into their spinal cord. That can be very dangerous. And, also, we wouldn't want, someone who is having a caesarean to be affected by blood thinners at the time. So often with advice from a haematologist, we look at when we pause blood thinners around IVF in pregnancy and when we restart them and how long we keep them going for. And often, another at risk period is the time after giving birth, just after giving birth for the six weeks. Afterwards, you can have an increased risk of blood clotting also. So quite often, if you do have a really serious risk of having a blood clot as a baseline finding, then at times during pregnancy and also after pregnancy, you might be advised to take some blood thinners.
Jordi Morrison:
We have a couple of questions about miscarriage. So pregnancy after miscarriage, so many different facts on the Internet. So we say to people, don't Google. What's your advice here?
Dr Raelia Lew:
Well, look, it's kind of futile to tell people not to Google because everybody Googles. You're gonna find lots of information on every topic. And actually, probably now with AI and chat GPT, you're probably gonna find more misinformation as well. What I would say is the Internet is very egalitarian, which means that anyone can publish anything there. And so when you see information on the Internet, unless it's from a very reputed source, you really cannot assume that it is correct or that it applies to your circumstances. So it's really easy to read a fact out of context and make a wrong assumption that then causes a lot of anxiety and misinterpretation. Miscarriage is incredibly common. It is not comforting to know that, but it is true. On average, one in five pregnancies ends in miscarriage, but that can be much higher for some groups of people. If you're 40, for example, as a mother, your risk of miscarriage is more like one in two pregnancy. And it really also depends on our definition of what is a miscarriage because if you count biochemical pregnancies where we have a positive pregnancy test and then get our period, the stats become much, much higher still for everybody. So counting all diagnosed pregnancies, most women who attempt a pregnancy will have had a miscarriage. Most miscarriages are not because of any underlying medical problem in the mother, and most miscarriages are of a random nature because of a mistake in the development of a baby. The mistake may be of a genetic nature, whereas the DNA code that the baby received from the egg and sperm that created the one cell embryo was wrong, was not balanced. There may have been a spontaneous error there. That's a problem that is called chromosomal aneuploidy, and it occurs more and more as people get older. It may also just have been, rather than a problem with the DNA instruction manual, just a random problem of implementing those instructions in the complex course that is foetal development. It's really common for things to go wrong in a developing pregnancy in perfectly healthy mothers. There are some rarer syndromes of recurrent miscarriage. There are also some anatomical problems like fibroids in the submucous space that can cause miscarriage. Things like trauma can cause miscarriage. And some hormonal conditions can predispose to miscarriage, like, for example, thyroid dysfunction as well as some autoimmune conditions like antiphospholipid syndrome, coeliac disease, and other disorders of clotting of an autoimmune nature. There will also be a number of miscarriages that are unexplained by today's medicine. It doesn't mean there's not a reason. It can just mean that we can't clarify what that cause was. What I would say to anybody who's experienced a miscarriage is that pregnancy after miscarriage does not necessarily have an increased risk of a future miscarriage. We don't define recurrent miscarriage as, having had fewer than three consecutive miscarriages just because miscarriage in itself is very common. Of course, those people who actually do have problems and and do have recurrent miscarriages when they have their first or second miscarriages in that very tiny group of patients, the information we give is probably incorrect. It's only retrospectively that we realise that they've had three consecutive miscarriages. But all of the guidelines that have developed to investigate recurrent miscarriage suggests that if you've had fewer than three consecutive miscarriages, especially early miscarriages, if we do all of the tests for very rare things on people in that category, they're most likely to be normal for the vast majority of people. And we're putting people through tests that they don't need most of the time. And we're also, from a health economic perspective, costing the government a lot of money in Australia, which we try and be responsible as medical practitioners and only order tests when we have a real suspicion that something's outside of the norm for a person. Miscarriage can be really, really hard to go through. It can be really, really hard to accept. A lot of people attribute blame to themselves even when on an intellectual level, they know it's not their fault. There's very few things you can do to bring on a miscarriage. I would say if you've had a miscarriage and you feel emotionally vulnerable, please do reach out for help, to your GP, to a counsellor. And if you need reassurance to a fertility doctor, most of the time, the advice that you'll receive is try again. There's not necessarily any benefit to waiting to try again. You're not more likely to miscarry in the cycle after a miscarriage, nor are you more fertile in a cycle after a miscarriage. But every cycle is an opportunity to attempt a pregnancy, and it may be your next pregnancy that ends up as a healthy baby.
Jordi Morrison:
My first pregnancy resulted in a miscarriage. I was meant to be eleven weeks, but the embryo measured seven. Is there anything I should do differently when trying again, or will I need more tracking or earlier scans?
Dr Raelia Lew:
This is a a good question to answer a few points that are really commonly asked about miscarriage. I'll first just preface that we cannot give personal advice to an individual on our podcast, and any statements that we make are based on medical knowledge but are general in nature. So there's a lot of unpacking to be done in this scenario. One is that a miscarriage was diagnosed at eleven weeks, but actually, the baby stopped growing at seven weeks. So this is what we call a missed miscarriage. And this scenario is where a miscarriage was diagnosed at eleven weeks, but actually the pregnancy stopped growing at seven weeks gestation. And so this is what we call a missed miscarriage. What this means is that the body has held on to a pregnancy longer than the pregnancy was growing and progressing normally. We can tell a lot about this. We can tell certainly that progesterone production was definitely adequate because the pregnancy hasn't ended by early bleeding. It's ended by the baby stopping normal development. We also know that at this time of pregnancy, there's no control that either a mother or a doctor has over the development of her pregnancy. And so there's nothing that can be done differently in a future attempt by the mother nor by the doctor. Early interventions such as ultrasound don't necessarily change the outcome of a pregnancy. It's hard to know if the baby had a heartbeat in an earlier scan, but if a pregnancy measures seven weeks, usually that's the case. We also don't know if abnormal chromosomes or abnormal DNA was the reason that the baby stopped growing. The way to find this out is through surgical management of miscarriage in a process called a d and c, which is a suction curettage procedure under anaesthetic. When we do this kind of procedure, we can take tissue from the pregnancy and send it off for further testing. And one of the tests we do is called a karyotype or a chromosomal study of the baby. Sometimes that's useful in that it tells us the reason for the miscarriage, and it's certainly one of the things we do in the workup of recurrent miscarriage. There are some tests that we can do for parents to check for rarer conditions that do cause a predisposition to future miscarriage. And while I mentioned previously that these are not routinely offered after a single miscarriage, if there is significant parental anxiety, worry, and concern that's causing distress, in my practice, I would, in that context, discuss potential investigations and offer them to a patient if I felt that knowing that things were normal would help them face the prospect of trying again.
Jordi Morrison:
Last question for today. Is it normal for sperm to fall out after intercourse, and why does this happen?
Dr Raelia Lew:
This is a really good question and one that a lot of people worry about. When you do a sperm test and you test the ejaculate, it's usually more than two mils that is ejaculated. And it's not just sperm. It's semen. It's glandular secretions. And it's only a tiny, tiny fraction of that sample that's going to swim forward. So it may be surprising, but actually quite obvious when you think about it, that sperm don't have eyes, ears, a brain, or a sense of direction. So it's only a tiny fraction of sperm that just happen to go the right way and find a cervical mucus column and move forward after intercourse. It's always gonna be the vast majority that come out again and that don't go anywhere near an egg. One of the ways that a technique called IUI or intrauterine insemination can help someone get pregnant if they're having trouble or if the sperm is slightly dodgy, not quite as good as average, but also not diastrates in terms of the parameters, is we can concentrate the sperm, the best of the bunch, put a little tube through the cervix, and deliver concentrated sperm closer to the egg. And we can give impaired sperm a helping hand. And for some people, that will get them over the line to get pregnant. And that's because in nature, there's a normal natural gradient where most sperm will go nowhere near an egg. And that's why men and people with testes make heaps and heaps of sperm because nature provides a very high number of sperm at the starting line so that by the time a minority get where they're going, there's still enough to fertilise an egg.
Jordi Morrison:
Thank you, Raelia. What a way to end the season.To support Knocked Up, leave us a review or recommend to a friend. Join us on Instagram at @knockeduppodcast and join Raelia at @doctorraelialew, and email us your questions to podcast@womenshealthmelbourne.com.au.