Journey From Contraception To Conception, Clinical Decision Making

Consider a couple, both husband and wife have been working and have used contraceptives for about 3-4 years. They decide that now is the right time for them to start a family. The couple is self-aware and they first visit a physician to know about where to start and what practices are to be followed to conceive as soon as possible. This is the case with most of the modern day couples that plan pregnancy. In other cases, couples try for a while to get pregnant for their first or second baby, but if it does not happen they immediately turn to Physicians to get expert advice about pregnancy and where to begin. It becomes vital on the physicians part to provide the couple with the basic information about pregnancy planning and where to begin. At the same time, they need to act as myth busters and clear some misconceptions. This preconception visit should mainly focus on identifying the lifestyle, and medical risks of a couple to conceive and then reducing those risks through education, counseling, and appropriate intervention when possible before conception. Let us discuss some important points that the physician should discuss during the couple’s first visit after they decide that they want to start a family.

How long does it take to get pregnant after stopping contraception?
a) Physician needs to stress that just stopping contraception does not mean that the couple will get pregnant. It can happen immediately, but it can take some time as well.

b) Mostly, women begin to ovulate normally and have their regular menstrual cycle 3 to 6 months after they stop using oral contraceptive pill. However, for a few it may take a little longer.

c) Clear the misconception that being on birth control may create problems conceiving, and stress that pregnancy will happen when your body is ready for it.

Age of the Couple
a) As the maternal age increases, the risk of infertility, fetal aneuploidy, miscarriage, gestational diabetes, preeclampsia and stillbirth also increase and should be discussed with the couple.

b) Paternal age can also have a role in conception, especially after the age of 50 years.

Medical History and Medications
a) Physician should know about the medications that the couple is currently taking, and counsel the patient about certain medication changes if necessary for better chances of conception as well as to avoid miscarriages. For instance, if a woman has hypo- or hyper-thyroidism, physician should make sure that the TSH levels are well under control (between 1.5 and 3) for the woman to conceive. Medical assessment can also help physician identify medications that are teratogenic, which should be either stopped (eg, isotretinoin) or changed to a safer medicine for fetus and the pregnant woman (eg, heparin for warfarin).

b) Pre-existing medical conditions or chronic conditions (eg, diabetes, hypertension, severe obesity, and obstructive sleep apnea) definitely affect the rate of conceiving and should be discussed with the patient. Additionally, physicians should advise the couples for screening of sickle cell and thalassemia which are inherited blood disorders. For instance, woman with inherited thrombophilia are at higher risk of thromboembolic complications.

Lifestyle factors
a) Healthy Eating Habits and Supplements
Healthy diet should be advised, especially to the woman, which builds the body with all the necessary nutrients that will be later supplied to the baby.

Folic acid supplements should be immediately advised when couple plans to get pregnant, as folic acid reduces risk of having baby born with spinal cord problem such as spina bifida

b) Avoid Consumption of alcohol, illicit drugs, smoking Consumption of alcohol, smoking and use of illicit drugs during pregnancy have been linked to various health problems like subfertility as well as premature birth, low birth weight, miscarriage, breathing problems for baby in first six months, sudden infant death syndrome of the baby. A study from about 11,000 smoking women and over 19,000 non-smokers demonstrated that cigarette smoking significantly increased the infertility as compared to non-smokers. Also, sperm concentration decreased 23% and sperm motility decreased 13% in male smokers as compared to non-smokers.  Similarly, moderate alcohol consumption (<2 drinks/day; 1 drink = 10 g of ethanol) has no or minimal effects on fertility, but higher alcohol consumption should be avoided when attempting pregnancy.

Therefore, Physician should strictly advice the couple to immediately stop their consumption for a healthy pregnancy.

Ovulation and Ovulation Tracking
For each woman, the ovulation cycle is different and it may not even be same from one month to another. Physician should first educate the couple about the menstrual cycle, calculating cycle length and the importance of cycle tracking to conceive at the right time. As the probability of conception is higher with intercourse 1-2 days prior to ovulation it is necessary to advise each couple about ovulation tracking.

The different ways to chart ovulation period are:
* Menstrual cycle charting (Calendar Method): Tracking the cycle length on monthly basis and considering the ovulation occurs in middle of the cycle. This method only predicts the ovulation but in reality time of ovulation may differ month to month.

* Basal body temperature monitoring: Progesterone released after ovulation has potent effects on hypothalamus and also increases basal body temperature. Daily temperature monitoring can therefore be helpful to detect progesterone production and therefore ovulation. However, this method detects ovulation after it has occurred and therefore can only be used to give general pattern of ovulation that the couple can follow.

* Measurement of LH surge using Home based Ovulation Kit: The luteinizing hormone (LH) surge can be detected in urine samples. Easy to use home based urinary kits are now available commercially and are helpful for women. The LH surge can accurately predict ovulation in advance and therefore help the couple deduce their fertile window & know the right time for intercourse. The kit instructions should be precisely followed as different kits are standardized to different times of the day. However, conditions associated with elevated LH levels like polycystic ovary syndrome (PCOS), primary ovarian insufficiency, and menopause, can yield false positive results and should be taken into consideration.

*Transvaginal ultrasonography: Ultrasonography can identify a large follicle that reaches diameter of 16 to 30 mm prior to rupture and release of the oocyte and hence is good tool to track ovulation. The transvaginal approach is generally preferred for women trying to conceive because of its closer proximity to internal organs which provides higher resolution and better insights. However the method is invasive, painful and time consuming. If the patient misses even one session, there is possibility that cycle is wasted.

This preconception counseling guide will help assure the couple that they have made the right choice visiting the concerned physician and will also increase chances of patient compliance. With help of these pointers physician can make a couple comfortable on their journey from contraception to conception.

References

“Attitudes, knowledge, and skills of internal medicine reside… : Academic Medicine,” LWW. [Online]. Available: http://journals.lww.com/academicmedicine/Fulltext/1994/05000/Attitudes,_knowledge,_and_skills_of_internal.14.aspx. [Accessed: 24-Nov-2016].

M.-K. Moos et al., “Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age,” Am. J. Obstet. Gynecol., vol. 199, no. 6, pp. S280–S289, Dec. 2008.

“Recommendations to Improve Preconception Health and Health Care — United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.” [Online]. Available: http://origin.glb.cdc.gov/mmwR/preview/mmwrhtml/rr5506a1.htm. [Accessed: 24-Nov-2016].

B. M. Sherman, J. H. West, and S. G. Korenman, “The Menopausal Transition: Analysis of LH, FSH, Estradiol, and Progesterone Concentrations During Menstrual Cycles of Older Women,” J. Clin. Endocrinol. Metab., vol. 42, no. 4, pp. 629–636, Apr. 1976.

“Timing Intercourse to Achieve Pregnancy: Current Evidence : Obstetrics & Gynecology,” LWW. [Online]. Available: http://journals.lww.com/greenjournal/Fulltext/2002/12000/Timing_Intercourse_to_Achieve_Pregnancy__Current.27.aspx. [Accessed: 24-Nov-2016].
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