2.11: Infertility and Complications of Pregnancy

Infertility and Building Families

When a couple has failed to conceive a child in a year, they receive the diagnosis of infertility. Infertility affects about 10-15 % of couples in the United States.

• Male factors create infertility in about 1/3 of the cases. For men, the most common cause is a lack of sperm production or low sperm production.
• Female factors cause infertility in another 1/3 of the cases. One of the most common causes of infertility is the failure to ovulate. Another cause of infertility in women is Pelvic Inflammatory Disease (PID), which is an infection of a woman’s reproductive organs.

Combined male and female factors contribute to the remainder of cases of infertility.

Options for Building Families

There are numerous options to pursue parenthood and building families.

• Assisted Reproductive Technology (ART)

The technology used to achieve pregnancy in procedures such as fertility medication (to stimulate ovulation), surgical procedures, artificial insemination IUI), in vitro fertilization (IVF) and surrogacy. These options are available for people who are experiencing infertility or cannot conceive children naturally (which also includes single parents, and gay/lesbian couples).

• Intrauterine Insemination (IUI)

A type of artificial insemination involves the placement of sperm directly into the uterus at the time of ovulation, either in a natural menstrual cycle or following ovarian stimulation.

• In vitro fertilization (IVF)

IVF generally starts with stimulating the ovaries to increase egg production. Most fertility medications are agents that stimulate the development of follicles in the ovary. Examples are gonadotropins and gonadotropin releasing hormone. After stimulation, the physician surgically extracts one or more eggs from the ovary, and unites them with sperm in a laboratory setting, with the intent of producing one or more embryos. Fertilization takes place outside the body, and the fertilized egg is reinserted into the woman's reproductive tract, in a procedure called embryo transfer.

• Donor Gametes & Embryos

People can also use sperm, ova (eggs), and embryos from donors in conjunction with ART. These donations take place through agencies and donor banks or between private individuals. In the U.S., donors can be compensated for their donations.

• Surrogacy

In surrogacy, one woman (surrogate mother) carries a child for another person/s (commissioning person/couple), based on a legal agreement before conception requiring the child to be relinquished to the commissioning person/couple following birth. There are different types of surrogacy which relate to whether the ova used to conceive the child are her own (traditional surrogacy) or not (gestational surrogacy).

• Adoption

People can also choose to pursue adoption to build their families (with or without experiencing infertility). Adoption can take place through the foster care system, privately, or through agencies. Adoptions can be domestic (within the U.S.) or international. And they can be open (with differing amounts of contact between biological/birth families and adoptive families) or closed.

Complications of Pregnancy

Health problems that occur during pregnancy are referred to as complications of pregnancy. Some women bring existing health issues into pregnancy that could lead to complications while others experience health issues while they are pregnant. Some health issues are common and minor, while others are more serious.

Fig. 2.11. 12 Common Complications of pregnancy: miscariiage, gestational diabetes, preeclampsia, preterm labor, infections, depression and anxiety, vaginal bleeding, congenital disorders, issues with the placenta, anemia, gestationaly hypertension, amniotic fluid complications.

Image Source: 12 Common Pregnancy Complications. ParentingStyles.

Common Complications (Side Effects)

There are several common side effects of pregnancy. Not everyone experiences all of these, nor to the same degree. And although they are considered "minor", this is not to say that these problems are not potentially very uncomfortable. These side effects include

• nausea (usually during the first 3-4 months of pregnancy as a result of higher levels of estrogen in the system)
• heartburn, gas, constipation
• backache, leg cramps, varicose veins, varicose veins (as a result of carrying a heavy load on the abdomen)
• insomnia
• shortness of breath

Less Common Complications

• gestational diabetes (high blood sugar levels that resolve after childbirth)
• infections
• depression and anxiety
• vaginal bleeding
• anemia
• gestational hypertension (high blood pressure)
• amniotic fluid complications (too little or too much fluid)

Serious Complications

Serious complications of pregnancy can pose health risks to mother and child and that often require hospitalization. These include:

• Hyperemesis gravidarum

Characterized by severe nausea, vomiting, weight loss, and possibly dehydration. Signs and symptoms may also include vomiting many times a day and feeling faint. The exact causes of hyperemesis gravidarum are unknown.

Risk factors include the first pregnancy or a multiple pregnancy (twins, triplets, etc.); obesity; prior or family history of HG; trophoblastic disorder - a group of tumors that develop in the uterus (womb) during or after pregnancy, originating from the trophoblastic tissue which normally forms the placenta; and a history of eating disorders

Treatment includes drinking fluids and a bland diet, medication, and intravenous fluids. Hospitalization may be required. Hyperemesis gravidarum is estimated to affect 0.3–2.0% of pregnant women. Those affected have a low risk of miscarriage but a higher risk of premature birth.

• Ectopic pregnancy

Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches to the lining of the uterus. In a healthy pregnancy, the fertilized egg attaches itself to the lining of the uterus. In an ectopic pregnancy, the egg attaches itself somewhere outside the uterus usually to the inside of a fallopian tube. This type of ectopic pregnancy is called a tubal pregnancy. Sometimes, an ectopic pregnancy occurs in other areas of the body, such as the ovary, abdominal cavity or the lower part of the uterus (cervix), which connects to the vagina. About 1 in 50 pregnancies in the United States are tubal pregnancies and this number has been increasing because of the higher rates of pelvic inflammatory disease and the STI, Chlamydia.

There may be no unusual symptoms at first. A pregnancy test, the result will be positive. As the fertilized egg grows in the improper place, signs and symptoms become more noticeable. An ectopic pregnancy can't continue as normal. The fertilized egg cannot survive. Often, the first warning signs of an ectopic pregnancy are light vaginal bleeding and pelvic pain. If blood leaks from the fallopian tube, the pregnant woman may feel shoulder pain or an urge to have a bowel movement. Specific symptoms depend on where the blood collects and which nerves are irritated. If the fertilized egg continues to grow in the fallopian tube, the growing tissue may cause life-threatening bleeding and can cause the tube to rupture. Symptoms of bleeding include extreme lightheadedness, fainting and shock.

Fig. 2.11. Illustration of a normal pregnancy where the fertilized egg (zygote) implants in the uterus, compared to an ectopic pregnance with the fertilized egg (zygote) implants in the fallopian tube.

Image Source: Ectopic Pregnancy. ©Mayo Clinic.

• Spontaneous abortion (miscarriage)

A spontaneous abortion, or miscarriage, is the loss of a pregnancy before the 20th week. Spontaneous abortion is experienced in an estimated 20-40 percent of undiagnosed pregnancies and in another 10 percent of diagnosed pregnancies.

Spontaneous abortions can occur due to a variety of factors: chromosomal abnormalities in the fetus (50-60%), maternal age (increased risk after age 35); infections, hormonal imbalances, uterine abnormalities, or trauma. When a miscarriage is due to chromosomal abnormalities, typically happens before the 12th week of pregnancy.

Symptoms of miscarriage may include cramping and bleeding, passing of tissue or clots result, decreased pregnancy symptoms and normal periods return after several months. Some women are more likely to have repeated miscarriages due to chromosomal, amniotic, or hormonal problems, but miscarriage can also be a result of defective sperm.

• Preeclampsia (toxemia)

Preeclamspia, also known as toxemia is characterized by a sharp rise in blood pressure, a leakage of protein into the urine as a result of kidney problems, and swelling of the hands, feet, and face during the third trimester of pregnancy.

Preeclampsia is the most common complication of pregnancy. When preeclampsia causes seizures, the condition is known as eclampsia, which is the second leading cause of maternal death in the United States.

Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth. Treatment is typically bed rest and sometimes medication. If this treatment is ineffective, labor may be induced.

Maternal Mortality

Maternal mortality refers to the death of a woman during or within 42 days of the end of pregnancy, regardless of the duration or nature of the pregnancy itself.

Maternal mortality is unacceptably high. Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with relatively low numbers of skilled health care providers, such as sub-Saharan Africa and southern Asia.

About 260 000 women world-wide died during and following pregnancy and childbirth in 2023. Approximately 92% of all maternal deaths occurred in low- and lower-middle-income countries and most could have been prevented.

The United States continues to have the highest rate of maternal deaths of any high-income nation and the rate is the highest for Black women. Over 80% of these deaths are preventable. Research has found Black people receive worse-quality care than white people and demonstrates that racial disparities and inequities in access to care and patients’ experience of care are often rooted in discrimination and health care provider bias.

All women need access to high quality care in pregnancy, and during and after childbirth. Maternal health and newborn health are closely linked. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death for the women as well as for the newborns. Access to high quality care in pregnancy, and during and after childbirth prevents the major complications that account for around 75% of all maternal deaths:

• severe bleeding (mostly bleeding after childbirth)
  • can kill a healthy woman within hours if she is unattended
  • injecting oxytocics immediately after childbirth effectively reduces the risk of bleeding
• infections (usually after childbirth)
  • can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated in a timely manner
• hypertension or high blood pressure during pregnancy (pre-eclampsia and eclampsia)
  • pre-eclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications.
  • Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia
• complications from delivery

Sources

• Ectopic Pregnancy. Mayo Clinic
• Gunja, Munira Z. et al. Insights into the U.S. Maternal Mortality Crisis: An International Comparison. The Commonwealth Fund. June 2024.
• Hyperemesis Gravidarum by Wikipedia is licensed under CC BY-SA 3.0
• Lally, Martha and Suzanne Valentine-French. Lifespan Development: A Psychological Perspective. Licensed under CC BY-NC-SA 3.0
• Maternal Mortality. World Health Organization (WHO).