What Really Affects My Pregnancy Chances?

I've decided that there's no such thing as reproductive justice. Many of my patients try desperately to prevent pregnancy in their fertile years...and an equal number are trying so hard to get pregnant when they're finally ready. I hear questions almost daily about what affects the chances of pregnancy (whether it's wanted right now...or not). So here is a run-down of what influences the pregnancy lottery.

These things CAN affect your fertility:

• A history of STDs. Specifically, gonorrhea and chlamydia can scar your fallopian tubes and prevent sperm from fertilizing an egg.


• Recent DepoProvera use. It takes the average woman 10 months after her last Depo injection to be able to conceive. (Of course, if you don't want to be pregnant, your fertility will return right away - call it Murphy's Law of Reproduction)


• Irregular periods. Irregular menstrual cycles may be a sign of polycystic ovarian syndrome (PCOS), which is accompanied by irregular ovulation. Since you're not ovulating every month, it's harder to conceive.


• Over- or under-weight. Weight that falls above or below the ideal for your height may also prevent you from ovulating regularly.


• Medical problems. In addition to PCOS, there are other chronic medical conditions--over or underactive thyroid, endometriosis--that can impact ovulation or your tubes.


• Age. It's incredibly unfair that just when many women are ready to have a baby, their fertility has started to decline. But "egg quality" begins to decrease after age 30, and this decrease picks up speed after age 35.


• Not having sex enough. Don't laugh - I have seen several patients who can't understand why they're not pregnant, when they're having sex maybe once a month.


• Having sex too much. Don't laugh - having daily sex at the start of your cycle may diminish the sperm count around the time it matters (generally, days 12 and 13 of a 28-day cycle).


• A family history of infertility. Because there's still so much we don't know about infertility, there may be unknown factors that run in your family.

These things WILL NOT affect your fertility:

• Wetness. No matter how lubricated or dry you are, there's no effect on the little swimmers heading towards your eggs.


• Sexual position. No, standing up does not reduce your pregnancy risk. And no, positions with deep penetration don't increase your chances.

• Uterine position. Having a retroverted uterus does not make it harder for the sperm to reach your egg.
  

• Orgasm (yours). No justice here, either - your chances are the same whether or not you climax. Heavens, if women couldn't get pregnant without coming, there would be MANY fewer unplanned pregnancies!


• Long-term contraception use. Prolonged pill, ring, or IUD use doesn't permanently reduce your pregnancy chances. Upon stopping the method, your fertility returns to what it would have been without the birth control.


• Genital warts or herpes. Annoying to live with, but won't risk your fertility.

Somewhere in the middle:

• High-risk HPV on your pap smear. IF the HPV causes moderate- to high-grade abnormalities on your cervix...and IF you have a LEEP or cone biopsy to remove the cells, there's a chance that you'll have complications with your cervix in a future pregnancy. But it won't affect at all your chances of conceiving.
  

Do you worry about something in particular affecting your chances at pregnancy?

Unsure About Essure

Dr. Kate,

I know I am done having children, but do not want to go under the knife for a tubal ligation. I have heard of a procedure called Essure. Have you heard of it? How does it work and is it safe?

Unsure

Dear Unsure,

Essure is the latest form of permanent contraception that combines the best of the IUD and tubal ligation. Essure is performed through a procedure called hysteroscopy. Your gyno places a camera through your cervix, up into your uterus, so she can see the openings to your fallopian tubes. Small coils (that look like the spring of a ballpoint pen) are placed into the tubes through this camera. The coils cause scarring in the tubes, and the tubes in essence block themselves around the coil. A special X-ray three months after the procedure confirms that the tubes are indeed blocked. So unlike tubal ligation and the IUD, Essure doesn't work right away, and you need to stay on another form of birth control until the X-ray.

But it is a permanent procedure, and you won't have any incisions made in your belly (so no scars). Doctors can perform this procedure in the operating room, and some can now do it in their office; either way it's a one-day, no-admission-to-the-hospital procedure. It is a relatively new procedure, though, so you may have to call around in your area to find a gyno who can do it.

Photo credit: Sekaino Ai

Birth Control For Him?

Dear Dr. Kate,

My boyfriend and I have been together for six months now, and we are thinking of becoming sexually active. But we are concerned about an unwanted pregnancy. I am currently taking oral birth control. I was wondering if there is a male contraceptive besides condoms? I am allergic to latex therefore I can't use condoms. Are there any latex-free condoms? A friend of mine once told me he was on a shot to prevent pregnancy - is there such thing and if there is what are some of the possible side-effects?

Curious

Curious,

First, yay for thinking about birth control before you have sex! And using two forms of contraception will make your chances of pregnancy even smaller. Unfortunately, there is no reliable, reversible male contraceptive besides condoms. (I don't think withdrawal, or pulling out, is effective enough to talk about here.) There are many reasons why we don't have a good hormonal method for men yet, though recent studies show a lot of promise. There are shots and pills for men that are not available in the US, but to the best of my knowledge, these methods aren't effective, or aren't safe (for him), or both. Not safe, because they're extremely high doses of hormones that have not been extensively studied and could put him at risk of cancer.

But the good news is that there are latex-free condoms available. They're made from polyurethane, and are available in major drug stores or online. Stay away from condoms made from natural materials like lambskin - they're more porous than polyurethane, so are less likely to prevent passage of microbes or sperm.

Stay safe,
Dr. Kate

Photo credit: adaptorplug

The Scoop On: Ovarian Cysts

What they are:
Ovaries make cysts for a living—each month your ovary “recruits” microscopic eggs to pick a candidate for ovulation. After the best-looking egg of the bunch is released, a small cyst is left behind (like a big pimple on your ovary). Normally, this cyst is absorbed by the ovary, but sometimes it seals over and fills with fluid or blood. Less commonly, an ovarian cyst is filled instead with mucus or fibrous tissue, and in some cases, hair and teeth.

What does it mean:
In most cases, nothing. Most cysts are considered “functional”—a sign that your ovary is working normally. If your gyno finds one on your exam, she may want you to have a follow-up visit, or an ultrasound, or both. Fluid-filled cysts will eventually be absorbed, but may linger for awhile, and may even get bigger before they get smaller. Sometimes, the cyst will rupture; this may happen randomly or during intercourse. While very painful, a ruptured cyst generally has no lasting consequences to your health or fertility.

How can you treat it:
Your gyno may decide that your cyst needs treatment: it looks suspicious for cancer on the ultrasound...it's rapidly growing...it's really large (6-10 cm in diameter)...it's twisting your ovary from its weight. If this is the case, surgery is the only option - there's no medication that can get rid of a cyst. Most of the time, the cyst can be removed laparoscopically. While you're under anesthesia, your gyno makes a tiny incision in your naval and places a skinny camera inside. Two or three other tiny incisions are made in your lower abdomen, and long skinny instruments are used to remove the cyst--in most cases, leaving your ovary behind.

How you can prevent them:
Using systemic hormonal birth control--pills, patches, rings--will reduce the amount of activity in your ovaries each months, and helps to prevent cysts from forming.

GynoLingo: Retroverted Uterus

Hi Dr. Kate,

I have a question about the uterus. I’ve been suspicious for a while that I have a tipped uterus (mainly because it seems to run in my family), and the gynecologist at my university clinic confirmed it during a routine pap smear. She didn’t seem worried about it, but commented awkwardly, “wow you’re reaaally tipped!” She didn’t talk about it further.

What exactly makes a uterus “tipped”? And does it tend to affect childbirth or sex? I’ve only recently become sexually active this past year and haven’t noticed anything yet, but I was just curious.

Tipped Off

Dear Tipped,

Almost every day in the office I mention to a patient that she has a retroverted uterus, and I'm met with a blank stare. Also called a "tipped uterus," a retroverted uterus tilts back in your pelvis, toward your tailbone. About one in five women have one--the rest have an anteverted uterus, that tips forward towards the bladder. You can't control this, it's simply your natural direction.

What does having a retroverted uterus mean? Probably nothing, but maybe two things--it may mean more difficult speculum exams, because your cervix tends to be hidden behind your pubic bone. If you feel like your gyno is mining for gold in there, tell her to "look up" to find your cervix. And if your uterus is tipped, sexual positions with deep penetration may cause discomfort: your cervix gets cranky when she's smacked, and can cause your uterus to start cramping. So positions where you control how deep he goes may be more enjoyable. Having a retroverted uterus does NOT affect your chances of pregnancy (so you still need birth control), or cause any complications when you are pregnant--the position straightens out (from either direction) by the end of the first trimester.

Photo credit: BeckyKP

The Scoop On: Gardasil

With all of the worries about the H1N1 vaccine this fall, I wanted to take a moment to talk about the other vaccine available in your doctor's office - Gardasil, the HPV vaccine featured in the ubiquitous commercials.

This vaccine protects against certain strains of human papillomavirus (HPV) that cause cervical cancer and genital warts. Gardasil doesn’t protect you from all of the types of HPV - there are over 100 in all (and that would be a mighty big injection). About 60 types of HPV cause common skin warts (plantar, hand); around 40 affect your genitals and are sexually transmitted (through both inter- and “outer”-course). Only a few of the genital types are considered “high risk” and can cause cancer. Gardasil is effective against four types of HPV: two of the types cause 90% of all genital warts; the other two strains cause 70% of cervical cancer cases.

Gardasil is given in three doses over 6 months and is FDA-approved for girls and women ages 9-26 years old. This means that your insurance company is likely to cover it only until you’re 26. While Gardasil may offer protection for women older than 26, the vaccine hasn’t been tested in them, so it’s not officially approved for that use. Plus, women who are in their 30s and 40s have a decreased chance of acquiring the virus - their cervix is a bit more resistant, and their partners (if of the same age) are less likely to carry the virus. But I have several patients older than 26 who have wanted to pay out of pocket for the vaccine, and I’ve gladly obliged. If you're still sexually active with new partners at any age, the vaccine is likely a good idea - there's no other cancer that you can actually get a vaccine against.

Have any of you run into trouble getting Gardasil because of cost or your age?

Photo credit: kelsey*

Skintight

Dear Dr. Kate,

I've been with my boyfriend for a year now and we tried having sex. For the first two times we did it, it hurt really bad...but only the penetration. After that I was fine. What can I do to make myself less tight and actually enjoy sex? I am afraid of the pain and don't want sex to be a thing I don't look forward to.

All Clenched Up

Dear Clenched,

I totally agree with you - sex should never be dreaded, and should never cause you pain. If you've been to see a gyno, and had a normal pelvic exam, there are two scenarios that can cause the kind of pain you're describing:

• Vulvodynia, a fancy-pants way of saying "pain in the vulva." Other signs that you may have vulvodynia: does it hurt if he puts a finger inside you? if you use a tampon? if you wear tight jeans or pants? Often, women with vulvodynia have pain on ANY contact to their vulva, not just intercourse. If you think this describes you, there are treatments available - most often a combination of oral medication and a topical anesthetic cream - so talk to your gyno.
  

• Tightening in anticipation. The vagina is a powerful muscle. If you're not fully relaxed before intercourse, you can feel a lot of pain with penetration. It takes the average woman 20-30 minutes of good foreplay to become both aroused and lubricated enough for intercourse. (And I don't mean him feeling up your boobs - that's foreplay for him - unless that happens to work for you as well!) Especially once you've had pain with sex, it's natural to "tighten up" when a penis is approaching you. So make sure that you get lots of playtime first (his fingers, or going down on you, or a vibrator)...use a lubricant on his penis and your labia before he enters you...and make sure he enters you really slowly, to give your vagina a chance to adjust. Better yet, you be on top, so you can control how quickly he enters you.

Whatever is happening, pain is your body's way of telling you to stop what you're doing. Once you can figure out why you're hurting, you can figure out ways to make sex more enjoyable - and something that makes you shiver in anticipation, not dread.

All the best,
Dr. Kate

"No One Wants To Have Sex With Me."

Dear Dr. Kate,

I am 32 and I am still a virgin. Nobody seems to understand how much this bothers me. I am not a virgin because I am afraid of sex or because I was brought up in a repressive household. No, I am still a virgin because nobody is interested in me. Nobody has ever asked me out. I've never even held hands with anyone.

I don't really know why.

I mean, I know I'm not that attractive (really, I'm not. This isn't low self-esteem.), but I don't think I'm actually *ugly*.

Now I'm not really sure what I should do. I'd really like to try partnered sex, but if nobody is willing to be my partner, there's nothing I can do about it.

I've tried before to just realize that it's never going to happen for me, but then after a while, part of my mind will ask, "So when are you going to do something about the sex thing?" and then I will feel bad about myself all over again because nobody likes me in that way.

What's your advice?

Alone at 32

Dear Alone,

I wish I could see you face to face in my office, but email will have to do. I know that I don't know anything about you, but I'm going to give you my best advice from both my professional and personal experiences. And it's just one woman's opinion, but I hope it helps.

Re: the attractiveness question. Yes, undeniably some human beings are considered beautiful, by most standards. But attractiveness isn't just about aesthetics. So often, a connection happens with someone because of who they are - their intelligence, their sense of humor, their skill in the kitchen, etc, etc - and the chemistry follows. Many women find themselves attracted to men that are so not the picture of what they thought they wanted (shorter, bigger, balder), but find the man becoming more attractive with time, because of how they feel about him.

This is my roundabout way of getting to how you see yourself, and how that matches up with reality. Do you have physical deformities? Are you morbidly obese? These things, I'll admit, pose challenges to finding a partner - but even they are overcome, routinely. And if you aren't at peace (at least somewhat) with your face and body, you'll signal that to everyone you meet.

So I don't believe that your problem is really how you look. I wonder if you're out there in the world in such a way as to make connections with others possible - not just romantic ones, but ANY connection. Are you able to meet people with shared interests? People you can spend time with to really get to know? Are you working? In school? What do you do when you're not doing that? Or are you around the same set of people all the time--folks you may love, but no one a potential partner?

When you've looked in all the places you can and are coming up short, you need to work on expanding the pool. Community service...alumni organizations...on-line dating - whatever it takes, to get new people to cross your path and into your life. Use the Internet. Use your family and friends. I'm trying to avoid the cliche of "there's someone out there for everyone." But in a country of 300 million people, the odds are pretty good that there are people for you to meet that you just haven't come across yet.

Two other things to consider...

* Your sexuality. Are you attracted to men? to women? to both? Are you sure? Because if you're sending out confused signals, it's hard for someone else to interpret them right.

* Your expectations. Don't have in mind "is there a chance that (s)he'll have sex with me?" when you meet someone. Get to know them as a person - let them get to know you - take the pressure of the sex question off.

Because in the end, I don't want you (or any of my patients or friends) just looking for sex. Believe me, you can find someone to boink you if that's all you want (peek at Craig's List if you need convincing). For sex to be good, it first needs to be comfortable...that means both arousal and lubrication, and both come more easily when you feel really good about the one you're with. And since you risk pregnancy and STDs every time, the sex should be worth it.

All the best,
Dr. Kate

I Must Increase My Bust

Dr. Kate,

I am almost to the point of desperation with the small size of my breasts. For years I have been contemplating a breast augmentation, but I am scared of the pain/recovery time, and nervous of the long-term possible effects, plus the expense is too much. Other than surgery, is there anything, ANYTHING AT ALL, such as herbal pills/supplements, estrogen pills/injections, whatever, proven to work and maintain, and/or to "restart" breast growth? I am on the Yasmin birth control pill, and one of the side effects of Yasmin is possible breast enlargement...didn't work on me! Please don't tell me to be happy with what I have; no offense but you don't know how I look braless or without padded, underwire bras! I am very self-conscious in intimate situations. To look semi-proportionate in t-shirts I HAVE TO wear thickly padded underwire bras while out in public/away from home. I don't wear tank tops, low-cut tops, bathing suits, or any top which focuses on the chest; I don't naturally fill them out. I am: female, 33 yrs., large body frame and heavyset, 5' 7"...with small B-cup breasts that make me feel deformed and disproportionate; I look like I have man-boobs!

Boobless

Dear Boobless,

The simplest answer to your question is no. Many pills, creams, etc. claim to enlarge your breasts, without any evidence that they do. And any medication that actually works to make your breasts grow--generally herbs and hormones--put you at an increased risk of breast cancer. Birth control pills do (safely) cause breast enlargement for some women - and if one brand of pills doesn't work, another might - but it's impossible to predict.

Mechanical means (suction systems, etc) don't seem to last long-term, and are arduous at best. The Bravia system makes you wear a suction-cup-like bra for 10 hours a day for 10 weeks. I believe it to be safe, but who can really do that? Plus, once you stop the suction, your breasts will go back to their normal size.

It's hard for me to not talk about breast acceptance - how any guy who sees you naked is simply happy to be there...how you always look thinner with smaller breasts...how there's less to sag as you get older. And B-cups are not that small - check out the photos in this month's Glamour magazine. It's got a feature all about breasts, including celebrities looking fabulous at every cup size.

So what can you do? Try a different combination of birth control pills, buff up your pectoral muscles to maximize what you've got, and only consider surgery as the final alternative if you feel you don't want to live any other way.

Have any of you tried things to increase the size of your breasts?

I-U-Don't? I-U-Do!

Hi Dr. Kate!

I can't take hormonal birth control; I've had terrible side effects and I just don't like it! My question is; what is the best non-hormonal option? My doctor will not give me an IUD because I've never been pregnant. How effective is coupling condoms with a diaphragm or the sponge? I've read that The Sponge increases the risk of contracting HIV, but I've been with the same guy my entire life, so I don't think this is too much of a concern for me. Thanks!

No Pills for Me!

Dear No Pills,

My first thought is...find a different doctor! There's no reason that you shouldn't be able to get an IUD before a baby, that's outdated thinking. And a copper IUD will give you 99+% effectiveness for up to 10 years, so it's hands-down the best non-hormonal option. Condoms plus a diaphragm should get you over 90% effectiveness, especially if you use spermicide with the diaphragm (available as creams, suppositories or film). And condoms plus the sponge should be about that good as well.

The sponge - like other spermicides - may increase your HIV risk if you're having intercourse, and using the product, multiple times a day, every day. (The studies that showed us this were conducted in sex workers in Africa.) Since this isn't the sex pattern of most people in the world, spermicides are still a good option, when used in conjunction with a barrier method (condoms, diaphragm) for greater effectiveness.

But my guesstimates on effectiveness are based on PERFECT use - using both products, every time, with no spillage. And that can be tough to do, long-term. I'd still think about seeing another gyno to get the IUD, then going back to your guy for your check-ups, especially if you know you don't want to be pregnant for awhile.

Have you been told you couldn't get an IUD? What was the reason?

Photo credit: Liz Henry

Backside Bump

Dr. Kate,

I have a rather embarrassing question to ask. A couple of months ago, my guy and I decided to try full-out anal sex. I think he didn't actually use enough lube, because it hurt more than I'd ever imagined and it bled a little afterward. We didn't do this again because of the pain, and the blood. A couple of days later, I noticed that I had developed a fleshy bit on the edge of my anus, which felt, to the touch, sort of like a skin tag. But it is sometimes itchy, and has bled again, once or twice. Is it possible to develop a hemorrhoid, or something like it from anal sex? And is this something I need to be worried about?

Tag, I'm It

Dear Tag,

It does sound like you've developed a hemorrhoid, a small prolapsed (bulging-out) vein that can pop out on the inside or the outside of your anus. 'Roids are known for being itchy, a bit painful, and occasionally bleeding. It's unlikely, though, that one act of anal sex cause the hemorrhoid to develop - you need more pressure on your bottom for a longer period of time (like chronic constipation or pregnancy). So it's possible that you're either noticing the bump for the first time, or that it was there before, and after sex has now dropped down to be exposed on the outside where you can feel it. Either way, it's nothing to worry about. Preparation H can help with the itch, and you'll only need it removed if the bleeding becomes serious (more than the occasional drop or streak when you wipe).

If you ever want to try anal sex again, definitely use A LOT of lube, and make sure he thrusts slooowwwly and gently. The back door is not like the front, and requires its own technique.

Have you had any problems when trying anal sex?

Photo credit: bleggg