Before trying to conceive you should make a preconception medical appointment. In this appointment it will be made a medical and surgical history and detailed physical examination (with special emphasis on history and gynecological examination), a family and marital medical history in search for factors that may affect prognosis of future pregnancy and which might be corrected before becoming pregnant or involving a specialized surveillance. In this consultation it will be prescribed folic acid (400 mcg / day) which must be kept up until 12 weeks of pregnancy, to decrease the probability of having a child affected by a neural tube disease (spina bifida, etc ...). A set of analyzes will also be resquested: complete blood count with platelet count, uric acid, creatinine, glucose, transaminases and bilirubin, blood group and Rh factor, proof of indirect Coombs, rubella serology, toxoplasmosis, hepatitis B and C, HIV, CMV. and syphilis, urinalysis and bacteriological urine. It will be also performed a cervical cytology (Pap smear). To increase the probability of becoming pregnant, a woman must know her fertile window. This period begins 5 days before ovulation and ends on the following day. This is because spermatozoa can survive up to 5-6 days in the vagina, while oocytes do not survive more than 24 hours. Identifying the fertile window may be difficult: menstrual cycles vary from woman to woman and the same woman can vary from one cycle to another. A woman with 28-day cycles, should ovulate by 14 days. Women with cycles of another length, in principle, ovulation occurs 14 days before the next menstruation. There are methods and techniques to determine the day ovulation: basal temperature graph and a small device that detects the rise of a hormone (LH), which usually occurs 26 hours before ovulation. WOMAN • Make a balanced diet • If you are overweight or underweight you should seek to achieve ideal weight • Reduce stress • Do not smoke: smoking increases the incidence of infertility, reduces the response to medications that are used to induce ovulation and increase the probability of an abortion • Do not take more than a coffee a day • Reduce or eliminate alcohol consumption MAN • Do not use tight pants or underwear • Avoid hot baths, especially immersion • Do not smoke or drink • Avoid exposure to chemicals and radiation • If you have overweight you should lose weight • Anabolics • Corticosteroids at high doses • Cyproterone, cimetidine, spironolactone • Colchicine, nitrofurantoin, sulfasalazine • Amiodarone • Nifedipine • Propranolol, quinine, chlorpromazine • Tricyclic antidepressants, MAO inhibitors, phenothiazines • Thiazide diuretics The success rates of the techniques of Medically Assisted Procreation (MAP) are easily manipulable. To make a critical analysis of the success rates there are certain facts that you must first know to avoid false expectations. • The main factor of prognosis or in natural reproduction that in assisted reproduction is the age of the woman, the greater the woman's age, the lower the probability of success. • The probability that a couple with less than 35 years has to conceive naturally within a given cycle is around 20%; this probability lows to 5% after 40 years. • The success of any technique rates depend on the characteristics of the population to whom a technique was applied: a program that restricts access to certain technique of couples with bad prognosis is obvious that this technique increases the success rates. • On FIV, the more embryos to transfer, the greater the likelihood of success, but also the greater the probability of multifetal pregnancies. One of the major problems in the way we deal with infertility is that we have the notion that we do easily, with a minimum of fears and anxieties. Very often, infertility is a failure crisis that repeatedly generates suffering. And we have to realize that this suffering, or rather, our reactions are natural and normal! Failures have to be seen as the 1st step to leave for a new investment / project. • REMEMBER WHAT YOU DID IN PAST SITUATIONS in which you also crossed DIFFICULT times. • ENJOY THE NEGATIVE ASPECTS of past situations, TRANSFORMING THEM IN POSITIVE ASPECTS AND LEARNING that in present / future situations, will give you clues as how to act. • WORK TO FEEL WELL: arrange some time to have fun, read, meet new people, go shopping, learn something you are long afraid to try, develop your sense of humor regarding the experience of infertility, use some time to develop relationships with your mate and other important people, do therapy, integrate groups of friends, talk and exchange impressions about your experience, or just do something that your "heart desires!" One of the events that generates more anxiety during the treatment of infertility is "waiting", after the treatment cycle between the arrival of menses or a positive pregnancy test. The uncertainty of "when" or "if will result" a baby is very stressful. It seems to be a "chronical crisis" in which people feel in constant tension and life decisions are difficult to make. The loss of control on feelings make up this picture! Anxiety and stress are often cofactors (psychological) that contribute to the failure in matters of sterility. They have physical and emotional effects, leading, most often negative feelings. But we also need the stress / anxiety to have "power" to act in the face of situations, if it is below a particular level, which is specific to each person. Thus, the CONTROL /MANAGEMENT OF ANXIETY (not its elimination) is essential: • Pay attention to the events that causes you greater stress / anxiety and your EMOTIONAL AND PHYSICAL REACTIONS. Do not ignore them ... LEARN TO KNOW THEM! • SEE WHAT CAN BE CHANGED: can you spend some time and energy to make changes that, for some time, you consider important in your life? • Ask QUESTIONS TO MEDICAL TEAM in order to understand what (and how) is wrong with you and with your case in particular. Don't ignore your situation! • REDUCE THE INTENSITY OF YOUR EMOTIONAL REACTION TO STRESS: - Aren't you looking at the events that generate stress in an exaggerated way, turning a difficult situation into a real disaster? - Exert yourself to to adopt a more moderate point of view. Try to temper your emotions, not allowing them to control yourself! - LEARN TO MODERATE YOUR PHYSICAL REACTIONS TO STRESS: Slowly... calm breathing restores you the right heart and respiratory rate. - Relaxation techniques help to reduce muscle tension. Learn them and put them into practice. - Take short periods of time throughout the day and week to relaxation techniques, in order to reduce your anxiety. Ex .: training of breathing, muscle relaxation with music, aromatherapy, massage, yoga, ... • MAINTAIN YOUR PHYSICAL RESERVES: - Physical exercise about 2-3 times a week and a balanced diet are fundamental - Keep the adjusted weight - Avoid nicotine, alcohol, excessive caffeine and other stimulants - Take breaks and walk whenever possible - Get enough sleep •MAINTAIN YOUR EMOTIONAL RESERVES: - Keep yourself, as much as possible, busy with planned activities such as hobbies, gardening, cleaning, walking, exercise, ... - Develop some supportive relationships with friends, family, therapist, others. Talk to them, even if some of these people do not seem to you sufficiently sensitive to your issues. - Set realistic objectives and transfer your energies into them, sharing them, whenever possible, with the people you expect to be with you. - Write what comes to your mind, even if it does not seem to make sense ... This will help you to organize certain ideas. - Decentralize the attention of the superfluous aspects of day-to-day, that others may solve as well as you. Do not worry for nothing, but ... Attention! Try to solve the issues that are still under your control and that really require your actions. Make a selection of urgent, priority and important issues, and devote yourself only to those which you can not escape (and give you some pleasure!) - Realize what gives you pleasure and believe (and exercise) your capacity for self-control. When your thoughts begin to focus on treatment results, change what you were doing, change location, focusing attention on something else. Avoid thinking about what happened (or did not) or try to predict what will happen. - Do not let others bother you with constant questions or "miracle stories". If necessary, give clear messages about your needs. Give your partner some extra attention and care, and take some time to make a balance of your life! GENERAL CONSIDERATIONS Recurrent Miscarriage is defined as the occurrence of two or more early embryonic or fetal losses. Most of the losses are pre-embryonic or embryonic (before nine weeks), being the recurrent fetal loss (between nine and 15 weeks) a rare situation. The recurrent miscarriage occurs in about 1% of women in reproductive age. Recurrent miscarriage should not be mistaken with sporadic abortion (not consecutive) which occurs in 10-15% of all clinically recognized pregnancies. The risk of miscarriage after two consecutive abortions is about 30% similar to the risk of miscarriage after three consecutive abortions. Maternal age influences the recurrent miscarriage rate (about 25% in women under 30 years and about 60% in women over 40 years). Only in about 50% of recurrent miscarriage is possible to establish a cause. A couple with unexplained cause of abortion has a probability about 70% of having a future successful pregnancy. CAUSES OF RECURRENT MISCARRIAGE Below are listed only causes that are not controversial. • STRUCTURAL CHROMOSOME ABNORMALITIES IN COUPLES In about 2 to 4% of couples, one of the elements carries a balanced structural chromosomal abnormality. • MOLECULAR GENETIC ABNORMALITIES Some molecular abnormalities associated to the X chromosome are cause of recurrent miscarriage. • RECURRENT EMBRYONIC ANEUPLOIDY It is possible, despite the couple's karyotype is normal, that the recurrent embryonic aneuploidy is a cause of recurrent miscarriage. • UTERINE ANATOMICAL ABNORMALITIES Approximately 10 to 15% of women with recurrent miscarriage have uterine malformations, being malformation most often implicated the septate uterus. • ANTIPHOSPHOLIPID SYNDROME The antiphospholipid syndrome is characterized by the presence of a significant level of antiphospholipid antibodies (anticardiolipin and lupus anticoagulant), in addition to one or more clinical manifestations, one of which is the recurrent miscarriage. COUPLE STUDY WITH RECURRENT MISCARRIAGE The tests indicated refer to the basic study: • Uterine malformations (e.g., uterine septum may be removed by hysteroscopy) • Couple's karyotype • Hysterosalpingography (hysterosonography, hysteroscopy) • Search of antiphospholipid antibodies RECURRENT MISCARRIAGE TREATEMENT Only some situations are liable to be treated: •Uterine malformations (e.g., uterine septum may be removed by hysteroscopy) • Antiphospholipid syndrome: treatment with low molecular weight heparin and low-dose aspirin. • Couples with balanced structural chromosomal abnormalities should receive counseling by a geneticist. In some cases you can put the hypothesis to resort to Preimplantation Genetic Diagnosis.
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