“Mailbag 19: What does the Fox say” – with Dr. Nathan Fox

Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

Welcome to Mailbag #19. What does the Fox say? Our first question is from Katie: “Hi, Dr. Fox. Love the podcast and thanks for everything you do. I’m 29 weeks pregnant. And at my 20-week ultrasound, it was discovered that my baby has a duplicated collecting system and a ureterocele on the right side. The right upper pole of the kidney is severely dilated, and in my most recent follow-up ultrasound, it was looking as though the left kidney is starting to show some mild dilation as well. My husband and I are obviously very concerned and anxiously waiting next steps and follow-up ultrasounds, but I wondered if you were aware of any intrauterine treatment options for decompression of the ureterocele. My maternal fetal medicine doctor said she would look into it, but that would likely all be investigational, which is what I found so far as well. I would really appreciate any insight you have into this, even if it’s just to confirm that no treatment options exist until after the baby’s born. Of note so far, the amniotic fluid level is normal. Thanks again for all you do, Katie.”

All right, Katie, that’s a good question. It requires some background. So, for our listeners, all of us, ideally adults, children, and fetuses have two kidneys. They’re located in the back side of our abdomen, so sort of closer to your back than to your front, a little bit high up, sort of just under your ribs in the back. What the kidneys do, again, this is true in adults, children, and fetuses, is the kidneys filter our blood, and they take out some stuff like some toxins or salts or whatever it is, and they produce urine, pee, which first collects inside the kidney, in the middle of the kidney, and then that urine drains out of these little tubes that exit the kidney, one on each side, called the ureter that goes to the bladder, right? And then at some point after the bladder fills, you pee and all that urine comes out. Okay, so that’s what normally happens.

Now when we do ultrasounds in pregnancy and we’re looking at the baby, starting at around 16-plus weeks, we usually take a look at the kidneys. And what we typically see, right, we see two kidneys, one on each side, and usually what we’ll see is that there’s sort of like spongy tissue on the outside, and in the middle, we’ll see a little collection of fluid, which is supposed to be there. That’s the urine they’re collecting. We do not normally see the ureters, those tubes that drain the kidneys, because they’re very, very thin and usually collapse, so we don’t usually see them on ultrasound. We know they’re there. We won’t see them. And then we usually will see the bladder with some amount of urine in it. And then what we see on ultrasound is the amniotic fluid, which is the fluid outside the baby, which after 16 weeks is predominantly baby pee, fetal urine. So, all of those things we look at to evaluate the urinary system in fetuses, and obviously in most babies, everything’s perfectly fine, but there are things that can be not so fine.

Now, when looking at the kidneys, it is very common that in one or both kidneys, we’ll see a little bit of extra fluid, and we call that sometimes pyelectasis. We sometimes call that urinary tract dilation or UTD for short. That is a common finding. It usually means nothing for the baby, nothing for you, nothing to do about it in pregnancy. It usually goes away either during pregnancy or after delivery, and the reason it’s normally there is the babies, they’re small, they’re kind of smushed inside there, and so those ureters, those tubes that drain the kidneys, since they’re very thin and very fine, they could get kinked or twisted or compressed, and there’s a little bit of backup of fluid. Think of it as plumbing. And as the baby gets bigger, those tubes open, the kidneys drain completely and everything is fine. So, that finding is rarely concerning and typically does not need anything done during pregnancy or after delivery, meaning not while you’re pregnant to the fetus, not after delivery to the baby, everyone’s typically fine.

Now there are circumstances that are a little bit more advanced than that, where we think there’s actual blockage, like obstruction of something in that system. So, Katie, what you described is, number one, that the baby has a duplicated collecting system. So, a duplicated collecting system means that on one of the kidneys, instead of one ureter, one tube coming out of the kidney, there’s two tubes coming out of the kidney, so that doesn’t sound so bad, but when fetuses have that, usually or often, one of those two ureters is not functional and is blocked. And so one of them works and the other one is blocked, so the one that’s blocked will just back up. And since that one backs up, you end up getting sometimes a dilated ureter, right? You do see the ureter in this case because it starts filling up, and you can get back up into the kidney, and you can get something called a ureterocele, which is where it sort of outpouches into the bladder, and you can sort of see it pouching into the bladder.

So, all those things, that’s one sort of abnormality that you could have that’s a little bit more…. I say the word severe, but I don’t mean that unhealthy that something’s going to hurt the baby but just severe in that we see it, it looks more prominent, more significant. Those types of abnormalities typically do need to be corrected after birth surgically, right? So, a pediatric urologist who’s a urologist for children will typically have to correct that with some sort of procedure, some sort of operation. Fortunately, those babies tend to be perfectly healthy. They recover fine and typically they go on in life with two working kidneys and everything is good. So, when someone’s pregnant and we see anything going on with the kidney, the first thing we try to differentiate is this one of those things that pretty much is going to be fine, going to go away either while you’re pregnant or after birth, or is this one of those things that we predict the baby will need surgery for. Now we’re not always right. We could be wrong. It was just a prediction.

Now your question was, okay, so you see one of these things that we think or predict is going to need surgery after birth. Is there something we can do during pregnancy to either fix it or make it better or whatever is? And the short answer is, no, there isn’t anything that we could do that is safe or that we would want to do because it is not common that one of these things would actually harm the baby inside, either the baby in general or the kidney. And so anything that you would have to do to “fix it” would basically be pretty invasive, right? You have to go in through the uterus into the baby to do something or drain and even if you drain something, it’s going to fill up again. You’d have to actually surgically do something to the baby, and that’s a pretty advanced and high risk procedure to fix something that doesn’t really need to be fixed typically while you’re pregnant. It needs to be fixed after birth, right?

The times when you do fetal surgery are usually situations where it’s either very dangerous to the baby during pregnancy and the only option is to fix it during pregnancy or if it’s known that if you take the risk and fix it during pregnancy, the outcome after birth is better than if you wait till after birth. So, one of the classic examples of that is in many cases of spina bifida, there’s data that, if you do fetal surgery and correct it during pregnancy, those babies tend to do better than if you wait till after birth. That’s not uniformly true, but whatever, that’s a condition where it’s on the table. It’s a possibility. But for kidney conditions, typically no, because the risk of the procedure would far outweigh any benefits. And again, these babies typically the main decision we’re trying to figure out is, “Will the baby need surgery or not?” It’s ultimately decided after birth, but we could help predict it. But what I like to remind people is that even if your baby needs surgery, they are typically perfectly healthy and grow up without any issues afterwards. Obviously, as a parent, you’d prefer your child not need surgery, obviously, but in those circumstances, they do tend to do well. Good luck.

All right, next we have two questions on epidural. The first one is from Sarah: “Hi, first of all, I love the podcast and especially these mailbag episodes. Please keep doing them.” Thanks, Sarah. “My question: is it normal if I still have back pain sometimes from the epidural that I got during my first birth? And does this signify that I will/can have future complications from a potential epidural in subsequent births? I also got spinal headaches from that epidural. How likely is that to happen to me? Again, thanks so much.

Okay, so let’s talk about back pain and epidural. So, there’s different kinds of back pain that someone can have from an epidural in theory, and I think it makes sense to differentiate something that’s what we call short-term versus something long-term. So, short-term means in the days or weeks or let’s say even months after delivery. I don’t know, Sarah, when you wrote this question, how far you are from your last pregnancy, but days, weeks or months, let’s call that short-term.” And so I would say most people don’t have pain from the epidural site more than a few days after delivery. But some people do for several weeks or up to a month or two, whatever. And that’s just because when they do the epidural, the needle they’re using, right, if you have an epidural, they’re sort of like a wider needle that they use to find the right space in your back. And then through that wider needle, they thread a very thin catheter, then pull out the needle. But the wider needle, they have to go through ligaments and some tissue. And putting a needle through there could, you know, lead to some soreness there afterwards, which is not so unusual. Again, it typically goes away in days to weeks, but it could last a little bit longer for somebody if let’s say went through a thicker spot or a more sensitive spot, or some people just have more sensitive areas or whatever it is. But that is short-term.

Long term, right, the question is, will getting an epidural cause me to have long-term back pain like people of chronic back pain?” And what pretty much all the data shows is no, they’re not linked. Now, obviously, a lot of people have babies will have epidurals, right, in the U.S., the majority. And there are a lot of people who end up in life with back pain. And so someone has back pain and five years earlier, they got an epidural, are the two related? And as far as we can tell, the answer is no. I mean, as far as we can tell, women who give birth with epidurals are not more likely to have long-term back pain than women who give birth without epidurals, right? Birth itself could in theory lead to back pain or having children, raising children, running after children, whatever it might be. There’s a lot of reasons people get back pain. Nothing to do with your children, but it does not seem to be linked to the decision to get an epidural or not, which is fortunate. And that’s for long-term pain. Short-term pain, yes, it makes sense that you could have that from someone putting a needle in your back. But long-term, it does not seem to be the case. So, that’s for back pain.

Now, there are rare instances where short-term back pain can be more severe like an infection in your back or this. But in that case, it’s not mild pain in your back. It’s severe pain. Usually the area itself is very sore and red. And again, that’s unusual. That’s part of the reason anesthesiologists like to look at your back after birth. And if someone did have back pain that’s more severe, someone should take a look at you in this. But those are very rare. But the typical pain people get sort of just some soreness in the area is common and long-term and should not relate to epidural.

What you also described, Sarah, is that you had a spinal headache after epidural. So, a spinal headache is different. As you know but our listeners might not, it’s not back pain. It’s actually a headache. And what happens is for about 1% of people overall who get epidurals, they can have a complication called a spinal headache where afterwards, one or two or three days after delivery, they have a very severe headache. It is a specific kind of headache that is a little bit unusual. It’s unusual in that if you’re lying down flat on your back, you typically have no headache. But once you sit up or stand up, you have a severe headache.

And the thought is that when you get an epidural, the goal of the procedure is not to puncture the spinal cord, right? When you get a spinal, the goal is to puncture the spinal cord. And if an epidural, the word epi means outside, you’re supposed to stay outside of it. But occasionally, because you’re going in a really fine space, occasionally the needle will puncture the dura, which is sort of the bag that holds the spinal cord. And then that slow leak out of that hole, but just temporary, not dangerous, but it can cause a severe headache. And when you sit up or stand up, there’s more gravity pulling down. There’s more of a leak, so you have a headache. Whereas if you’re lying flat on your back, there typically isn’t that sort of leakage and so you don’t have a headache.

It does go away on its own eventually, but there are things that one can do or that can be done to sort of make it go away quicker. There’s certain… Sometimes it’s giving fluid, sometimes it’s giving caffeine. And there’s a procedure that can be done where you sort of repeat that epidural and do something called the blood patch to sort of try to fix it quickly. But again, that is a different kind of complication, and that happens about 1% of the time. That’s not backache. That’s headache.

And so the question is, how likely is it to happen to you again? As far as I know, getting it once does not mean you’re more likely to get it again. It’s usually just sometimes the procedure leads to that and sometimes it doesn’t. And I don’t think, as far as I know, that it’s related other than if someone had a particularly difficult back, like someone with scoliosis, they have rods in their back, and it’s very hard to place their epidural. That might increase the risk of getting a spinal headache. And since they have the same back on their next pregnancy, they could be at increased risk. But it’s not the fact that you had a spinal headache once puts you at risk for the next time.

All right. Second question on epidural. This one is from Jill: “Hi, Dr. Fox. Thank you for your helpful podcast, and I love the new book. It’s Jill. I was induced in my first baby and had a poor reaction to the epidural. I became faint, disoriented, and nearly passed out. I would like to try for a VBAC, mostly because I want at least two more children. Two questions. What is the ideal range of time between deliveries for an epidural? Second, I’m not sure why I had the bad reaction to epidural, but I don’t want another. What are my options if my VBAC fails? So, I need a C-section but don’t want an epidural. Thank you.”

All right. So, Jill, in terms of what happened to you and your poor reaction to the epidural where you became faint, disoriented, and nearly passed out, what I would say is most likely what happened is after the epidural, your blood pressure dropped, which is a common happenstance after you get the epidural. Many people afterwards, their blood pressure drops, and the anesthesiologists usually try to prevent this by giving you fluids beforehand. And after you get the epidural, they typically lie you down, put you sort of on your side, check your blood pressure frequently. There’s medications they can give you, but sometimes the blood pressure still drops. And when your blood pressure drops, you feel symptomatic, and you feel exactly what you described. You can feel faint, you nearly pass out, you feel disoriented, lightheaded. Some people get very nauseous, and they throw up. Very, very common thing. It is treatable.

So, the first thing I would say is just because that happened to you the first time, A, it does not mean it will happen to you again. And B, if you let the anesthesiologist, the next time around, know that that happened to you the last time, they could be extra vigilant about keeping your blood pressure normal to lower the chance that it would happen again. So, even though you said you don’t want an epidural next time, which is fine, if you did want one or you’re thinking about it, that’s something you can maybe even speak to the anesthesiologist about before you come into labor or anything. You know, during pregnancy, you can do consultations with them and say, “Hey, this is what happened to me. What are the chances we can avoid that next time?” And maybe you actually have an opportunity to get an epidural if you want one.

But let’s say you don’t, right? You don’t want to get an epidural the next time around, which is fine. So, the question is, what are your options for pain relief if you have a C-section and you don’t want an epidural? Well, there’s only two options, right? If you’re having a C-section, either you get an epidural/spinal, right? If you’re just doing this for a C-section, usually they’ll do a spinal, which from your end seems the same way. But instead of the needle going outside the spinal cord, the spinal needle is thinner but goes into the spinal cord. They inject the medicine and pull everything out. There’s no catheter left. It’s a more dense block. It’s much more predictable to be enough for surgery. An epidural can be enough for surgery, but you have to sort of dose it differently. So, that’s one option.

And the only other option is really to be put to sleep, to have general anesthesia, which is, you know, they give you medicine through the IV to fall asleep. They put a tube in your throat to breathe for you, just as if you were having any other surgery. Now, general anesthesia is a safe option if someone needs it, but generally we try to avoid it and try to do epidural or spinal for C-sections because there are some complications that go up if you have general anesthesia, like the risk of what’s called aspiration, which is where you vomit. And then, since you’re asleep, you don’t cough it out but it goes into your lungs. So, that’s a concern. Also, if you have that when you wake up, you will not have been present for the birth, right, to speak. I mean, you will have been present physically, but you will not have any memory of it because you will have been asleep the whole time. And so a lot of people do want the experience of being awake for when their baby is born. And also, when they give you an epidural or spinal, there’s a medication they can put in there, which is a long-lasting morphine, which essentially gives you a lot of good pain relief the first 24 hours after surgery. And you can’t get that if you just have the general anesthesia.

So, you have an option for general anesthesia if you do not wish to have an epidural or spinal, but I’m pretty sure that a lot of people are going to tell you, you really may want to reconsider that because there’s some extra risks to having general anesthesia for a C-section, and the experience tends not to be as good for people. And you don’t have that 24-hour coverage of pain control after delivery.

In terms of your question of how much time between deliveries for an epidural, I’m not aware of any time that makes really a difference. So, typically, if your body’s ready or you’re ready to get pregnant again, it wouldn’t really… The epidural would not impact the timing between deliveries or the ideal timing between deliveries, if I understood your question correctly.

Okay. Next question is from Christine, and it’s about abdominal pain in pregnancy: “How do I know if I’ve just strained an abdominal muscle or it’s something more serious? I’m 31 weeks and I’ve had pain down the middle/slight right side of my stomach and just below the center of my ribs, especially when turning at night. I suspect it’s just my growing stomach straining my abs, but how can I know if it’s something more serious like a placental abruption or any other scary thing I could find on Google?”

Yes, Christine, you can find all the scary things on Google. So, it’s a very, very good question, and it’s a very common question. And it’s not just pain in your belly or your stomach, but when people have aches and pains in pregnancy, how do you know if they’re concerning or if they’re sort of expected? The short answer is you don’t have to know. The short answer is obviously you can ask your doctor or midwife. I would recommend them over Google. But what are the sort of signs that we’re looking and you could look for things to indicate that it is or is not concerning?

So, things that would make something more concerning is if there are symptoms that go along with the pain. So, for example, someone who has pain and bleeding is much more concerning than pain and no bleeding, specifically for something like a placental abruption. Or, if someone has pain and they also have nausea, vomiting, fevers, things like that. Again, none of this means definitively that it’s a problem but it would make us much more concerned that there’s a problem and much more likely to want to evaluate you in person and figure it out. So, associated symptoms is one thing.

Another thing is obviously the severity of it and the pattern of it. Is it something that’s mild? Is it something that’s severe? It doesn’t take a genius to realize that the more severe the pain, the more likely it is to be problematic compared to the more mild it is. But also, what is the pattern? Is the pain getting better? Is the pain getting worse? Again, same concept. If it’s getting worse, it’s more likely to be an issue than if it’s getting better.

There are certain things that we can sometimes elicit, like the location of the pain, that for us might be more more likely to be an issue. Like, do we think it’s in the area of the appendix, or is it the area of the gallbladder, or the area of a kidney? It’s not something you would typically know. Maybe you would, maybe you wouldn’t, based on your sort of medical education. But those are things that we ask about as well.

Another sign that would make it more concerning is I’ll often ask people if they’re having aches and pains. Does it get better or go away if you sort of lie down and rest? And if someone says, “Well, yeah, the pain’s really only there if I’m moving around or if I’m bending or twisting or this,” but if I lie still and I’m just watching TV or lying in bed at night, I pretty much feel fine. Those things are typically not concerning. Again, there’s exceptions to everything, but, you know, this is a podcast, so we’re just going with the typical. So, they’re typically not concerning.

And so, if it’s something related to stretching parts in your body, or movement, or growing uterus, usually, those things get a lot better if you’re just lying and resting. And so, if it’s not obvious to me that it’s concerning and we’re not quite sure what it is or what’s going on, one of the things I’ll usually ask people to do is, “Hey, why don’t you just lie down and rest for, you know, half an hour and see if it gets a lot better?” And if the answer is yes, it’s probably or much less likely to be concerning.

And so that’s sort of one of the things. And then, you know, sometimes even with associated symptoms, it could be more typical of a real diagnosis, but they don’t always need treatment. For example, someone might have abdominal pain, and it’s clear to me they have vomiting, then they have diarrhea, and this or that. Maybe they got food poisoning. So, food poisoning, that’s a real diagnosis. That’s a thing that’s not just aches and pains. Sometimes, with food poisoning, people need to be seen, and people need to be treated, and sometimes they don’t, right? So, that’s sort of one of the things that’s… We’re going to help with that decision. Obviously, that’s not something that you would need to know for yourself. Or, if it’s a stomach bug or something like that, then obviously, it’s something that sometimes needs treatment and sometimes doesn’t. It depends on the circumstances.

But I hope that’s a framework for you and for others to get a sense of the things we’re thinking about when somebody calls. Obviously, there’s other things. If we think the pain is not from your abdomen, like your belly but actually from the uterus, is it a preterm labor symptom, right? Is the baby moving or not? Do you feel contractions, or is your belly getting harder? There are risks involved, right? There’s a whole lot of things we go through on our end, but that’s usually a different quality of pain than what you’re describing.

Okay, next question is from Faye: “Hi, Dr. Fox. Thanks for such an awesome podcast. I love listening.” Smiley face emoji. Thanks, Faye. “Here’s my question: I recently had a baby.” Congratulations! “In the car—not recommended.” Her words, not mine. “And I keep wondering if I’m being foolish for not wanting to switch practices to one that delivers closer. The hospital my doctor delivers at is a 50-minute drive away. On the morning I went into labor, there was a snowstorm, and it took us an hour and a half to get to three blocks from the hospital where our baby was born. From the first contraction until the baby was born was less than three and a half hours, technically enough time to get to our hospital. I really like the practice, but is using this practice and hospital setting me up for another emergency? My doctor said inducing early to avoid this might be tricky, as I was 39 weeks exactly at that point. So, an induction earlier than that would probably not be an option. Ultimately, my baby is 100% healthy, thank God, but it was a frightening experience. He had a hard time breathing and needed NICU, stay on CPAP for a short time. Is switching providers to one that delivers closer the safest plan, or do you have any other good ideas? Hope to hear this on the pod.”

Well, Faye, you’re hearing it on the pod. Hope you’re listening. So, first of all, congratulations. Second of all, yes, not ideal to deliver in a car. I would say that your experience, in terms of the baby doing well, is typically what happens. When people go into labor and deliver fast and deliver in a car, in the ambulance, in the lobby, in the waiting room, the bathroom, triage, whatever it is, it’s obviously a very harrowing experience. It’s always a great story, but the babies do, fortunately, tend to be fine, so that’s good. But yes, we would all prefer that that not happen. So, what do you do?

There isn’t a perfect answer, obviously. So, precipitous delivery, which is the medical term, is when labor and delivery happen in under three hours. You said that yours was three and a half hours, so technically it didn’t even make that definition, as you said. But that’s fast, obviously. And so what do you do in that circumstance? So, there’s a few options. One option, like you said, “I don’t want to sign up for this. I don’t want any chance of this. I’m going to go to a practice that delivers within 15 minutes from where I live.” Now, for some people, that’s an option; for some people, it’s not an option, right? Either there isn’t a place within 15 minutes, or they have some issues with the pregnancy or conditions, or whatever it is, that that place isn’t appropriate for them, or they really just don’t want to deliver there, whatever it is, okay?

Another option that your doctor brought up, but didn’t think would be a great idea, is to induce. Usually, if we’re going to induce someone because they have a history of precipitous delivery, like you said, we’re usually going to do it around 39 weeks, a week before the due date. The reason we pick that time is that earlier than that, you could sometimes run into issues where the baby ends up in the NICU. Again, it doesn’t tend to be long-term issues if you deliver at 38 or 37 weeks, but it’s pretty much frowned upon to deliver what we call electively without a medical reason before 39 weeks. So, typically, we plan it at 39 weeks. So, anyone who’s going to deliver at 39 weeks or later, that plan is going to work. You come to the hospital not in labor. If you want an epidural, you get an epidural. If you don’t want an epidural, don’t get an epidural. Induce the labor. Baby comes out. Anyone with a history of a precipitous delivery, it’s unusual that their induction is going to fail and lead to a C-section. And so it usually is a plan that works if that’s what they want to do.

After that, there are some options where people maybe where they live until, let’s say, 38 weeks, and then move somewhere closer to the hospital. You know, in our practice, we’re in New York City. And so people who live in the city tend to be close, but we have patients come to us either because they just want to, or because they have high-risk issues. We’re talking up to two to three hours away from here, and God bless them, they come in for their visits. They schlep all the way in every time, sometimes once a week or twice a week. And then, for delivery, that’s obviously a concern for them, “Hey, I live two to three hours away, what am I going to do?” And so obviously we have to individualize it. Some of the times we don’t think it’s going to be an issue. Some of the times, at the first contraction, they are in the car ready to go and they start driving in. And other times when they get closer, whatever that means for each person, they’ll find somewhere to stay that’s closer, whether that’s at a relative’s, whether that’s at a hotel, or whether that’s an Airbnb. Whatever it might be. And again, these are all very individualized, but that’s another option.

We can try to predict when someone’s going into labor, you know, check the cervix if it’s closed, if it’s open. But the problem is none of those are perfectly predictive, right? Your story sounds like nothing was going on until you woke up in labor, and it’s entirely possible that the day before, your cervix would have been closed. I mean, who knows? So, there isn’t a perfect answer, but there are some options available to you. This is something that definitely comes up.

I’ll say, again, we have a very busy practice. We do a lot of deliveries, and I would say the number of times someone delivers in a car, or in the lobby, or whatever it is, is pretty low overall, even with people living very far away. So, what happened to you is still unusual, I guess, is what I would say. I’m glad everyone’s okay.

Last question is from Amy: “Hello, I recently listened to your podcast while the fuss about advanced maternal age and really appreciated the level of detail on risks—just facts to be aware of with plenty of reassurance. I really would love a similar episode about pregnancies resulting from IVF. Not IVF itself but the pregnancy after IVF. What are the risks, if any, or extra monitoring, or are those pregnancies not too different? Anything else we should know? Also, I would love to hear how any of this may be different if the pregnancy resulted from donor eggs. Thank you so much.”

Okay, so Amy, good question. It’s interesting—IVF pregnancies, right, or pregnancies that result from IVF. If you look statistically, there is an increased risk of certain complications in pregnancy. Specifically, there’s an increased risk of preeclampsia, there’s a very slight increased risk of birth defects, and there’s an increased risk of fetal growth restriction, where the baby’s not growing so well.

Now, a few things about that. First of all, even though that’s true, it’s not a reason to discourage IVF. If someone, that’s what you need to get pregnant, we definitely will talk about the risks, but we don’t discourage people from getting pregnant because of them. And they don’t tend to be very high; they’re just a little higher above baseline.

Sort of in a similar magnitude to getting pregnant after age 35, meaning being pregnant after 35, your risk of preeclampsia is somewhat higher than if you’re younger. And if you have IVF, it’s a similar level of higher, which leads to the second point, which is why are pregnancies from IVF at slightly increased risk of complications compared to non-IVF?

And there’s two theories. Theory number one is that it’s not the IVF process itself but rather that women who use IVF are different from those who do not, which makes sense, right? They tend to be older or they tend to have medical issues or they tend to have had miscarriages or complications before, meaning it’s not the IVF but it’s the cohort of women, the group women who have IVF are at baseline higher risk for these complications than the women who don’t need or don’t do IVF. And so if you see an increased risk, it’s not from the IVF, but it’s just the person who needs IVF is a higher risk pregnancy to begin with. So, that’s one theory.

The second theory is that it’s actually the IVF process itself. Something about whether it’s the hormones, whether it’s doing the fertilization outside of the body, putting it back in, whatever it is, something about that process increases the risk of pregnancy. And what’s interesting is the data shows that it’s probably a little bit of both. And how do we know that? So, the way we know that there’s something related to the IVF process itself is that there are women who use IVF for reasons sort of not related to their fertility, their complications.

So, for example, let’s say someone’s doing IVF because she and her husband are carriers of Tay-Sachs, right? And because they’re carriers of Tay-Sachs, if they conceive and have a baby, there’s 1 in 4, 25% chance that the baby would have Tay-Sachs. As you know, we don’t want to be a part of that. We don’t want to put our baby at risk for that. We don’t want to have to test during pregnancy and maybe have an abortion or not.

So, what this is, we’re going to do IVF, and we’re going to test the embryos, and then put the embryo in. So, they’re not doing IVF because they “need” IVF for fertility reasons or complication reasons. They’re doing it sort of as a way to avoid having a baby with a specific genetic mutation. So, those pregnancies do seem to be at slightly increased risk, which would lead us to believe that the reason for the risk in IVF is the process itself, not the population.

But there’s also studies that show that if you look at women who see IVF doctors for whatever issues they’re having but don’t actually use IVF to get pregnant, they get pregnant on their own. It happens all the time, right? I’m seeing a fertility doctor. He or she is doing this test, they’re going to do this. My plan is to do a transfer in a month, you know, yada, yada. And, hey, I’m pregnant beforehand. Amazing. So, no IVF process was done. Those pregnancies also seem to be at slightly increased risk.

So, what I tell people is it’s probably both or a combination of both reasons. But ultimately, if for whatever reason someone has IVF, I tell them that they have a slightly increased risk of complications in pregnancy. Again, predominantly, there’s an increased risk of getting preeclampsia, which is high blood pressure at the end of pregnancy. There’s a slightly increased risk of fetal growth restriction, where the baby is not growing as well. There’s a very small increase, it seems, in the rate of birth defects. So, what do we do? We basically follow the pregnancies a little bit closer. We use extra ultrasounds. We look at the baby head to toe. We, in our practice, usually do a fetal echocardiogram to look at the baby’s heart, head to toe, during pregnancy. I usually have them take a baby aspirin during pregnancy to lower the risk of preeclampsia. And again, similar to an otherwise healthy woman who’s 38 years old and gets pregnant and has some increased risk, usually the pregnancy goes fine and she and the baby do well. Good question, Amy.

All right, thank you all for tuning into our mailbag podcast. We’ll see you next week.

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