If you haven’t already read the incredible journey to parenthood by Faith and Yanga, then you must. This brave couple explained that following the devastation of losing their young baby, who was still born, they sought help from the team at Hart Fertility in Cape Town to conceive again.
In their story, they spoke of the suggestions and actions that their doctor, put forward, following tests and investigations. However, to fully understand what these actions and suggestions were, we needed help understanding the medical terminology, so we got on the phone and asked Dr Faesen, the amazing doctor who helped Faith and Yanga, to explain.
What is cycle tracking?
Cycle tracking means that with ultrasound scans we check the development of the growing egg (the follicle) on the ovary. Once the developing egg is very close to ovulation we then tell the couple the days for sexual intercourse (Timed intercourse).
What is an incompetent cervix?
The cervix plays a very important role in keeping the pregnancy inside the uterus during the 9 months of the pregnancy. The vagina is acidic, and always has normal bacteria in there. The inside of the uterus during pregnancy is sterile. To keep the two environments completely separate, the cervix needs to stay closed so that no bacteria and no acidic secretions can go up into the uterus. At the end of the pregnancy the cervix slowly opens a bit, probably due to the very early contractions of the uterus at the end of the pregnancy, and then the membranes of the pregnancy sac may get exposed to the vaginal acidity and bacteria, which weakens the membranes surrounding the pregnancy. Slowly these membranes then get weaker and weaker, and finally the membranes rupture (“the waters break”). So in normal circumstances this is only supposed to happen towards the end of the pregnancy when the baby is mature.
In some women, either due to damage to the cervix or sometimes due to congenital weakness of the cervix, the cervix cannot stay absolutely tightly closed during the whole pregnancy. As a result, the cervix opens far too early, the same sequence of events happen, and either the membranes start bulging into the vagina, or the waters break, which means from then on the pregnancy does not have a chance to last much longer, with increasing risk of infections going into the uterus. So usually this happens around the middle of the second trimester in women with an incompetent cervix, resulting in loss of the pregnancy around 18 or 20 or 22 weeks.
During the weeks before the opening of the cervix, usually the cervix first starts shortening before opening up. This can be detected by serial ultrasounds done with a vaginal probe, measuring the length of the cervix. In women who have had this before, these scans are sometimes done weekly, and if the cervix is seen to shorten, a bandage (cerclage) is stitched around the cervix, to keep it tight and closed for the rest of the pregnancy.
What is a cervical cerclage?
There are basically two types of cerclage: one that is stitched from below (vaginally) and one that is stitched around the cervix through the abdomen via laparotomy (open surgery) or laparoscopy (endoscopy or keyhole surgery).
Progesterone issues. What are these and how do they affect fertility?
Progesterone hormone prepares the endometrium for the arrival of an embryo. It transforms the glands from rapidly growing (proliferation) to glands that are secreting nourishment for the embryo (secretion). The progesterone also has a calming and relaxing effect on the smooth muscles of the uterus, preventing irritability and contractions. And finally progesterone also thickens the mucus secreted from the glands in the cervix, thereby building a barrier between the contents of the uterus (pregnancy) and the vaginal acidity and bacteria. Lack of progesterone in the phase after ovulation, is called luteal phase deficiency and progesterone supplementation then is given to make up for the shortfall.
When do you take progesterone during an IVF cycle?
Progesterone is given after the collection of the eggs in the IVF cycle, to assist with the proper development of the endometrium in preparation for the embryo transfer, and to keep the endometrium optimal during the development of the embryo inside the uterus in the weeks after the transfer. Once a stage of 10 weeks (counting from the last menstruation) is reached, usually the placenta is strong enough to produce adequate amounts of progesterone to take over from the progesterone medication.
Faith and Yanga explained that at six weeks, you confirmed that they were pregnant and referred them to their nearest maternity clinic with a referral letter, which noted what interventions needed to be done, to preserve their pregnancy till viability and beyond. Can you explain what interventions needed to be done?
This particular lady had an incompetent cervix, discovered during her first pregnancy, when she lost her baby at 20 weeks with a sudden opening of the cervix without contractions, breaking of the water, followed by pregnancy loss. In a subsequent pregnancy I referred her early to the public sector for the cervical cerclage to be done there. Unfortunately she was not considered a candidate for cervical cerclage by the doctors looking after her, and at 21 weeks again she lost her baby. Only then was she considered a high enough risk for subsequent pregnancy losses, and only in the third pregnancy the cervical cerclage was used to save her pregnancy. That time she carried to 9 months and delivered normally.
Thank you so much to Dr Faesen for explaining in more detail what these medical expressions mean. To contact Dr Faesen, click here.