Jaundice, Part I: Baby Boy Turns Yellow

This is the first in a two-part feature on jaundice. In this post, I'll tell you Baby Boy #4's jaundice story, and in the next post I'll address jaundice from a more clinical perspective. Now that Baby Boy has been named, we'll call him Y.

At 5:30 a.m. on Tuesday morning, when Y was about 27 hours old, the nursery did a heel stick to draw blood for his PKU test. This is a standard newborn screening done at approximately 24 hours of age. At the same time, they checked his bilirubin levels to see if he was at risk of needing treatment for jaundice. Most people know jaundice as a yellowing of the eyes and skin due to various problems associated with the liver. In newborns, it's a relatively common condition due to the breakdown of excess red blood cells in the baby's body after birth. Most babies will clear out the bilirubin on their own without needing special interventions, but some babies will have bilirubin levels high enough to elicit concern, as very high levels of bilirubin may cause irreversible brain damage called kernicterus.

But back to Baby Y. When the pediatrician came in to check him over and report on his test results, the first words out of her mouth were, "Did any of your other kids have jaundice?" When I told her all three had, and two had required home phototherapy, she nodded. She showed me his bilirubin level, which was 8.6. For his age, this was considered "high intermediate risk". If the number climbed into the "high risk" zone, he would require treatment. The chart below is the standard risk chart for newborn jaundice. You find the baby's age in hours along the bottom, then plot the bilirubin level on the left and see what curve you fall along. A level of 8.6 in a 28-hour old baby was near the high end of the high intermediate risk zone.

The question then was, do we take a wait-and-see approach, or do we take it on more aggressively, knowing that (a) all three of his brothers had relatively high bilirubin levels, and (b) he was already nearing the high risk zone? Levels usually peak between 4 and 6 days of age and then fall off gradually. To clear out bilirubin, the baby needs to poop, which means the baby needs to eat. Since breastmilk supply doesn't usually increase until day 3, and most babies under 3 or 4 days of age are still clearing out meconium, it takes a few days for the excess bilirubin to be excreted. I was still only producing a small volume of colostrum, and Baby Y wasn't pooping much, so we knew his levels would continue to rise for another day or two, at least. But we didn't know if they'd rise sharply or level off. There's really no way to know what will happen in any given baby.

I had been planning to go home on Tuesday, though I was technically entitled to another night in the hospital if I wanted to stay. The pediatrician suggested that I stay Tuesday night and let Baby Y have jaundice treatment through the night. In this way, we might be able to bring down his bilirubin levels to the low intermediate risk zone and then, even if the levels continued to rise a bit for another day or two, they would likely stay on that low intermediate risk curve. If we didn't treat Tuesday night, we would need to monitor him closely (by taking blood daily to measure his bilirubin levels), and if his numbers rose into the high risk zone, then we would need to treat, which might entail readmission to the hospital for him, meaning I'd have to find a place to stay because I would no longer be an inpatient there.

This put us in a tricky position. On the one hand, I really didn't want to spend another night in the hospital. I wanted to get home to my other three kids, I wanted to come back to life and out of the sickly-feeling, "I'm in the hospital" mode. On the other hand, it seemed the easiest way to ensure that Baby Y's jaundice would be managed with the least amount of hassle. A secondary, but real, consideration was that if his jaundice became severe, his bris would have to be delayed. This had happened with our second baby, and we needed to know if that would be necessary for Baby Y. It seemed that treating him Tuesday night would stave off this potential complication as well.

The pediatrician suggested that we talk it over and that she order another blood test for the afternoon. If the number still placed him on that high intermediate risk curve, or, G-d forbid, was even higher, then that might help us decide for sure whether to stay the night or not. I agreed that this was a good suggestion. So, at 36 hours of age, his blood was taken again, and his bilirubin level was 10.7, still on the high end of the high intermediate range, and likely to continue to rise for at least another day or more. We decided to take the aggressive approach. The goal was to keep him under the "bili lights" for the night, in the hope of getting his bilirubin levels to level off or even drop. If the numbers fell into the low intermediate risk range by morning, then we could feel comfortable going home and not worry so much about having to be readmitted for treatment or taking blood daily to monitor him. A clinical approach, visually examining his color, looking at other symptoms, would be enough to monitor his health, and further testing or treatment would only be required if any other symptoms gave his doctor or me cause for concern. (I will discuss all of these symptoms and risks of jaundice in part II of this article.)

At about 7:00 p.m., Baby Y was whisked off to the NICU to be placed under the bili lights. Basically, bili lights are flourescent, blue lights that break down the bilirubin into a water-soluble form that the baby can then pee out, in addition to the bilirubin being excreted in his bowel movements. It's important to maximize the amount of skin exposed to the lights, so the baby is placed in his bassinet in only a diaper, on top of a pad that shines light up against his back. The bassinet is then placed under a second light that shines down from above him. He wears eye covers to protect his eyes from the bright lights, and he basically just sleeps there. The baby should eat about every three hours but should not be off the lights for more than 30 minutes at a time. The idea is to find a balance between maximizing his time under the lights while still getting milk into him so that he can pee and poop. It's a tricky thing, especially with a newborn who wants to nurse a lot but is still getting colostrum and not the mature milk that will encourage more wet and poopy diapers!

It was strange for me, to spend a night in the hospital without my baby by my side. It was also strange to visit him in the NICU, my otherwise big, healthy boy in there with the sicker babies who needed so much more care. We got off to a bit of a rocky start, too. He was there only about 45 minutes before he was brought back to my room, screaming. "He says he's starving!" my nurse said. I nursed him, then wheeled him back to the NICU to go back under the lights. The nurses there were trying to get him to take a pacifier, but he was protesting it.

I was advised that if he was going to need to eat so often, the lights wouldn't be very effective. The protocol was three hours on, 30 minutes off, but he wasn't willing to go three hours without nursing. And normally I would have been perfectly fine with that! A two-day-old baby shouldn't necessarily go three hours without nursing, both for his sake and for mine! His suckling encourages my milk production to increase, as well as nourishing him and stimulating his digestive system. I was happy to feed him every hour or two, but that would render our night in the hospital ineffective. I was frustrated, and so were they.

One of the nurses told me that giving him a little formula would probably help, since it would fill him up so he could wait longer to nurse again, and it would make him pee. Without peeing, he wouldn't clear out the bilirubin. "You have to decide what's your priority - breastfeeding or treating the jaundice," she said. I felt a bit threatened or judged, like maybe by clinging so hard to the "exclusively breastfeeding" mantra, I might be causing my baby harm or wasting my time (and hers?). I was taken aback. I had made it clear that he was not to receive formula, his case of jaundice wasn't severe (yet?), and I was educated enough to know that giving even one bottle of formula when supplementation wasn't medically necessary could cause long-term harm. But I'll tell you something, in all honesty: I almost gave in. I was desperate for him to stay longer under the lights. I was so nervous about "wasting" our extra night in the hospital. I really wanted this treatment to work. And if a couple ounces of formula was all he might need...I hesitated. I felt like I was already breaking so many "rules." Here I was, a trained Lactation Educator, on my fourth baby, a self-proclaimed breastfeeding advocate and expert, and my baby was spending a night in the nursery, being offered a pacifier, and now I was thinking about delaying feeds and supplementing with formula besides.

I gathered myself. "Breastfeeding is my top priority," I told the nurse. "I don't want to mess up his gut with a bottle of formula if he doesn't really need it." If my head had been more in the game, I would have known what to do immediately, but since I was groggy from two nights without sleep, thrown by this change of plans, and caught off guard by this sudden suggestion of formula, I couldn't think of a solution. "Maybe he'll go longer this time," I said, and went back to my room.

The first thing I did back in my room was Google "formula supplementation for newborn jaundice" on my phone (thank G-d for smartphones!). I thought I remembered reading an article from the Academy of Breastfeeding Medicine on whether formula supplementation for normal newborn jaundice was necessary or standard protocol, and I wanted to refresh my memory. I found exactly what I was looking for (PDF). In short, formula supplementation is not recommended for treatment of newborn jaundice unless there are other complicating factors. Short-term formula supplementation can have long-term risks. While it will help to clear the jaundice, it may interfere with establishing a good milk supply, may cause nipple confusion in a baby who is still learning to latch and breastfeed, and will cause the gut flora to be affected by introducing cow's milk proteins and non-breastmilk compounds into the developing digestive system. My Lactation Educator classes came back to me in a rush, and I remembered what we had learned about jaundice and supplementation. There are indications for short-term "interruption of breastfeeding" under certain conditions, but my baby and my situation did not call for such a drastic measure at this point.

And like that, I knew what I needed to do. I marched myself (figuratively) back to the NICU and found a different set of nurses sitting near my sleeping baby.

"Is the reason you'd want to supplement because you could feed him while he's still under the lights?" I asked.

"Yes," one of the nurses said.

"So, if I were able to pump some colostrum, you could feed him that instead of formula?"

"Sure. We do that all the time. Ask your nurse to get you set up with a pump. You can bring us whatever you pump."

I tracked down my nurse and explained what I wanted to do. She said no problem, and within the hour, I was set up with a pump and had started harvesting that precious, precious liquid gold. I felt if I could get at least 10mL (about a third of an ounce) in any given sitting, that should be enough to tide him over between the every-three-hour breastfeedings. I had a mild concern that giving him bottles might affect his desire and ability to latch, but I felt it was worth the risk. At least by pumping between at-breast feedings, I was giving myself the breast stimulation I'd need to establish a good milk supply, as well as giving Baby Y the colostrum he needed to keep him full and happy and able to pee and poop.

On my first go, I got 10mL from both breasts. Thrilled with my success, I happily delivered my first of what would be five 10mL bottles of colostrum that night. In between 30-minute feedings and 15-minute pumping sessions, I'd conk out, sleep for an hour or 90 minutes, to be awakened from a weird dream or a deep sleep by my nurse wheeling in a crying baby ready to breastfeed again. Tired but pleased, morning came and we eagerly awaited his latest blood test, to find out the result of our night's effort.

Liquid Gold

After 12 hours on the bili lights, at 51 hours of age, his bilirubin levels were down to 9.9, lower than they had been at the previous test, and down into the low intermediate risk range for his age. Yes!

We came home later that morning with instructions to have him seen by his regular pediatrician on Thursday. His doctor checked him over and decided that doing another blood test was not necessary. He told me to keep an eye out for more yellowing, lethargy, or not waking to feed, but as long as he was producing diapers, was waking up when he was hungry, and was feeding well, he was not concerned.

Thankfully, Baby Y's breastfeeding was not negatively affected by the use of a pacifier or by giving bottles. My mature milk appeared, on cue, at about 2.5 days postpartum, and he began gaining weight at an incredible rate. At hospital discharge, he was 7lbs., 14oz., about 8 ounces below his birth weight of 8lbs., 6oz. On Thursday, he was up to 8 pounds even, and on Friday, he had gained an additional 3 ounces in 24 hours, to reach a weight of 8lbs., 3oz. Though he has not been weighed since, I'm certain that he has surpassed his birth weight already, at eight days old.

In the next article, I'll discuss jaundice from a clinical angle. I am grateful that I had the experience and educational background to be able to effectively advocate for myself and my baby. Don't be afraid to do your own research and ask questions. When it comes to your baby's health and your breastfeeding relationship, it's important to speak up!

My Fourth Birth!

I started out my fourth pregnancy confident. I knew my body could grow and birth healthy babies in a healthy way. I knew the "rules" of pregnancy and childbirth, breastfeeding and infant care. I found myself quite laid back about the whole process.

Until I neared the end. I was due October 22 (also my oldest son's birthday!), and we had moved to a town that is usually very quiet and relaxed, except one weekend a year, the Pumpkin Festival, when something on the order of 200,000 people flock over the hill on the one-lane, one road to the coast to...look at big pumpkins and explore the street fair (at least, that was my impression of it). The traffic makes it nearly impossible to take the most direct route to the other side of the hills, where the hospital is. We could still get out if we needed to, but it could take a while (possibly over an hour). This year, the Pumpkin Festival was October 19 and 20, and there was a very good chance, based on my history, that I could go into labor that weekend and that my labor would be short enough to be a nail-biter on that long way around.

We had also arranged for my mother-in-law to fly in from Israel a few days before my due date, hoping she would arrive before the baby so she could stay with the other kids when we went to the hospital and then to help out after the birth.

At my 38-week visit with my OB, we both felt it was reasonably likely that I would have the baby quite soon. I was 3cm dilated already (not terribly unusual in someone who's been pregnant before) and experiencing strong (but not painful) contractions. Panicked, I spent the evening arranging with the neighbors to help with backup childcare in case baby decided to make his appearance.

But labor did not start. We got through another week, Pumpkin Festival weekend loomed, but at least it looked like my mother-in-law would be there in time after all. At my 39-week appointment that Wednesday, October 16, my OB and I decided to play it safe and try not to stir anything up. Thursday, my mother-in-law indeed arrived, and still I remained pregnant. Saturday, Pumkpin Festival day one, came, bright and sunny, and we went for a walk down to the main road to see the traffic, which was about as spectacular as promised. The walk turned into a leisurely day near the harbor, where we went to a pumpkin patch, had a panini, and enjoyed a sunny day without labor.

We found a pumpkin to match my belly.

Sunday was gray and cold, and still labor-less. If we could just make it through the day, it would be "safe," travel-wise, to have the baby. And boy was I ready. I'd been uncomfortable for weeks, with pain in my pelvis from the pressure of his head every time I stood up. I was big and ponderous. I was ready for this baby.

But I had a nagging fear that the baby was not positioned well. He was head down, but I worried that he was posterior (OP), meaning the back of his head (occiput) was toward my back, rather than the more ideal anterior position (OA), in which the back of the head is toward the mother's front. It is easier for the baby's head to make it under the pubic bone in the OA position, because the occiput is the smallest point on the head and helps to make way for the rest of the skull. As well, this position allows him to flex his neck and point his chin down to his chest to better fit under the pubic bone, rather than having to tilt his head awkwardly backward. OP babies are more likely to get "stuck," cause more damage as they come out, or even be unable to drop completely into the pelvis and require a c-section. Also, a baby in a less-than-ideal position can cause labor to stall or be slow to start. I was afraid the reason I was having so many contractions that weren't building into labor was because he was malpositioned.

So, naturally, I worried. I had worried for weeks about his position, and consulted the Spinning Babies website for ideas on getting him to turn. I half-heartedly tried one of the exercises (getting into an inclined, upside-down position for 30 seconds a day), and I spent time trying to open my pelvis by getting on my hands and knees and into a modified Child's Pose, hoping to give him the space he needed to turn.

Traffic wasn't bad Sunday morning, and we decided to see what all the fuss was about at this Festival, so we drove down to the town. We walked around for several hours, exploring. I was in a fair amount of pain by the time we started back to our car, underwhelmed and kind of cold.

N carves a pumpkin with S's supervision

Within a few hours of returning home from the Festival, my contractions, which had for weeks been strong but not painful, picked up in intensity, if not frequency. Every 10 to 20 minutes, sometimes with as long as 30 minutes in between, I would have a contraction I would label as painful, if not stop-me-in-my-tracks agony. Also, contractions that infrequent that did not build into more couldn't be called labor. We ate dinner. We put the kids to bed. I thought maybe, just maybe, this was the night. He had kindly waited until Sunday night, as requested. But would these contractions build into something more or fade away?

I discussed with my husband what we should do. I didn't feel an urgency to get to the hospital, but I wasn't sure whether we wanted to try to encourage labor along or get some sleep. Around 10:00, I said I'd like to take a walk and see whether that made a difference. If not, I would try to go to bed. If so, we could hop in the car.

We took a half-hour walk around the neighborhood with no appreciable effect on the contractions. They were still no closer than 10 minutes apart, and some of them were hardly painful. I never had to stop walking or talking to breathe through one. At 11:00, I called L&D at the hospital to ask what they thought. She said she couldn't give me advice over the phone and that we could come in if we wanted, but at 10 minutes apart, we were likely to be sent home. I explained that we were about 35 minutes away and couldn't be going back and forth. She suggested I wait an hour and see if there was any change, then call back if we were planning to come in so they could prepare a room and get ready for our arrival. I thought that was reasonable and said we would do that.

After another half-hour or so, I thought I may as well try to get some sleep. If I was having the baby soon, it might be nice not to have been up all night. I laid down in bed, but with every contraction (still about 10 minutes apart), I found I needed to get up on my hands and knees until it passed. And I certainly couldn't sleep through them. When I finally had two in the space of six minutes around 12:40 a.m., we said let's do it. I called to let the hospital know we were on our way, gathered some stuff to take with us, let my mother-in-law know we were leaving, and hit the road.

There was no traffic, and my contractions kindly picked up as we drove, to the point that I was concerned my water would break in the car. I figured I still had a few hours until delivery, judging from the spacing of the contractions and comparing to my third birth. Having contractions in the car is so much worse, too, because I didn't have the option to move around to find the most comfortable pose for riding out the pain. At home, I had been going on hands and knees with each contraction, and reclining in the front seat of the car was about the least comfortable position I could think of during each painful minute.

We got to the hospital a little after 1:00 a.m. and dashed through the ER to wander the maze of hallways until we found the birth center. The nurses were ready for us and got us into the room as I continued to contract frequently. I changed into a hospital gown, went over my birth preferences with the nurse, and had my cervix checked. I was 5cm, and it was about 1:30 in the morning. She had them call my doctor and started taking my medical history, getting an IV started just in case I needed fluids, Pitocin, or other meds. She attempted to get my blood pressure, but the contractions came faster and stronger, and every time she tried to get a read, I was in the middle of another one! My blood pressure was measuring a little high (really?!), which concerned her.

Are we having fun yet?

She continued to attempt to get my medical history, while I continued to have contractions reasonably close together. I had a chance to catch my breath in between, but after about half an hour, I found I was shivering and shaking and felt nauseous, all hallmarks of transition for me, but I didn't make the connection. After all I was 5cm only half an hour before, and I hadn't even gotten up to walk around, hadn't used the shower, hadn't done any of the things I'd intended to during my labor to help it along.

My "contraction face."

We noticed the baby's heart rate dropped slightly with each contraction but recovered just as quickly, so no one seemed concerned. I joked that he didn't like the contractions any more than I did.

My doctor arrived, got the story, and said she'd be back in a few minutes. I'd finally had enough of reclining in the bed and decided to at least go back to the more comfortable hands-and-knees position. Once there, I just stayed that way, my hands at the very top of the bed, my knees resting flat. They offered to raise the head of the bed so it was practically vertical. I found this to be perfect, dug my hands into the top of the cushion, and rode out each wave. My water broke with a pop, and I realized that my feet were in the danger zone. Ew. But I was locked into this position. I couldn't imagine trying to move again, even to turn around and squat like I'd planned.

At 2:13 a.m., about 45 minutes after first having my cervix checked, my doctor wanted to check again. It seemed everyone around me realized I was ready to deliver, even though I was certain there should be a few hours left of this labor. She checked me as I knelt, and, sure enough, I was complete. What?! "You can push whenever you want to," she declared. 

Let's do this!

With the next contraction, I bore down for all I was worth. I yelled until I was hoarse. I felt like nothing happened. My muscles were jelly, my stomach was weak, and still I pushed. I screamed "GET OUT!" I could feel his head against the pubic bone. I was so scared he was stuck. I had to push harder. I had to get him out. "GET OUT! GET OUT!" I shouted at him (I still feel bad that the first thing my new baby heard was me yelling at him). I'll go ahead and admit it, here, that I pooped, too. Pushing is pushing. They asked if I wanted to get the squat bar and turn around, but I was certain I couldn't move. My arms and legs were locked in place. I was delivering in that awkward position whether that's what I'd intended or not. I said, "If it's okay with you, it's okay with me," when the doctor asked if I was happy where I was. She said it was fine with her. I had the fleeting disappointment that I wouldn't be able to see him born - that was something I'd wanted this time around - but I knew I couldn't move. We were doing this, and we were doing this here and now. "GET OUT!" I screamed again, and then felt like I was out of power. "I can't do it," I said. "I can't." Three nurses, a doctor, and my husband assured me I could, that he was almost out. Another push, and I could feel his head straining against my perineum. I could feel the burn, the pressure, the stretch. "Let him stretch you. He's almost here," the doctor said. Then, "I see a face!" Another push, and he was through! I collapsed forward onto my arms, exhausted, but I still couldn't move, locked on my knees as I was.

Time of birth: 2:31 a.m. We'd been at the hospital for just over an hour.

I had wanted immediate skin-to-skin and delayed cord cutting, which they had said was fine. But he didn't cry right away and apparently was more purple than they liked. His cord was around his neck loosely, which they were able to unwrap, but they needed to take him to the warmer for stimulation to get him breathing. By the time I was able to turn myself over and recline against the bed, they had whisked him away, and the doctor was pulling gently on the cut cord to encourage the placenta to deliver. That, I got to see. The baby, I couldn't. My husband stood guard over him as he let out a lovely wail and pinked up nicely. They weighed him and measured him, then, finally, they brought him to me. He wasn't rooting, but he had a good suck reflex, and after a couple of tries and a bit of coaxing, we got him latched and sucking nicely. His Apgars came in at 9 and 9. A perfect baby boy, with a head of thin but noticeable black hair. Black?! We're a family of gingers!

Okay, okay, I'm crying. Where's my mommy?!

Because of my history of hemorrhage, they gave me Pitocin to help my uterus clamp down. They also massaged my belly - hard - OW - to encourage it to contract and to make sure there were no large clots or excessive bleeding. Once the bleeding slowed, my doctor was able to assess the damage. Surprisingly, and thankfully, I had but two skidmarks and a 1st-degree tear that needed just one stitch! SO much better than an episiotomy, and much easier than I'd hoped.

I asked the doctor if he'd been OP or OA, and she had to do some mental gymnastics, since I'd been facing backward. Since his face had been toward her, that meant he was indeed OA. I don't know if my prenatal attempts had encouraged him to turn or if he'd turned during labor, but I'm certain that listening to my body and finding the most comfortable - if incredibly awkward - position for laboring made everything go so smoothly.

This hospital's birth center was nice, because we didn't have to move rooms after delivery. The nurse sent me to pee while they converted the bed and cleaned up the room. This room would also serve as my postpartum room for recovery and care. They brought in a bassinet for the baby and put a mattress pad on the bed, changed the linens, and, voila!

The nurse said how she loved natural deliveries, because the babies were always so much more alert, and mom was ambulatory. I could barely walk with a midsection of jelly, but I also felt an incredible sense of accomplishment, and quite a bit of shock, at the speed and relative ease of the delivery.

My main wish for this birth had been that it would be drama-free. No side-of-the-road delivery, no unassisted bathtub birth, no complications or hemorrhaging or surgery or NICU admissions. Just get to the hospital and have the baby. Well, we took that one rather literally, didn't we?

Welcome, Baby Boy #4! 

Born 10/21/13 at 2:31 a.m.

8 lbs., 6oz.

20" long

14.5" head

I'll write about our hospital stay in another post. We had a bit of an interesting time after all, and I got to put my CLEC training to work...for myself!

Brighten Someone's Day

I hope this story will brighten your day and think of something you can do to brighten someone else's.

Yesterday, I took my kids to McDonald's for lunch. I'm nine months pregnant, my oldest was off from school, and the weather was just about perfect (72 degrees, bright and sunny). I thought we'd eat and then find a park so they could run around and I could be forced to walk myself closer to labor.

Anyway, McDonald's. We place our order, and I reach into my wallet to find that I had no payment method! I remembered that I had put my credit and debit cards into a just-in-case hospital bag on Saturday and had forgotten to transfer the cards back to my purse when I didn't go into labor over the weekend. I had no cash, either. Drat. I apologized to the cashier and told him I needed to run home (about a 20-minute round trip) to get my credit card. I apologized to the kids and told them we needed to go home for a minute, but that we'd come right back. I tried to herd them out the door. My middle son (4-1/2 years old) was upset with me: "Why do you always forget stuff?" It wasn't true, and I know he was just disappointed at the delay, but I was irritated and irritable and stressed out, and his accusation upset me more. I must have seemed extremely frazzled (and embarrassed) by the whole event. We made it out the door and started back to the car when a middle-aged woman called out to me.

"Ma'am? Let me pay for your meal."

I stopped, stunned, and turned around. "Oh, that's so nice of you. It's okay, though. I really did just forget my cards."

"I know. It's no problem. I'll pay for your food."

"Really, it's okay. We'll go home and come back."

"No, no. I had six kids. I know how much trouble it is to load everybody into the car. Don't worry about it. You go order your food, and I'll follow you to the register and swipe my card."

What could I say? "Thank you so much. That's so kind." So kind. The kids and I went back inside, placed our order again, and the lady swiped her credit card without comment.

"Is the fourth one a boy, too?" she asked.

I smiled and nodded.

"Just wait until you have six!" she said.

I thanked her again and she went back to her table. About 10 minutes later, my toddler requested water, so I went back to the register to ask for a water cup. The kind lady was standing there and reached for her wallet. "Did you need something else?" she asked.

"No, no, just water!" I said.

She smiled.

I told my kids that a stranger had just done something very nice for us, and we needed to find a way to pay it forward. I explained the idea to my 6-year-old, who really seemed to understand the concept of making others happy so that they would go forward and make more people happy, that it's not about paying someone back when they do something nice for you, but that you need to take that good feeling and good deed and pass it along to someone else.

If you see an opportunity to help someone out in some small way, I hope you'll do so. I know I'm going to make more of an effort to brighten someone else's day the way mine was brightened yesterday.

Circus of the Epidurals

My husband and I are long-time fans of the British TV sitcom "Coupling," which ran for four seasons from 2000 to 2004. The fourth and final season followed one of the character's pregnancy and eventual delivery, and one episode, entitled "Circus of the Epidurals" discusses the character's desire for a natural childbirth, and her boyfriend's inability to understand why in the world she would want to forego drugs.

"There's pain, and there's pain relief," he says. "This is not a test anyone should fail!"

The episode is hilarious, and there's no question that it accurately reflects the basic tension between those who desire natural childbirth and those who can't understand why you'd want to "be a martyr" and refuse an epidural when it's right there and available to you. Why would you want to experience pain when you don't have to?

While I enjoy watching this and all of the other episodes of "Coupling," the amount of education I've had on this particular subject does make me want to throw things at the screen. First of all, the female character makes no effort to explain to any interested party why she wants a natural childbirth. (I'm avoiding names to try and limit the spoileriness, in case you decide to investigate the show - available streaming on Netflix!) The closest she comes is, "The pain of childbirth is part of being a woman," to which her boyfriend replies, "Yes! And it's the part we can fix!"

Now, since about the 1970s, there has been a movement toward "natural childbirth," as we well know. It became a trend to eschew any available methods of pain relief, including twilight sleep, Demerol, other narcotics, and epidural, in order to be fully present for the birth of your baby. Medical research has also demonstrated that the use of interventions such as epidurals may attach risks to the birth that otherwise would not exist. While, certainly, "Because I want to experience natural childbirth" is a perfectly valid reason for refusing pain relief, there are also scientifically sound arguments for avoiding or delaying interventions during birth and instead turning to "natural" methods of coping with the pain of labor and delivery.

The prevailing attitude of Western medicine is that our lives are substantially improved by removing pain and treating disease. And I have absolutely no argument with that stance in most cases. However, birth is not a disease, and the pain associated with childbirth is not necessarily an indication that something is wrong. Thus, while normally I'm all about feeling better, experiencing less pain, and reducing discomfort, the process of childbirth, when allowed to progress without intervention, without medication, without probes and monitors, and without interruption, has better outcomes than if we try to "treat" it.

I'm not saying we should never use pain relief, never do surgery, never use the available technology to assist in birth. No one is arguing that infant and maternal morbidity and mortality have not plummeted over the last century, largely due to improvements in medical technology and knowledge surrounding pregnancy and childbirth. However, there is still room for improvement, and mounting evidence suggests that likely over 90% of women will be able to give birth safely and successfully to healthy babies without any medical intervention at all. Allow her the space and time to labor, give her a clean and safe environment in which to birth her baby, have an experienced and well-trained birth attendant by her side, give her a supportive labor coach or two, and she will birth her baby in the most natural and ideal way possible, which will benefit her in her recovery and her baby in his development.

Studies have shown that the use of epidural, especially when in place for a long period of time (more than 10 hours), can interfere with a baby's ability to effectively breastfeed in the first day or two of life. Studies have shown that the use of epidural increases the "need" for Pitocin to augment labor, as the use of the epidural drugs and the fact that the woman is then required to remain on her back may slow labor contractions. Restricting a woman's movement during labor, forcing her to give birth lying on her back, and the use of sensation-dulling medications make it more difficult to push effectively and get the baby into an ideal birthing position. This increases the risk of c-section due to "failure to progress", "long labor", or "large baby." In addition, even if the baby is birthed vaginally, the risks of perineal tearing or episiotomy are increased, which may complicate the mother's recovery. The drugs in the baby's system may dull his sucking reflex and make him more lethargic, contributing to early breastfeeding difficulties. And, finally, the need to push IV fluids to maintain the mother's blood pressure when an epidural is administered may cause edema (swelling) in the mother's breasts within 12 to 24 hours of the birth, making it more difficult for her tiny new baby to latch and suck effectively at the breast, which can delay increased milk production and create a need for formula supplementation where none would otherwise have existed.

The point is, while many women desire a natural childbirth for non-medical reasons, many, many women have solid, evidenced-based reasons to eschew medical intervention and strive for a drug-free birth, for their safety and the health of their babies. Epidurals aren't going away, and many of the risks are manageable or can be mitigated by taking other steps such as allowing immediate skin-to-skin, encouraging rooming-in, and providing in-hospital breastfeeding support, but when women are made aware of these risks, they can make an educated decision as to how much risk they are willing to take on.

My personal desire to avoid the epidural is not a point of pride; it is not a hippier-than-thou exhibition; it is not out of an "I am woman; hear me roar" attitude. It is fear. Plain old fear that getting an epidural might cause a cascade of other interventions that would lead to an undesirable outcome for ME. It's important to note that what I find to be an undesirable outcome, other women may not. This is why women need to be informed, listened to, and included in the decisions made during their births.

So, thanks, "Coupling," for the laughs, but I'll stick to science, and not sitcoms, for birth education!

New Edition of Kindle Book is Available!

Check out the new, updated Jessica on Babies Breastfeeding FAQ, available for Kindle from Amazon.com. Makes a great new-mom gift or a quick purchase just before (or just after) you have your own baby. At $1.99, you get Jessica's basic breastfeeding advice in the palm of your hand, accessible any time and anywhere you need it.

Some sample questions and answers from the book:

What is the most important piece of advice you would give a new mother about breastfeeding?

The first thing I would say to any new mother is, “Keep nursing!” The more you nurse, the easier it gets, and the more you nurse, the more milk you make. You’ll often hear “breastfeeding is normal” or “breastfeeding is natural,” which is true, but it’s important to remember that breastfeeding is a skill that must be learned and practiced, by both mother and baby. Just like with any skill, the more you do it, the better at it you get. When my first son was born, I was so convinced that breastfeeding was natural and instinctive that I was very discouraged by how complicated it all seemed. I felt like I needed three or four hands. When my second son was born, despite all the reading I had done, it still took several weeks for me to find comfortable positions and the easiest way to get him latched on and sucking as quickly as possible. As awkward as you may feel in the first few weeks, you’ll find it getting easier by the day if you just keep at it. The third time around, I knew things would get better, but the first three days or so were very hard; he would scream every time I unlatched him from my breast. I had to keep reminding myself that the more he nursed, the better things would get. Sure enough, by the end of the third day, he became a much more content baby, and I was able to settle into a more comfortable nursing routine.

The second basic piece of advice I always offer is, “Give it six weeks.” The first few days and weeks can be challenging, and even painful, as you adjust to having a new baby and all the new demands placed on you by this change in your life. If you persevere through the first six weeks, nursing on demand, getting used to the baby’s cues and needs, it only gets easier. I’ve seen new mothers go from “Why is this so hard? I don’t want to do this anymore!” to “Oh yeah, I think I’ll nurse for at least a year,” in the space of just those few weeks. There’s something about that six-week point after which everything starts to seem easier. Also, as the baby grows, breastfeeding gets easier just because the baby’s mouth gets bigger, his neck is stronger, and he is more able to support himself. If you stick it out for those first six weeks and put in the work at the beginning, you’ll be able to continue your breastfeeding relationship for as long as you and your child desire.

I heard that giving a bottle of formula before bed, or adding rice cereal to the bottle, will help my baby sleep better and longer. Should I try this?

It is not a good idea to offer anything but breastmilk to your baby before six months of age. Remember that your milk supply is governed by the baby’s demand. If you give a bottle or other food instead of nursing the baby from the breast, you are telling your body that your baby doesn’t need milk at that time. This can cause your milk supply to drop, requiring that you continue to give your baby a bottle, which can cause your milk supply to drop further. It’s a vicious cycle that is difficult to get out of. 

There is no evidence that giving a bottle of formula at bedtime will help your baby sleep better at night. There is mounting evidence that doing so may be harmful to your milk supply as well as possibly contributing to postpartum depression or other maternal health issues. Recent studies show that mothers who breastfeed exclusively in the early months feel happier and better rested than those who attempt to supplement with formula in order to get more sleep. My sons woke frequently to nurse, and it was much easier just to pull the baby to my breast and go back to sleep than it would have been to get up and prepare a bottle for him. My husband and I were both much more sleep-deprived with our first son, who was formula-fed, than we were with our breastfed babies.

As for adding rice cereal to a bottle, or giving any other kind of solid (non-breastmilk) food to a young baby, this is highly discouraged by the American Academy of Pediatrics, the World Health Organization, and many other groups. It is recommended that you do not feed any foods or liquids except breastmilk to an infant under six months of age, unless under a doctor’s direction for a medical reason. Putting rice cereal in a bottle is also a choking risk. 

Also, giving a bottle in the early weeks of life may have a negative effect on the baby’s desire to latch properly on your breast (see “Should I give my baby a bottle?” below for more on bottles).

My nipples are bleeding. What do I do?

For short-term care, squeeze a little milk from your breast after a feeding and apply it to the bleeding nipple. Breastmilk has healing properties that will help the nipple heal faster and prevent infection. You may also purchase pure lanolin (usually found under the brand name Lansinoh) to apply to your nipples after a feeding. Lanolin is safe to leave on when your baby is ready to eat again and will soothe your nipples and help them heal. However, bleeding nipples are typically a sign of a bad latch or other feeding problem, and you shouldn't hesitate to contact a lactation consultant if the problem doesn’t resolve within a few days. 

The Last Few Weeks of Pregnancy: What to Expect

Pregnancy is a crazy time. It'll throw you for a loop over and over again. (May as well get used to the idea; babies and kids will surprise you at every turn, too!) But now you've finally made it to the third trimester, the last three months, the almost-end. You think you've experienced it all. You've gotten through morning sickness, back aches, frequent peeing, and lots of tests. You've dealt with constipation and heartburn and insomnia.

And then you hit about 36 or 37 weeks.

Just when you thought pregnancy couldn't get more uncomfortable; just when you thought you couldn't get more impatient for your baby to be born, you hit the home stretch.

I firmly believe that the last bit of pregnancy is so unpleasant so that you'll wish for labor just to get pregnancy over with. Otherwise, labor is pretty scary to contemplate, but if it means being done with this gigantic midsection, clothes that don't fit, sweating in weird places, aches and pains you couldn't imagine, heartburn and reflux and shortness of breath, loose tendons and nausea and insomnia and weird dreams, peeing constantly, hemorrhoids, constipation, and food cravings, well, maybe labor won't be so bad after all! At least it will end, and take with it a lot of these other discomforts and inconveniences.

So, what can you expect in those last few weeks?

Well, having just entered week 38, myself, let me tell you what's changed in the past week or so!

• Stronger and more frequent Braxton Hicks contractions. I've been having noticeable (but not painful) contractions for many weeks. These are totally normal and to be expected. You only have to worry if they become increasingly painful and more regular (more than 4 in one hour) and don't stop when you hydrate and rest. The contractions I've been having the last couple days are more powerful, occasionally borderline painful, more frequent, and certainly more noticeable!
• More pain in lower abdomen. The stretching of the ligaments that support the uterus (round ligaments) continues right up to the end. In the last few weeks, the baby is putting on half a pound to a full pound per week, which means you're still having to make room for him, and you're toting around all that extra weight. This stretching causes "round ligament pain," which you've likely been experiencing throughout the pregnancy. I'm finding it just continues to increase, and at times the pain is quite intense. It passes after just a few minutes, fortunately, but it's certainly unpleasant while it lasts. (If you have any reason to suspect that the pain you're feeling is not normal, or if any pain is accompanied by vaginal bleeding, contact your provider right away!)
• Increased pressure in the hips and pelvis. As the baby starts his downward journey to the eventual exit, his head will start putting pressure in new places. I feel like I constantly have to use the toilet, but most of the time I can't produce or don't actually have to go. (Too much information? Get used to it. Pregnancy robs you of all modesty. May as well be honest!) 
• Reduced heartburn and shortness of breath. One perk of the baby "dropping" is less pressure on the stomach and diaphragm, which means I can breathe better and am having less acid reflux. So there's that!
• Increased low back and hip pain. I find it increasingly difficult to get comfortable in bed, and I wake up with achy hips and lower back which often persist at a mild level throughout the day.
• Harder to get off the floor, reach my feet. Putting on socks and shoes is a whole new adventure. And if I get down on the floor to play with the kids, sweep, or pick up toys, getting up involves a lot of grunting and groaning.
• Less stamina. I run out of steam in the afternoon and absolutely must lie down. I often fall asleep when I do. Any extra physical activity takes more out of me than it normally would, so even going food shopping or taking the kids to the park feels like a much bigger energy investment than it did a few weeks ago or will after I recover from the birth.

Of all of these changes, I think the increased pressure as the baby drops is the most irritating. It's this feeling of "almost there" that is such a tease. And I know my life won't get easier once he's born, but I won't miss being pregnant, either.

It's also these big changes near the end that make women very impatient to give birth. Three weeks of this might seem interminable, and if you're one of the many women who goes "post-dates" (beyond the estimated due date), those "extra" days can be even more torturous. 

However!

Remember that every day makes a difference in your baby's development. Every day that your baby stays inside you is one more day for his lungs and brain and gut to develop properly, for him to put on fat stores that will see him through the first few days of life. Every day that you can wait is contributing in a positive way to your baby's overall lifetime health. Unless there is a medical reason for yourself or your baby that might require giving birth before you go into labor spontaneously, you are doing your baby good by being as patient as you can be. Continue your routine, pretend you've still got a month to go, make plans with friends, go for walks, see movies, go out to dinner with your partner, watch TV, read books, surf the Web, and go shopping. Pass the time. 

And if you are at or past your due date, here are some ways you might be able to help labor start, if your body and your baby are ready. At the very least, it might make you feel like you're doing something to move things along.

• Get that oxytocin flowing! Oxytocin is the hormone that promotes uterine contractions, and there are two ways outside of labor to get oxytocin going. One is orgasm. Another is nipple stimulation. As long as your provider has deemed it safe for you, and as long as your amniotic sac isn't broken, go ahead and have sex. As a bonus, semen has prostoglandins in it, which are hormones that help the cervix ripen (efface and dilate), so if you have intercourse, you might be helping yourself in two ways. Nipple stimulation can be done in a fun way (use your imagination) or by using a breast pump. If you've got a double electric breast pump, hook yourself up for 20 minutes or so. You might even mine some precious golden colostrum, which you can save in your freezer just in case your newborn needs a little extra or has any trouble breastfeeding at first.
• Walk! Walk up and down stairs, up and down hills. Alternatively, do some cleaning or gardening. Anything that gets your body moving in a way that will encourage your baby to move down, get his head bumping against the cervix, and open up your pelvis (squatting to clean the floor, for example) can help settle the baby into the most ideal position for giving birth. At the very least, this will help your labor be more efficient and the birth easier. At most, the physical activity might help labor get started.
• Look up some folk remedies. Some people swear by eating certain meals, drinking certain teas, or using certain herbs. I can't recommend anything specific, and I would definitely do some research before you ingest anything that you don't know is safe.

There's no real way to know if any of these methods actually induce labor, but it might help you psychologically to feel that you are making an effort to move things along. I want to reiterate that once your water breaks, nothing should go into your vagina! The amniotic sac protects your baby and uterus from infection. Once that membrane is broken, it's very easy to introduce bacteria in places you do not want it to be. Nothing nothing nothing, not fingers, not bath water, should go up there. If your water has broken and labor doesn't start within about 24 hours, contact your provider.

How were your last few weeks of pregnancy? How did you psych yourself up for the big day? Did you try any of these "natural" induction methods? Do you think they worked? What other methods have you heard of?

Check out my Ask-Me Monday video on this same topic, also published today!

Adjusting to a Second (or Third, or Fourth) Baby

While there is always plenty to worry about when you're pregnant, you'll have different concerns when you're pregnant with your second (or third, or fourth...) than you did with your first. When you've already had a baby, your life has already adjusted to the presence of a child. But now you need to adjust your older child(ren) to the presence of a sibling, and you have to figure out how you are going to care for yet another child. Here are some of the common concerns parents have when adding a new baby to the family.

What if I don't love my new baby as much as I love my son/daughter? 
This is one of the most common questions I hear from second-time moms who are expressing their worries about the impending birth of their next child. The overwhelming love we experience when our first baby is born is indescribable, and we worry that it can never be matched. Fortunately, love is not finite, nor is it parceled out. Bonding with your first baby left physical changes in your brain that mean bonding with your next will happen in just as breathtaking a fashion. Love expands into a bubble that encompasses every child together and each child individually. You may not love your second in the same way that you love your first, but the quantity and quality will not be in any way diminished. Finding that each of your children is an individual with different needs for attention, affection, and interaction brings a whole new dimension to the overall love you will feel for your family as a whole and for each child. And the love between siblings gives your heart a whole new reason to swell.

What if I love my new baby more than I love my older child?
This is a different sort of worry. You know you love your child, but maybe you had trouble forming a bond the first time. Maybe the birth was traumatic, maybe you were separated for a hours or days, or maybe you were so befuddled and overwhelmed by the addition of a new baby to your little family that you took a few days or weeks to feel the kind of love you were looking for. What if, this time, you bond faster, your love is stronger? It is, in fact, likely that you will bond faster with subsequent children than you did with your first. While some parents had no trouble bonding the first time, it is very common, too, for it to take a little time to understand how this new little person fits into your world. Rest assured, your capacity for loving your children is not limited or finite, and you will find that as you experience a new bond with your baby, your bond with your older child will increase as well.

The baby will require so much attention. I don't want the older sibling(s) to be jealous.
Yes. The new baby will require a great deal of attention. This is true. And you will be tired and overwhelmed and discombobulated. And your other child(ren) will still need you for diaper changes, potty help, baths, reading books, helping with homework, meals, laundry, and everything else you already do for them. And it is entirely possible that they will get tired of hearing, "Mommy (or Daddy) will be with you in a few minutes, just as soon as I finish feeding/bathing/holding the baby." Remember, though, that a lot of the attention the new baby needs at first is fairly passive. Nursing (or giving a bottle), holding and rocking, carrying around, keeping an eye on, are all things you can do while you give attention to an older child. Your older child can cuddle with you while you nurse the baby. One great bit of advice that many new parents find helpful is to set up a "nursing basket." Put together a box or basket of special books, toys, and movies that you can engage in with your toddler or preschooler whenever you sit down to feed the new baby. Your older child will still get to spend quality quiet time with you, and may even begin to see nursing-the-baby time as a special Mommy time for him/her, too. In addition, make sure your older child(ren) get a chance to hear you say, "Hold on, Baby, your brother needs my help first." Let him know that he's not always going to be second to the needs of the baby. Also, if you can, arrange for regular one-on-one time with the older child with one parent or the other.

A second bit of advice that works well for toddlers is to have the "baby" give the older sibling a gift. When the baby is born, you'll likely receive gifts for yourself and for the baby. Store away something in advance that the baby can give to his big sister or brother. Also, if you can enlist a relative or two to give the big sibling a gift (even something small), she or he will feel less left out of the excitement.

Another part of this equation is giving your older child(ren) the chance to become helpers and caregivers for the new sibling. I have found that this facilitates the sibling bond and makes the older child feel needed and special, too. Give them a "job" (equal to their abilities, of course). "Can you help me out and be such a big girl? Can you run upstairs to the baby's room and get Mommy a diaper? I think the baby needs a change." It may sound corny, but if you make your child feel like she is the only one who can do this monumental task to help you and the baby out, she will be full of pride. And if she doesn't want to help you, no big deal. She'll still appreciate that you asked her. Another way a verbal toddler or preschooler can be of great help is by "watching" the baby for you. When the baby is in a safe place such as a swing or on a blanket on the floor, if you're trying to accomplish something like fold laundry or make dinner, ask your older child to watch the baby. Have him sit down beside the baby and talk to him, keep him company, try to make him laugh. Make sure you've already established boundaries like no touching the baby's face and no trying to pick up baby, of course, for safety. Make sure he knows what a great help he's being.

It takes me 10 minutes to get out the door with just one kid. How long will it take with two?!
You'll find that because you've already got experience with packing up a diaper bag and getting everyone dressed and ready to go, adding a baby to the mix likely won't end up doubling your "out-the-door" time. Certainly, at first, you will need to leave yourself extra time to get where you're going. In my experience, it's always just as you're about ready to leave for an appointment that the baby poops and needs to eat. But getting everything else ready shouldn't take too much more time than it already does. Snacks, diapers, wipes, change of clothes for the older one (as needed), diapers, wipes, change of clothes for the younger one (and bottles if applicable) all go in the bag, and off you go. Some people find it easier to keep two bags ready, one for the older child and one for the baby, although I find this just means more to carry and keep track of. If your older child still needs to be carried out the door and into the car, leave the baby in a safe place in the house (already buckled in the infant car seat, for example), run the toddler out to the car, buckle him in, then go back for baby. I find that if I start encouraging the older child to be able to walk out to the car and climb in before the baby's born, while I can help him figure it out, getting everybody in is much quicker once you're juggling more than one child. This, of course, depends on your older child's age and abilities. Of course, if you live in an apartment or have to park on the street or have another circumstance where something like this scenario isn't realistic, you'll find a way to make it all happen. You've already worked out how to get one kid out safely, after all!

How will I manage bedtimes, naps, and errands?
I like to plan ahead and understand how the bedtime routine might change, where I'll put everyone when I go grocery shopping, and when and how everybody will get the naps they need. The thing is, it's hard to really plan ahead for any of this, because you have to see how your older kid(s) will react to the new baby, you have to see what the baby's needs are, and you need to know how much help you'll have in terms of other adults around. If you can share the bedtime routine between both parents, then I'd start making any necessary transitions at least a few weeks, if not a few months, before the baby is born. If Mommy usually cuddles with the toddler until he falls asleep, can Daddy do it now instead? Or can you help the toddler learn to fall asleep on his own, or after just a few minutes of cuddles? If you are alone with your kids at bedtime and you're used to "doing it all," you may have to improvise. At first, you can likely just hold and/or feed the baby while you do any book reading, cuddling, and so forth. If your baby is fussy or needy right around your older child's bedtime (which is common!), this may be more difficult. I find that it's usually helpful to get the older child to bed and then deal with the baby, if that's possible.

Naps are really the place where the younger sibling will suffer. I've been in the situation where the toddler's nap falls exactly between the baby's naps, and I feel like I can't ever leave the house because one or another of my kids is supposed to be sleeping. Unfortunately, it may happen that your baby becomes a slave to the routine and schedule you've already established. If that means baby naps in the car or during errands, at least he's getting some sleep, right? If you can baby-wear and/or arrange to take your longest car trips when baby needs to sleep, you'll at least be able to ensure that she's getting some nap time in, even if naps aren't always in bed!

As for errands, baby-wearing will be your friend, here, too. If you have a toddler who still needs to sit in the cart, for example, you can wear the baby and still put the toddler in the cart. Some of the larger stores have carts that can accommodate more than one child at a time, but in a regular grocery store, you may not have any other options. It is dangerous to prop the infant car seat on the child seat in the cart, so I don't recommend doing that, regardless of how many children you have. One thing I used to do when my third was born was take all three of my kids shopping. My oldest was capable of pushing the baby in his stroller while my middle sat in the cart, which I pushed. My oldest really liked having that important job to do. Better still is if one adult can run to the store while the other stays with the kids! Or take just one kid with you on errands and make that a special one-on-one time. Maybe you can get ice cream or buy him a special treat once in a while if he comes with you, so that he'll see that he still gets a fun time alone with Mommy or Daddy.


The best observation I can make is that, yes, the first several weeks will be a period of adjustment. You'll fumble with figuring out how to integrate the new baby into your routine. You'll have to figure out how to meet the baby's needs without depriving your other child(ren). You'll have to get used to dividing your time and attention. Your older child(ren) will likely act up or behave strangely because they will also be affected by the change in their routines and their lives. They'll notice that you are not as readily available to them. They'll be aware that things are different now. Be sure to acknowledge those feelings. Also, know that things will get easier. You will adjust. Your family will adjust. Give it some time and get a little creative, and, most of all, take what help you can get!

Enjoy your growing family!

What tips do you have for parents adjusting to the birth of a subsequent child? How did you help your older child(ren) get used to having a new baby in the house? How did you integrate the new baby into your established routine and busy day-to-day lives?

Guest Post: Information about Mini IVF

Today, we have a guest post from Dr. Mor, at the California Center for Reproductive Health. Dr. Mor tells us about Mini IVF, an effective option for assisting families struggling with infertility to become pregnant. Infertility is an emotional subject that many couples deal with silently. It can be difficult to talk about problems getting pregnant or maintaining a pregnancy, especially when friends and family seem to be popping out babies all around you. For couples who desperately want a child but cannot seem to conceive or maintain a pregnancy through more traditional means, modern medicine has a lot to offer. Fertility treatments can be expensive, time consuming, and sometimes have unpleasant side effects. Fortunately, technology is always advancing, and in this article, you'll learn about a method which is less invasive and less expensive than traditional IVF.

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Mini IVF is an increasingly popular option for families struggling with infertility who would like to save money and avoid excessive amounts of medications. Compared to traditional IVF treatments, Mini IVF is a gentler technology that involves minimal stimulation of the ovaries. Mini IVF commonly begins with the use of oral ovulation induction agents, such as Letrozole, Tamoxifen or Clomid, sometimes in combination with low-dose gonadotropins. This stimulates growth of a small number of eggs. When the eggs are mature, they are removed through a minor procedure and fertilized in a laboratory before being placed back inside the mother's uterus. 

In contrast with traditional IVF, Mini IVF focuses on quality rather than quantity of embryos. As a result, Mini IVF costs less, avoids the potential risks of taking too many medications and is becoming more popular at fertility clinics. Because the ovarian stimulation in Mini IVF results in three to four eggs and two or three embryos, it maximizes the efficiency of the cycle.

When families choose Mini IVF instead of traditional IVF, they can often get more eggs and reduce or avoid the risks and discomforts that accompany traditional IVF. In addition to its other benefits, Mini IVF reduces the time spent waiting between cycles and cuts or eliminates the pain associated with frequent injections. Finally, Mini IVF decreases the discomfort and health problems that result from ovarian hyperstimulation syndrome. Mini IVF cost is typically half the price of traditional IVF and may be covered by health insurance.

The procedures followed for Mini IVF can vary, but all focus on gently stimulating the ovaries to create eggs and embryos of high quality. Birth control is commonly given before ovarian stimulation, but stimulation may be given without first using birth control in women who are over 35 years old. Gonadotropins are sometimes used in low doses. Fertility clinics use ultrasound and some blood testing for monitoring. Unlike with traditional IVF, Mini IVF requires less anesthesia during egg harvesting depending on the patient. IVF lab clinicians fertilize the eggs through insemination or, if male infertility is present, intracytoplasmic sperm injection (ICSI). Once the embryos are between three and five days old, they are placed back inside the uterus. Altogether, the process of Mini IVF takes between seven and 10 days.

Success rates with Mini IVF are comparable to or better than those of traditional IVF, especially in women younger than 35 who have normal ovarian reserve. Women with lower ovarian reserve tend to respond equally to Mini IVF compared with traditional IVF in terms of egg production and should consider this newer form of ART (Assisted Reproductive Technology). Finally, women older than 40 tend to have better results from Mini IVF because its lower level of stimulation is more likely to produce higher-quality eggs and embryos.

About the Author

Doctor Mor is a board certified reproductive endocrinology and infertility expert who specializes in assisted reproductive technology (ART). Having completed his fellowship training at the University of Southern California, Dr. Mor now serves as the Medical Director of the California Center for Reproductive Health, a leading fertility center. With an innovative approach towards fertility treatments and minimally-invasive reproductive surgery, Dr. Mor offers Mini IVF along with a host of other ART options to his patients. 

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Have you struggled with infertility? It is a difficult subject to discuss and is often suffered in silence by those facing reproductive issues or going the ART route. I hope that by talking openly about treatments and solutions, we can move past the stigma of reproductive difficulties and facilitate supportive dialog among those who have been affected by infertility and fertility treatments.