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Julie groverYours, Mine and Ours: Reproductive Issues YOURS, MINE AND OURS: REPRODUCTIVE ISSUES I think that it’s kinda fitting that I was asked to speak on reproductive issues since I’m about 2 or 3 weeks away from reproducing again. So, I’m happy to be here though talking to people about getting pregnant or not getting pregnant and ways that they can stay healthy both before, during, and after pregnancy. It’s kind of one of the most important parts of my job and what I do all day everyday. I can first of all I want to say just from a personal note that having a healthy relationship is important. And having children is one of the ways to add incredible joy and strength to any healthy relationship. It certainly won’t make a bad relationship better but I think that sharing the experience of having and raising children with your spouse is one of the most wonderful things that you can do. I get more joy, more challenge, more tears, from the experience of raising my boys than I ever do from being a doctor. So you have a healthy relationship and you have a married relationship and one of the first important questions that newly married couples face is the question of whether, when, and how to get pregnant or not get pregnant. One of the important topics that I think is important for couples to talk about even before marriage, but also definitely right after getting married is the question of birth control. This is a little bit of a sticky question for some people and a lot of times the question comes up what is the church’s stand on birth control? Is there official church doctrine about birth control or not? The closest thing that I know of to official church doctrine is a statement from the first presidency and while there are no official statements directly on birth control that I’m aware of from the first pregnant, from the first pregnant, from the first presidency. The closest thing that I have found to one comes from this book right here, it’s the true to the faith booklet, I hope that all of you have a copy of this or at least have access to one. The introduction to this book is a letter, a message from the first presidency and in it they say that they are to keep this booklet to be studied with our scriptures and that material from this book can be used in teaching classes and church and so I think that this is a pretty solid, the closest thing that you are going to get to official church doctrine on birth control. And there is about a half page statement in here and I’d like to read it just so I don’t miss quote it at all. What it says is “when married are physically able they have the privilege of providing mortal bodies for heavenly father’s spirit children. They play a part in the great plan of happiness which permits God’s children to receive physical bodies and experience mortality. If you are married, you and your spouse should discuss your sacred responsibility to bring children into the world and nurture them in righteousness. As you do so, consider the sanctity and meaning of life. Ponder the joy that comes when children are in the home. Consider the eternal blessings that come from having a good posterity. With the testimony of these principles, you and your spouse will be prepared to prayerfully decide how many children to have and when to have them. Such decisions are between the two of you and the Lord. As you discuss this sacred matter, remember that sexual relations within marriage are divinely approved. While one purpose of these relations is to provide physical bodies for God’s children, another purpose is to express love for one another, to bind husband and wife together in loyalty, fidelity, consideration, and common purpose.” WOMEN’S SERVICES PRESENT THE HEALTHY RELATIONSHIP CONFRENCE YOURS, MINE AND OURS: REPRODUCTIVE ISSUES So I think that it’s pretty clear here that that this statement isn’t saying that that birth control is bad or is good, but that it is an important decision that couples should make together. It also says that couples should decide when they could they should have children. It doesn’t give any specific guidance on what method we should use to decide when. You know I think that the church when it when it doesn’t give a direct opinion about something, there’s usually they are not giving a direct opinion on purpose. In other words, there is no clear preference here saying its ok to use birth control pills, but it is not ok to use an IUD or you know it’s ok to use one birth, one type of birth control but not another type. And so I think that those decisions are to purposefully left to us to, hoping we will take into consideration you know the purpose of our being here and the purpose of our being married. I also think it’s really great that they mentioned that the purpose of the intimate relationship, intimate physical relationship between a husband and wife is not only for having children, and it’s also for the strengthening the bond between husband and wife and for bringing joy into their lives. So we shouldn’t feel that if we’re not having sexual relations for the purpose of conceiving children that it is not still a good thing and an important part of our relationship. Having said that, I’d like to talk a little bit about a few of the different methods of deciding when you are going to have children. You know, a lot of the times, people say well we’re going to just leave it up to the Lord and if he wants to send us a baby, he’ll send us a baby. And that’s great if that’s the way you want to think about it. But I think that that this statement is saying that we should put some thought into it and we should decide when is the best time in our lives and in our relationships to welcome children and to not leave everything completely in the hands of the Lord. When a lot of people hear the word birth control they immediately think of birth control pills. And there’s actually several different other options. Birth control pills are one of the most popular forms of birth control because they’re sort of in the control of the woman. And she controls when she starts and when she stops and doesn’t have to consult a doctor about when she is done and when she is ready to go ahead and conceive and have a baby. Birth control pills obviously have to be prescribed by a doctor and there are some very important health considerations to consider when starting birth control pills. There are a few different health problems, especially things like high blood pressure or having severe migraine headaches or things that could promote blood clotting that are reasons why you shouldn’t take birth control pills. But some of the advantages are that they are very effective. If you take birth control pills completely, correctly and on time they are 99% effective. If you aren’t such a good pill taker they are more like 95% or less effective. They have the advantages that they can make periods more regular, they can decrease blood flow, and they can decrease cramping. They actually have some long term health benefits in terms of preventing certain types of cancer especially ovarian and uterine cancer. Other options. A lot of people don’t consider other options because they don’t know a lot about them. One of the more common types of birth control that is used WOMEN’S SERVICES PRESENT THE HEALTHY RELATIONSHIP CONFRENCE YOURS, MINE AND OURS: REPRODUCTIVE ISSUES around the world that is less popular in the United States is an inter-uterine device or an IUD. And this is something that is inserted into a women’s uterus at the time of a doctor’s visit which prevents pregnancy. It used to be thought and many people especially inside the church were hesitant to use an IUD because it used to be thought that IUD’s function mainly by preventing implantation of a fertilized egg. And some people considered this you know a pro-abortion, so to speak. We now know that that IUD’s usually function by preventing fertilization just like birth control pills usually do. The advantage of an IUD is that it can stay in place for between 5 and 10 years and so its low maintenance. You don’t have to remember to take a pill everyday. You don’t have to keep getting a prescription refilled um. The main disadvantages are that it’s expensive up front. They can cost in the range of 500 dollars or so, but if you’re thinking that you want to delay child bearing for at least a couple of years, averaged out over a couple of years, that’s a lot less expensive than pills. And actually, most insurance companies are starting to pay for IUD’s now because they are realizing that they would rather pay for that than a pregnancy. Other options. Another main category of option is the Depo-Provera injection or the shot that people talk about sometimes. This is a shot that you get every three months. This is also very effective. As with IUDs the failure rate for the shot is less than 1% and you don’t have to do anything right to get that less than 1% failure rate. Um, with the shot the woman gets an injection every 3 months. It tends to make periods lighter, but sometimes causes irregular bleeding. Um, one of the main disadvantages with the Depo-Provera shot is that if you are trying to time your children precisely it’s not the greatest thing. It can take anywhere from three months to a year after the last shot is given for it to wear off completely. But it is also fairly inexpensive. Other options of course there’s always barrier methods, mainly the most popular one is condoms. Which of course form a barrier that block sperm from getting through to the egg. And condoms work best if they are used with spermicide. And if they are used with spermicide and every single time they are also very effective in the range of 97 to 98 % effective. But that’s difficult to do sometimes. So in actual use they have a higher failure rate closer to 10 to 15%. But they have the advantage that you don’t have to have a doctor’s prescription; they are available in any drug store. The disadvantage of course is that you have to use them every time. Of course the kind of the final and ultimate form of birth control is sterilization or having your tubes tied for a woman or having a vasectomy for a man. This probably isn’t an option that most BYU students are thinking about at this point in their lives but it can be a good option for once you have your family completed and you are certain that you don’t want to have any more children it can be a secure and inexpensive and easy way to preventing children later in life. Or if you have severe health problems or reasons why you medically shouldn’t have children it can be an option earlier on in life as well. So what if you get through those that first period of your marriage and you’re ready to. Or if you decide right away you’re to go ahead and have a baby. So what do you do? Obviously you stop using whatever birth control method that you are on, but there are some steps that you should take even before that. And one of the most important ones is to see a doctor before you even get pregnant, and let the doctor know that you are WOMEN’S SERVICES PRESENT THE HEALTHY RELATIONSHIP CONFRENCE YOURS, MINE AND OURS: REPRODUCTIVE ISSUES planning on, you know conceiving within the next year. And some of things that he or she should recommend to you, first of all you should go on prenatal vitamins. Prenatal vitamins are most important and actually in the first two months of pregnancy they help to prevent uh serious birth defects of the brain and the spinal cord called spina bifida. The folic acid in prenatal vitamins is the most important part of them for doing this. And it is important that women be on folic acid or folic acid containing prenatal vitamin for at least a month before conception. And if you have a family history of people in your family having this type of birth defect then you should be on higher doses of the folic acid. Later on in pregnancy it is important that that you have a supplement that contains iron which most prenatal vitamins do, as well as there is growing evidence that supplementation with Omega 3 fatty acids which are not a component of most prenatal vitamins, is very helpful for a baby’s brain and eye development, especially in the second and third trimesters. But that’s more important later in pregnancy. One, what the only vitamin really to avoid taking high doses of in pregnancy is vitamin A. It’s actually been shown to cause birth defects when taken in very high doses. Certainly much higher than are going to be found in prenatal vitamins or most vitamin supplements. But there are a few herbal or mega vitamin supplements that you should be careful of if they have more than a 100% of the daily value of vitamin A. Some other things that you should consider or that you should talk to your doctor about before you decide to get pregnant are any medical problems that you may have. There are certain medical problems that can uh greatly affect pregnancy or that can be affected by pregnancy even very early on. Some of the most important ones is diabetes. Especially diabetes that is bad enough that you need insulin. This can cause severe birth defects if blood sugars are not controlled very tightly in the first or two of pregnancy. Women with severe heart problems should see their doctor before they decide to get pregnant, because there are few severe heart problems that can be life threatening to the woman if she does get pregnant. Most minor heart problems can be dealt with just fine with pregnancy. Women who have a rare but serious metabolic problem called PKU or phenylketunuria. It’s very important that they see a doctor before pregnancy. This is a condition where women have to be on a special diet as children but often they kind of get lax as they become adults with this special diet. But if they don’t go back on their special diet it can cause defects in the baby. And the other main category is any problem with blood clots. If you have had a blood clot in the leg or in your lungs or if you have people in your family who have had problems with this it can effect pregnancies and make you more likely to get a blood clot during pregnancy as well. Other things that are important to your doctor if you have lupus or kidney problems or high blood pressure, those are also important to control before or very early on in pregnancy. Medications are also a very big question that most people have in the early stages of pregnancy. Most prescription and over the counter medications are actually pretty safe WOMEN’S SERVICES PRESENT THE HEALTHY RELATIONSHIP CONFRENCE YOURS, MINE AND OURS: REPRODUCTIVE ISSUES during pregnancy. There are only a few medications that have shown to definitely cause birth defects during pregnancy. Some of those are blood thinners that are taken as pills. Certain blood pressure medications, certain seizure medications, and of course the big one is the Accutane which is an oral acne medication. Those are all things that should probably be stopped early in pregnancy, although you wouldn’t want to stop any of those without talking to a doctor, especially seizure medications or blood thinners, because those, stopping those medications could also be dangerous to a woman’s and the pregnancy. Most over the counter cold medications etc. are fairly safe in pregnancy although to be 100% certain you should talk to your doctor about those too before using them early in pregnancy. One thing that that I always talk to patients about but that is not hopefully not a big problem with anyone in this room if you are living by BYU standards is the issue of using tobacco or alcohol during pregnancy. Tobacco can be extremely damaging to pregnancy. Can cause babies not to grow well, can cause severe bleeding. Can cause bleeding from tear in the placenta later on in pregnancy, can cause problems with increased blood pressure, and can make other problems in pregnancy worse. Drinking alcohol during pregnancy also can cause facial deformities, mental retardation, growth problems in babies, so hopefully nobody in this room has a problem with tobacco or alcohol use, but if you do or if you know someone you do who is thinking about getting pregnant, make sure that they get help or talk to their doctor about it right away. Other things to think about when you are thinking about getting pregnant or that your doctor should talk to you about before you get pregnant are making sure that your immunizations are up to date. There are a few infections that can cause severe birth defects in babies that we like to make sure that mothers are immune to before getting pregnant. One of the major ones is rubella or German measles. This is one that most kids are vaccinated against when they get their MMR shot when they are a year old and usually a booster several years later. But occasionally the immunizations don’t work, or you think that you got your immunization but you didn’t, and you won’t be immune to rubella. And so, most doctors will check for that and give you the immunization if you are not immune. It is a live virus vaccine. So that means that we can’t give it once you are pregnant. It has to be done before you get pregnant. Another one to think about is chicken pox. You know it sounds pretty benign you know that all little kids get chicken pox, but if you don’t get chicken pox when you are young and then you get it when you are pregnant, it can also cause severe birth defects in babies. And, so if you don’t know for sure if you had chicken pox when you were younger, you can be tested. There is a blood test that we can do to find out if you are immune. A few people will have just had a mild case of it and won’t know if they had it when they were little. If you are not immune to chicken pox there is now a vaccine that we can give and that most young children are getting now to prevent chicken pox. Other things that can be useful in a visit with your doctor before conceiving are talking about any family history issues that you may have. If anyone in your family, either the husband or the wife has genetic problems or birth defects in their family, these are sometimes things that either your doctor or a genetic counselor can talk to you about and give you a WOMEN’S SERVICES PRESENT THE HEALTHY RELATIONSHIP CONFRENCE YOURS, MINE AND OURS: REPRODUCTIVE ISSUES better idea of your risk of your baby having one of those things. These are things like cystic fibrosis which is a severe disease of the lungs. Or heart defects or again spina bifida, a defect of the brain or spinal chord, or any problem that tends to run in families. There are actually ways that we can test you to find out if you are a carrier for one of these things. Especially testing for cystic fibrosis is becoming more and more common because about one out of twenty Caucasian people in the United States are a carrier for cystic fibrosis. It may or may not change your plans as far as deciding whether or when to have children. For a few people it could make them not to want to have children if they both they and their husband were carriers or make them choose to adopt instead rather than risk having a baby with this severe disease that is likely to kill them before they reach adulthood. But it can also give couples peace of mind and kind of a warning of what to expect. And again cystic fibrosis carrier testing is something that that all Caucasian people can consider doing but that is more important if you have any one in your family with this condition or who is known to be a carrier for this condition. A few other things to think about before you get pregnant. One is just optimizing your own health, specifically diet and exercise. A lot of times people once they get pregnant start worrying about well should I start exercising or what should I be eating or not eating. But really, the things that are healthy for you when you are pregnant are the same things that are healthy for you when you are not pregnant. And all people regardless of age or gender should try to get some form of exercise almost every day. That means you know working hard enough to get your heart rate up a little bit and to get maximum benefit from it you need 30-40 minutes of aerobic exercise everyday. Now, this doesn’t mean that you need to start marathon training if you haven’t been exercising before. But something as simple as brisk walking or one form of exercise once you become pregnant is swimming because it takes and it doesn’t take the same stress on your joints especially the low back that other weight bearing exercise might put there. But starting now to get your body healthy and to get used to exercising almost everyday is a great way to prepare for pregnancy. Once you get pregnant you don’t want to start a really vigorous exercise program, but if you have been exercising pretty vigorously before pregnancy continuing exercise at a similar or slightly reduced intensity is very safe for the baby and is good for your health. Other things to think about is your diet, and making sure that you are getting plenty of healthy foods everyday. Plenty of fruits and vegetables, whole grains, minimizing fats, especially trans fats and saturated fats, and also getting plenty of fiber in your diet. Once you get pregnant you need about 300 extra calories a day and ideally those should come from those same food groups, fruits and vegetables, lean protein. You need extra protein during pregnancy as well as extra calcium during pregnancy. A lot of young women don’t get enough calcium. You actually need about 1000 milligrams a day of calcium when you’re not pregnant and about 1200 milligrams a day of calcium when you are pregnant. That’s about 4 servings of dairy products a day, so if you don’t think you drink 4 glasses of milk a day you might want to think about taking a calcium supplement once you get pregnant. But also before pregnancy just to build up your bones to their maximum strength so that when you are older and in your fifties and you go WOMEN’S SERVICES PRESENT THE HEALTHY RELATIONSHIP CONFRENCE YOURS, MINE AND OURS: REPRODUCTIVE ISSUES through menopause you don’t end up having spinal fractures or hip fractures or things like this. Ok so let’s talk a little bit about what if you don’t get pregnant. What if you decide you want to get pregnant and you are doing everything right, and you get on your birth control pills, you have your visit with your doctor, you get on your prenatal vitamins then you go off whatever birth control form that you are using, and you know all your friends got pregnant within two months of when they started trying, and its been 3 or 4 months. And then it has been 6 or 7 months, and then it has been 8 or 9 months and you are starting to worry if something is wrong. One of the first things that you should know is that there is only about a 20 to 25 percent chance of conceiving in any given cycle for any perfectly normal, healthy couple. You know the system just isn’t a 100% perfect. And its normal to take up to a year, a full year for couples that are healthy with nothing wrong to conceive. And so although it can be trying on your patience, once you have made the decision to go ahead and get pregnant it takes several months, you shouldn’t worry that anything is wrong and don’t need to see doctor about worries about possible infertility until it has been an entire year that you’ve been trying to get pregnant. The exception to that is if you know that either the husband or the wife has a problem that could interfere with infertility. For example, if the man had a severe infection that could have affected his ability to make healthy sperm, or the woman have very irregular or infrequent periods. Usually greater than 40 days between periods can be a sign that a woman isn’t ovulating or making an egg every month. And if that is the case, then it might be a good idea to see a doctor a little sooner to see if there is something wrong that might be able to be fixed. About 80% or so of the time, we can find a reason why couples are not able to get pregnant, and it’s about 10-15% of all couples who are not able to get pregnant within a year. About 40% of the time or so it is a problem with the woman and about 40% or so it is a problem with the man and there is a fair amount of overlap with couples where there is a problem with both the man and woman. Some of the tests that might be done are things to find out if a woman is ovulating, making sure there are eggs available, things to check the quality and number sperm in a man’s semen, so there are sperm available. And things to check the shape or the size of the uterus and the tubes to make sure the egg and the sperm can get together and implant in the uterus to grow a pregnancy. The most basic fertility testing is even the most basic testing is still fairly expensive and something that isn’t usually covered by insurance so it can be a big step to make that commitment to make some of those tests. But, very often there is a reason found and especially with in vitro fertilization becoming so commonplace and so successful, there is very good reason for hope for most couples. Another problem that sometimes arises is the problem of miscarriage. And this is especially frustrating when a miscarriage happens with the very first pregnancy. About 15 to 20% of all pregnancies will miscarry and most of those are quite early within their first 10 to 12 weeks of pregnancy. About 70% of the time the reason for miscarriages is an abnormality in the chromosomes, either an extra or a missing chromosome that either was not there or extra from when the egg and the sperm got together. And it’s almost never something that the WOMEN’S SERVICES PRESENT THE HEALTHY RELATIONSHIP CONFRENCE YOURS, MINE AND OURS: REPRODUCTIVE ISSUES woman did or didn’t do. You know sometimes women blame themselves for miscarriage, and it can be a very emotional time. And even though its only a tiny piece of tissue that miscarriages and never really developed into a baby, that pregnancy had all your expectations and hopes for having a baby and so its normal for women to grieve after a miscarriage, just as if they had lost a full term baby or a child. It can also be normal to not grieve though and to see it as you know not too much more than a heavy period and kind of everything in between there is in the range of normal after a miscarriage. But it can become very frustrating if a woman has more than one miscarriage. And this is again a situation that’s a little bit like the problem of infertility where there is a lot of testing that we can do. Unfortunately with recurrent miscarriage there is less often an exact reason found or a reason that we can do something to alter with recurrent miscarriage. Regardless of the cause though, most women who have a miscarriage still have a very good chance of getting pregnant again and carrying that pregnancy to term after having one miscarriage, your chances of having another miscarriage does go up slightly. But still the vast majority of women who have a miscarriage will have a normal pregnancy with their next baby. One of the other things that I wanted to touch on briefly in talking about reproductive issues, even though it is not really involved with getting pregnant, it is certainly pregnant it is certainly involved with having a baby, is the issue of breast feeding. And this is something that fortunately becoming more and more excepted and even more the social norm, but it is something that every couple and every woman ought to at least consider when thinking about having a baby, cause often the decision is kind of made early on and your decision whether to breastfeed or bottle feed can be influenced by your parent’s attitudes, your friend’s attitudes and your own thoughts or your own experiences related to other people breastfeeding. Breastfeeding is the perfect form of nutrition for new born babies and also leads to a lot of health benefits for moms and babies, especially decreased ear infections, decreased infections of any kind in babies. Decreased chance of breast cancer for women later on in life is one that a lot of people don’t know about. There are even one or two scientific studies that have shown a few higher IQ points for babies who were breast feed by the time they get to kindergarten. And it’s easier and snugglier and cheaper and so it’s something that you really ought to consider in planning when and how to have children. I think that we have a lot of time left. That is most of the things that I wanted to cover. Are there any questions that anyone would like to ask? Yes. WOMEN’S SERVICES PRESENT THE HEALTHY RELATIONSHIP CONFRENCE
Nombre del curso de posgrado: TÓPICOS DE QUIMIOMETRÍA Director del curso: Dr. Héctor C. Goicoechea (FBCB-UNL) Docentes: Dr. Rafael Lisandro Althaus (FCV-UNL), Dra. María Silvia Cámara (FBCB- UNL), Dra. María Julia Culzoni (FBCB-UNL) y Dra. Luciana Vera Candioti (FBCB- UNL). Objetivos: El objetivo del presente curso de postgrado es brindar a los participantes aprendizajes si