Photo by Omar Lopez via Unsplash
It was Jan. 6 when Richmond resident Nicole Brenner gave birth to her son, William Ross Grogg V, at Henrico Doctors’ Hospital. Her husband, Ross, was with her, and her longtime OB/GYN, Dr. Siobhan Dunnavant, delivered the baby. William is an extraordinary boy: He was 1 pound, 7 ounces at birth, and entered the world at 23 weeks of gestation, or five months before his May 5 due date.
“It was a total surprise,” Brenner says. “Everything was completely normal until I was admitted to the hospital eight days before he was born.”
Brenner was admitted because the placenta was threatening to separate from the womb prematurely, a condition known as a placental abruption.
Babies are considered premature when they are born before 37 weeks of gestation, according to the U.S. Centers for Disease Control and Prevention. About 10% of births are considered premature each year in the United States by that measure. Infants born at 22 weeks have a 25% to 50% survival rate, according to a 2019 article in the journal Pediatrics.
Henrico Doctors’ Hospital has a do-not-resuscitate policy for infants born before 23 weeks, so Brenner held on for a week, and William was born at 23 weeks exactly. After heroic effort, there was still a lot of uncertainty. Brain bleeds, organ infections and premature lungs are all mortal threats to a baby born so early. But after three months, William was released. Now he lives at home with his parents, as healthy as he can be.
“His 3-year-old sister might be the happiest one to have him here," Brenner says, then laughs. “When we told her that she couldn't see him in the hospital [due to COVID], she said she was going to get her own car and see for herself.”
For people who choose to have children, medicine has proved particularly effective in improving the odds of survival for an infant born prematurely. “We have a lot of the same technology that we had 20 years ago,” says Dunnavant, who runs her own practice, OB/GYN Associates. “But now it's much more sophisticated, and much less invasive.
One of the most significant changes in caring for premature babies is the way that lung immaturity is treated, as well as improvements in ventilator technology for early babies, Dunnavant says. “There's also new information about how to prevent brain injuries, for instance, using infusions of magnesium sulfate to prevent brain hemorrhage. Medicine is always learning.”
Such technological advancements in neonatal medicine have made a striking difference for many parents across the commonwealth and the world at large in recent years. Yet, even as more prematurely born babies are surviving, there’s been a steady decline in the birth rate in the United States. At its peak in the 1950s, a woman could expect, on average, to bring four children into the world. By 2010, that number had halved, to two. It has continued to fall, with the average in the U.S. now at 1.73 children per woman, an all-time low.
Dunnavant says that she knows many couples who decided not to try for children during the pandemic. “I'd hear people tell me, ‘Anyone who spends all of their time locked inside with their children is not going to try and make another one right now,’ ” she says, laughing. But the trend goes beyond the past 15 months or so; Dunnavant suggests a change in culture may be the reason.
“Once, people got married to build a home and have children,” she says. “Now, a lot of people want to travel and live their lives first. When I got married, the average age for a first-time mother was 23. Now it's 27. They do things differently now than they used to.”
Dr. Erika Johnston-MacAnanny (right) says that in vitro fertilization is becoming a safer and more successful option for those seeking to become pregnant. (Photo by Monica Escamilla)
Advances in Fertility
As with technology dealing with premature births, treatments for people contending with fertility issues have also continued to improve.
For those who can't seem to get pregnant in the first place, in vitro fertilization (IVF) is becoming a safer and more successful option. Dr. Erika Johnston-MacAnanny, a reproductive endocrinologist and medical director of Shady Grove Fertility, says that this is the technology that's changed the most in recent decades.
“There have been a couple substantial accomplishments in IVF research,” Johnston says. “There are better success rates, and as a result, a lower multiple birth rate.” Once, in vitro fertilizations were famous for producing twins and triplets, as multiple fertilized embryos would be inserted into the uterus. Now, because of advancements in genetic screening, this is less common.
In vitro fertilization is a process in which eggs and sperm are mixed in a lab setting to create an embryo, which is grown for five days in a lab. “We try to mimic the conditions present inside a woman's body,” Johnston says. “Everything counts: temperature, oxygen percentage, vibrations. Each one we understand more as time moves forward.”
At the turn of this century, these conditions could only be successfully modulated for three days, at which point the genes would be screened to determine which embryos were the healthiest. Now, embryos can be grown in the lab for five days, and the gene screenings are much more in-depth and accurate. Johnston says the two-day difference is exponential, comparing it to running a marathon instead of a 5K.
Other newer technologies include the ability to preserve eggs for later use. Sperm-freezing has been an understood practice for decades, but eggs, which have a high-water content, could not survive a deep freeze until recently. In a culture where women are choosing to start families later in life, this technology — called oocyte vitrification — is becoming crucial.
“Particularly this last year, there's been an increase in egg vitrification,” Johnston says. “We've learned a lot in the past few years about stabilizing and dehydrating eggs, and it's proven to be very successful.”
Barbara E. Kahn, a male infertility specialist at Virginia Urology, stresses that fertility is not just a feminine issue. “I'd argue that, in the case of a challenge with fertility, the man should be evaluated right away, at the same time as the woman,” she says. “Statistically, they contribute to 50% of the problem.”
A male evaluation consists of two semen analyses to look at quantity and quality. There are different solutions to different potential problems. Low testosterone, for example, might be treated with a supplement. More sensitive issues might require surgery.
“There are a lot of microsurgical procedures done now that were not done 10 to 20 years ago,” Kahn says. One of these, called microdissection testicular sperm extraction (or microTESE), was developed in 1998. The process harvests sperm directly from the testes for in vitro fertilization.
“Before microTESE, sperm retrieval rates were around 20%,” she explains. “Now, those rates are at 60%. There are also less complications, and less pain.” Other advancements include microsurgery to reverse vasectomies.
Johnston says that often, she tells clients to optimize their own health before wondering if something is amiss down below. “Toxic habits are not good for fertility in general,” she says. “We encourage all of our patients to be in routine gynecological care. They should also maintain a normal BMI and eliminate alcohol, tobacco and drug use.”
(From left) David Graff, embryology laboratory supervisor, with Dr. Erika Johnston-MacAnanny (Photo by Monica Escamilla)
Testing and Taking Control
Another modern innovation is prescreening. Genetic tests can determine if partners are silent carriers of 183 different diseases and autoimmune disorders; the result of pregnancy between two people with recessive genes for a deadly disease is often tragic. The solution, says Johnston, is in vitro fertilization, where another genetic test can determine which embryos will be affected.
“When I started my practice, I'd meet couples who had lost a child due to a fatal disease and wanted to avoid facing this trauma again,” she recounts.
As an OB/GYN, Dunnavant often treats the same women over the course of their lives — now, she even treats women she once helped to deliver.
“The advice I usually give is how conception happens,” she says. “You have to anticipate ovulation. You have to have sperm waiting for the egg when it pops loose. Knowing how to control these variables yourself is very empowering.
“I also want to set realistic expectations — it can take up to a year to get pregnant. In this modern society of immediate gratification, that can be stressful. Women love to know: If this doesn't work, what's next?
“Well, it's not behind a dark curtain. If this doesn't work, we'll do a fertility evaluation, to see if the tubes in the uterus are open. We'll check to see if she's ovulating, to see if she has a thyroid disorder. We'll do a semen analysis. There's an evidence-based set of guidelines that we follow to make sure everybody can get pregnant and have a healthy pregnancy.”
