sperm analysis

Recent studies have revealed that male infertility accounts for more than half of the fertility issues experienced by couples trying to conceive. Therefore, if you and your partner have been trying to get pregnant for over a year without success, sperm analysis may prove useful in identifying the issue.

Understandably, it can be daunting going for a fertility check-up. So, to help ease your worries, below you’ll discover everything you need to know about sperm analysis and the type of issues it looks out for.

What is the purpose of sperm analysis?

There are numerous reasons a sperm analysis may be provided, but it’s most commonly carried out for males experiencing fertility issues. It’s estimated that around 2% of men experience problems with their sperm including a low sperm count, poor mobility and issues with the size and shape of the sperm.

A sperm analysis is used to identify whether any of these problems are contributing to a couple’s difficulty in conceiving.

What type of things does it look out for?

Sperm analysis will assess the amount of sperm contained within every 1 millimetre of semen, its ability to move correctly, and its shape and size. From the results, it’s possible to establish whether the man’s sperm is the cause of a couple’s fertility issues.

Collecting a sperm sample at home

While sperm samples may sometimes be collected within the fertility clinic or doctors, patients may be required to collect a sample at home. If you do need to collect a sample at home, you’ll need to ensure it is kept at room temperature and delivered to the clinic shortly afterwards.

You may be required to follow a few guidelines prior to collecting the sample too. For example, you may need to avoid masturbating or having sex for a few days prior to the test. You’ll also need to avoid drinking caffeine and alcohol, as well as avoid taking marijuana before the test.

If you’re taking any medications or supplements, you’ll need to tell the specialist before giving your sample. Finally, if you’re feeling unwell or overly stressed, you’ll also want to avoid giving a sample until you’re better.

For most accurate results, you may need to provide two to three sperm samples in two-week intervals. This is because your sperm profile can actually fluctuate on a daily basis, so an average may need to be taken from a few separate samples.

What if you have abnormal results?

If your sperm analysis samples come back as abnormal, it doesn’t mean you are permanently infertile. Instead, it simply highlights potential problems which could be causing your fertility issues.

After abnormal results come back, you’ll usually need to undergo further testing to establish the exact cause of the problem. Then, once that has been identified, treatment will be suggested to resolve the fertility issues present.

Overall, it’s understandable to be apprehensive about undergoing a semen analysis. However, the process is quick, painless and can help to provide peace of mind, as well as set you on the right treatment path to resolve any fertility issues that you may have.

early menopause

A new study has revealed that the onset of early menopause isn’t related to the amount of exercise you do. The study, published within the Human Reproduction journal, is the largest of its kind to answer the question of whether or not physical activity is a risk factor for the menopause.

Here, we’ll look at what the study revealed and what factors are known to link to early menopause.

Understanding the study

The study, carried out by the University of Massachusetts, analysed the data of a staggering 107,275 women. It revealed that there was no correlation between natural early menopause and the level of exercise conducted.

Previous studies have shown conflicting results, with some suggesting exercise may be linked o the menopause, and others suggesting it doesn’t. However, all previous studies have been carried out on a much smaller scale. So, this latest study provides the most compelling results, taking into account the sheer number of women analysed.

The data was taken from female nurses in America who joined the Nurses’ Health Study II in 1989 and it followed them through to 2011. By the end of the study, 2786 women had experienced the early menopause before turning 45. After assessing their physical activity levels, it was determined that exercise didn’t seem to have any impact on the age the women entered the early menopause.

What the study did reveal, is that the risk of early menopause is typically determined by environmental factors. For example, a higher intake of Vitamin D and Calcium, lowers the risk, while being underweight and smoking increased the risk.

Researchers stress exercise is still important

While the amount of exercise you do won’t impact your chances of going through the early menopause, the researchers still stress that regular physical activity is important. This is because keeping active greatly reduces the risk of numerous diseases.

Once you do enter into the menopause, your risk of developing serious illnesses such as heart disease does increase. Exercise is known to reduce the risk of these conditions, so it isn’t something which should be ignored. It’s also generally better for your overall health if you exercise regularly too.

What factors can trigger early menopause?

So, now it’s been established that lower levels of exercise don’t appear to trigger early menopause, what factors could cause its onset? There are several known causes which could lead to early menopause including:

  • Genetics
  • Autoimmune disease
  • Lifestyle factors

If your mother or grandmother went through early menopause, it is more likely that you will too. However, genetics isn’t the only potential trigger. If you suffer from autoimmune diseases such as rheumatoid arthritis or thyroid disease, your risk also increases. Then there are lifestyle factors such as smoking and body mass index which can contribute to early menopause.

As you can see, there are several known risk factors associated with early menopause. However, thanks to this latest study, exercise levels can be ruled out as a potential link. Just remember, that doesn’t mean you shouldn’t exercise as it’s still important for overall general health and it could even help to reduce the symptoms of early menopause if it does occur.

male fertility test

Androvia LifeSciences has developed a brand-new test which is capable of measuring male infertility. Up until now, current methods have been unable to explain over half of male infertility cases. So, could this new test prove evolutionary in the detection of male fertility troubles?

Here, we’ll look at how the new test works and why it could change the male infertility sector forever.

What is the new male fertility test?

The new fertility health check, known as the Cap-Score, is designed to analyse the changes within a sperm cell which allow it to fertilise the egg. This provides much more advanced results compared to current tests and helps experts to more accurately diagnose male fertility issues.

Prolific doctor Alexander Travis, who was responsible for developing the test, was the first to recognise the ganglioside GM1 as a useful biomarker for the capacitation of sperm cells. Previous studies had already shown that the Cap-Score could differentiate between samples from men seeking help with fertility and fertile men. It also managed to detect between males who failed at intrauterine insemination and those who succeeded.

Cap-Score male fertility test study proves promising

The most recent Cap-Score study collected 208 semen samples from men who were undergoing medical evaluations regarding their fertility. As well as carrying out traditional semen analysis, the scientists tested the samples, arranging them into groups dependent upon their CAP-Score. Out of the 208 men, 91 reported clinical outcomes.

It was discovered through the study, that men who had a normal score, were 2.78 more likely to succeed at pregnancy than those with a low score. They also had a 4.23 increased chance of success for their first attempt using IUI. More interestingly, it discovered there was no relationship found between male fertility and factors such as sperm concentration and mobility which are typically assessed in traditional methods.

That wasn’t the end of the research either. The researchers then collected additional clinical outcomes and Cap-Scores from an additional five urology and fertility clinics. They used data from a further 124 men to develop a curve which translated a Cap-Score into the likelihood of achieving a pregnancy.

How does it compare to current testing?

The new Cap-Score testing is much more accurate at identifying the likelihood of achieving pregnancy than any current tests on the market. It is still designed to be used alongside traditional testing, but it offers a more definitive and clearer picture of a male’s fertility issues.

The researchers are hoping these results will enable specialists to introduce the new testing to personalise a patient’s journey into fatherhood. More targeted treatments will be able to be provided, saving couples time, money and emotional distress. Urologists are also going to be using the method to assess how different treatment plans, such as surgery and nutritional supplements, will affect male fertility.

The CAP-Score method has already started to be implanted into fertility clinics across America. However, it’s likely to take longer to reach across the pond. For the time being, traditional sperm analysis tests will continue to be used to identify male infertility.

menopause symptoms

There are a lot of unpleasant side effects associated with the menopause, and anxiety and forgetfulness are just two of them. These menopause symptoms have long been affecting menopausal women and they can be really difficult to deal with.

Now, a new study carried out on rats has revealed that these nasty side effects could be caused by low oestrogen levels. So, could this aid in the development of new menopausal treatments? Here, you’ll discover more about the study and how these symptoms can be treated if you are menopausal.

What did the menopause study reveal?

Researchers from a Brazilian university and Georgetown University in the US discovered the link between low oestrogen and menopausal anxiety and forgetfulness. The study involved female rats which didn’t have ovaries, and it assessed anxiety and short-term recognition through standardised testing.

It showed that the menopausal rats had a higher level of anxiety and reduced recognition compared to non-menopausal rats of the same age. This suggests that hormonal imbalances do contribute to the anxiety and forgetfulness menopausal women experience.

Memory problems worse during the lead up to the menopause

Other studies carried out over the years have also revealed a link between memory loss and the menopause. One study revealed that those who were in the early perimenopausal stage, specifically within the year leading up to the menopause, had more issues with memory and forgetfulness than at any other time.

Interestingly, studies have also shown that these memory problems do tend to improve over time. It was long believed hormones were the culprit, but until this recent study, there was no real confirmation that the drop in oestrogen was linked to the memory loss experienced.

Can these menopause symptoms be prevented?

It may not be possible to fully prevent symptoms such as anxiety and forgetfulness, but there are some things you can do to reduce the risk. Ensuring you eat a balanced diet, for example, can help to boost brain function and regulate the mood.

Ensuring you’re getting plenty of rest is also key. As you enter towards the menopause, you may find you have extra difficulty sleeping. So, it’s a good idea to ramp up your exercise and focus more on lowering your stress levels.

How to treat menopausal anxiety and forgetfulness

For many women, the memory loss and anxiety they experience due to the menopause is very mild. However, if it does start to affect your everyday life, there are things you can do. Pay a visit to your doctor and they may suggest starting menopausal hormone therapy. This will help to replace the oestrogen lost, which should naturally improve the symptoms.

However, it’s important to remember that long-term use of oestrogen treatments can increase your risk of other illnesses including cardiovascular disease and breast cancer. The risk is small, but it’s still worth being aware of the potential risks involved.

Overall, this recent study does confirm the anxiety and forgetfulness experienced during the menopause, is down to low oestrogen levels. While you may not be able to prevent these menopause symptoms, there are ways to treat it and the majority of women do see improvements over time.

Baby Monitoring Method

A UK university has developed a new method for checking baby’s heartbeat in the womb. Designed to take away the stress and provide a more accurate result, this new method can even be used in the patient’s home, rather than having to go into hospital.

So, what is this new method and how will it compare to traditional testing? Here, you’ll discover everything you need to know.

Understanding this new baby monitoring method

The new baby monitoring method was developed by Dr Elizabeth Rendon-Morales at the University of Sussex. The sensor can potentially be used to detect congenital heart-related conditions, as well as help to identify a need for medical intervention during pregnancy.

What’s most impressive is the sensor can be used at home, eliminating the need for expectant mothers to actually visit a hospital. It’s been described as the biggest development within the sector in 40 years.

With the use of Electric Potential Sensing (EPS) technology, Rendon-Morales created the electrometer amplifier prototype. It works by being placed onto the skin on the abdomen, allowing for non-invasive utero-foetal electrocardiogram monitoring.

It’s a huge step forward for home-device monitoring and can provide peace of mind through fast results. This will also benefit health service providers, allowing for resource optimisation.

How does it compare to traditional baby monitoring method?

The traditional method of monitoring the baby’s heartbeat is the classic ultrasound scan. While this is also a non-invasive method, many pregnant women do find the scan both stressful and uncomfortable.

There is also the chance that health service providers will not be able to differentiate the baby’s heartbeat from the mother’s heartbeat with ultrasound scanning. This new test, on the other hand, successfully isolates the baby’s heartbeat for more accurate results.

With the traditional tests, a gel also needs to be applied to the abdomen, whereas with this new test, no gel is required. This also makes the method more accurate as the gel can sometimes produce an inaccurate reading.

The hope is that the new technology will be able to help health care practitioners determine earlier on whether a baby needs to be delivered quickly. It will be able to accurately monitor when the baby’s heartbeat drops and doesn’t recover quickly.

What pregnancy scans are currently available?

While the new testing isn’t currently available, existing tests are still typically very accurate. As well as the standard testing available on the NHS, women can also choose to have private scans throughout the pregnancy. These scans include:

Early pregnancy scan
Reassurance scans
Viability scan

The early pregnancy scan can be carried out after six weeks into the pregnancy and it’s largely used on women with a high-risk pregnancy. A reassurance scan also monitors the baby’s heartbeat to double check that everything is going as planned. Then finally there’s the viability scan which can be provided to couple’s who have experienced fertility issues and miscarriages in the past. This looks into whether the pregnancy is developing as it should.

Overall, this new sensor test is going to revolutionise the baby monitoring method sector. Being able to monitor the baby’s heartbeat in the home will really help to ease the stress and discomfort felt during traditional testing.

placenta complications

The Royal College of Obstetricians and Gynaecologists (RCOG), has updated its guidelines to suggest that early diagnosis is essential for reducing placenta complications.

Conditions such as placenta accrete and placenta praevia are often only diagnosed upon delivery, increasing the risk of neonatal and maternal mortality and morbidity. Both conditions have become a lot more common in recent years, highlighting the need for early detection and treatment.

Here, we’ll look at why placenta complications are becoming more prevalent and the new guidelines that have been introduced.

Why are placenta complications on the rise?

Placenta complications are said to be on the rise due to an increase in both the use of assisted reproductivity technology and caesarean births. Many women are unaware of the risks a caesarean birth presents in terms of placenta complications. However, with each subsequent caesarean procedure, the risks of both placenta praevia and placenta accrete are increased further.

The new guidelines introduced by RCOG highlight the need for healthcare professionals to inform their patients of the risks involved with both fertility treatment such as IVF and caesarean births.

Understanding the complications

Placenta praevia occurs when the placenta attaches itself to the lower womb. It can potentially end up covering the entire neck of the womb and cause heavy bleeding throughout the pregnancy or during labour. It is typically checked for at around 20-weeks into the pregnancy, and if detected a caesarean birth is often recommended.

Placenta accrete is a lot less common and the risk of developing the condition is increased with each caesarean birth. It can affect anything from 1 in 300 pregnant women, to 1 in 2000, depending upon prior caesarean history. With this condition, the placenta either invades or sticks to the womb muscle, as well as nearby organs such as the bladder. If the condition isn’t picked up until the birth, heavy bleeding can occur leading to an emergency hysterectomy. If it is picked up prior to the birth, the healthcare provider may recommend giving birth earlier.

New guidelines also released to address Vasa praevia

The guidelines regarding Vasa praevia have also been updated. This rarer condition occurs in between 1 in 1200 up to 1 in 5000 pregnancies. The blood vessels leading from the placenta to baby pass extremely closely to the cervix. This can cause them to tear once the waters have broken. If this occurs, it can pose a high risk to the baby.

Like placenta praevia, this condition could be detected at the routine 20-week scan. Known risk factors for the condition include abnormal umbilical cord or placenta development, multiple pregnancies and a low-lying placenta. If the condition is diagnosed, a planned caesarean is usually advised between weeks 34-36. If it isn’t detected prior to the birth, an emergency caesarean will usually be carried out.

As placenta complications can be dangerous to both mother and baby, early detection is crucial. These new guidelines will help healthcare providers to better discuss the risks and options available to patients considering a caesarean birth and work towards diagnosing the conditions early.

IVF success

A new machine has been developed could be used to boost the IVF success rate up to a staggering 85%. Capable of identifying embryos which are more likely to lead to a live birth, the machine could potentially spare couples the distress and agony of stillbirths and miscarriages commonly experienced during the fertility treatment.

Here, we’ll look into this exciting development and whether artificial intelligence could prove the key to boosting IVF success rates.

Knowing which embryos to use is key to IVF success

It is estimated that approximately half of the losses experienced within early pregnancy are down to abnormal embryos. Therefore, in order to boost success rates, identifying the healthiest, normal embryos to use in IVF is crucial.

While time-lapse technology has been successfully used in IVF since 2010, it doesn’t have the same accuracy and scope as artificial intelligence. So, the development of this new machine is a great step forward and promises to improve the success rate of current technologies.

Understanding the study

The AI technology was jointly developed by the Cornell University in New York and the Imperial College London. They nicknamed the machine ‘The Beast’ and initially gave it 700 embryo images, telling the machine which ones resulted in a live birth and which led to a stillbirth or miscarriage. This helped it to identify subtle changes which could point to a potential problem.

During the trial, 328 embryo images were tested in the machine that had already been implanted into patients. Scientists asked the machine to identify which embryos would lead to a live birth and it correctly predicted 280.

What makes this new machine so impressive, is that it continues to learn as it goes along. From the data provided, it learns more about which embryos are the best to use, making it much more accurate in future.

However, experts are keen to point out that embryo health is approximately 80% to 90% of the reason a pregnancy could fail. There are other factors which could contribute too, meaning the results of the machine will never truly be 100% accurate. However, it certainly boosts the chances of success and significantly reduces the risks of a miscarriage and stillbirth.

Results of embryo viability study prove promising for future treatment

The results of the study have proven both exciting and revolutionary. The ability to increase success rates by as much as 85% is fantastic. What’s more, experts claim the technology could be used in mainstream fertility treatment within just five years.

Many fertility clinics are already using time-lapse imaging, so they’ll be able to start using the machine as soon as it becomes available. The images simply need to be sent digitally to the machine, which will then provide feedback. So, there’s no real cost of using it as everything can be done online. This makes it an especially great option to be used on the NHS.

Overall, the risk of miscarriage and stillbirths is prevalent in IVF treatment. However, this new artificial technology could soon drastically reduce the risks, enabling the majority of women to be spared the devastation of losing the baby.

menopause tests

The menopause is something no woman likes to think about. While it typically occurs in women over the age of 50, it can also present early for many patients, sometimes even in their early 20s.

Prior to entering the menopause, it’s common for women to experience symptoms, sometimes many years before the actual menopause kicks in. This is referred to as perimenopause and it can wreak havoc on the body. So, how can you tell if you’re going through the menopause? Here, you’ll discover everything you need to know.

Common changes which occur in the lead up to the menopause

In the months or years leading up to the menopause, you may start to experience some changes within the body. These include:

  • Hot flashes
  • Irregular periods
  • Insomnia
  • Mood swings
  • Forgetfulness

Some of the menopause symptoms above can pinpoint other issues, which is why many women miss the initial signs of perimenopause.

Hot flushes are one of the most common menopause symptoms, though not every woman will experience them. You’ll basically start to feel really hot very suddenly, causing the skin to flush and your heart rate to quicken. This hot spell disappears just as quickly as it began, and they tend to be most common at night time.

By far one of the most tell-tale signs you’re heading towards the menopause, is when your periods start to become more irregular. They could become heavier or lighter and last for longer or shorter periods of time. The irregularity of your periods can make it difficult to get pregnant. It’s worth noting that some medications and treatments can cause your periods to become irregular, so it is worth seeking advice from a doctor before dismissing it as the menopause.

What menopause tests are available?

If you are concerned you are heading towards the change of life, there are menopause tests which can be done to confirm or dismiss your concern. Saliva tests used to be provided, but these typically have very low accuracy rates. So, healthcare professionals tend to use follicle-stimulating hormone testing.

Follicle stimulating hormone testing is a blood test which identifies the FSH levels within the blood. However, there are many things which can affect the outcome of this menopause test. During perimenopause, oestrogen and FSH levels tend to fluctuate, making it difficult to achieve accurate results. Unless the woman is actively in menopause, the FSH blood test isn’t going to accurately identify the issue.

Seeking treatment for menopausal symptoms

The best way to determine whether or not you are heading towards the menopause, is to have a full health check. This includes looking over your medical history and menopausal history, alongside the signs and symptoms you’re experiencing.

Menopause itself is diagnosed when you have gone 12 months without a period. However, any perimenopausal symptoms you do experience should be checked over by a doctor to ensure it isn’t down to any other medical condition. Changes in periods should especially be assessed professionally as they can potentially point to a more sinister problem.

As you can see, it can be difficult to diagnose perimenopause. However, the symptoms above can be a clear sign you’re heading towards the menopause. Be sure to have any symptoms checked out as soon as you can and arrange menopause tests as there are treatments available which can help you to manage the side effects.

fertility health check

If you’ve been struggling to get pregnant, a fertility health check can prove invaluable at diagnosing the issue. While it’s common for couples to try for at least a year before they conceive, if you’re still trying to get pregnant after a year it could be a sign that something is amiss.

Going for a fertility health check can be daunting, especially if you have no idea what to expect. However, the process isn’t as gruelling as you might think and if a problem is detected, there are numerous treatments on offer to help increase your chances of conception.

Below, you’ll discover what to expect from a fertility health check to help ease your concerns. However, it is worth keeping in mind that health checks are carried out dependent upon personal circumstances. Therefore, some of the tests mentioned below may not relate to you.

Fertility health check: going over your medical history

The first thing that will be addressed at your fertility health check is your medical history. This helps the specialist to identify any medical issues, both in the past and present, which could be impacting your fertility. Some conditions such as sexually transmitted diseases, thyroid disease and diabetes can contribute to issues with fertility.

You will also discuss any medications you currently take, along with the frequency and times that you usually have intercourse. Understandably, many patients find it embarrassing to open up about their sex life, but the specialist will help to make you feel comfortable and you can guarantee there’s nothing they haven’t heard before.

Fertility health check: basic fertility tests

Once you and your partner have had a chat about your medical history, some basic tests will need to be carried out. Men will be required to provide a sperm sample and undergo a blood test to check hormone levels. The sperm sample is analysed to detect the number, motility and shape of the sperm.

The woman will start by undergoing an ultrasound to identify the number of resting eggs and assess the uterus. A blood test will also be carried out to identify her reproductive hormone levels. These basic tests will then either identify the cause of the issues, or further tests may be required.

Fertility health check: additional fertility health tests which may be required

If an initial cause cannot be identified or based upon your medical history, you may be required to undergo the following additional tests:

  • Blood tests
  • Cervical mucus test
  • Laparoscopy
  • Endometrial biopsy
  • Hysterosalpingogram (HSG)

Blood tests may be required to test the thyroid levels, the follicle stimulating hormone and Oestradiol levels. A Cervical Mucus test may be carried out to determine how well sperm survive in the woman’s body after intercourse. A laparoscopy is a surgical procedure which is used to examine the fallopian tubes, ovaries and uterus, while an endometrial biopsy looks at whether there is a hormonal imbalance preventing the woman from sustaining a pregnancy. Finally, a Hysterosalpingogram is an x-ray procedure which can detect whether the fallopian tube passages are blocked.

These are just some of the additional tests which could be required. However, most are minimally invasive, and the fertility specialist will help to put your mind at ease every step of the way.

Overall, while it may be daunting heading to a fertility health check-up, there really is nothing to worry about. It can help you to get to the bottom of your fertility troubles and put you on the right treatment path to increase your chances of conception.

Non-invasive prenatal test

The NHS is set to offer a new non-invasive prenatal test (NIPT) which will help with the early identification of genetic abnormalities. Given at just ten weeks into the pregnancy, the simple blood test is also able to identify the sex of the baby. However, experts are calling for the early gender reveal to be banned amidst worries it could be used for gender selection pregnancies.

Here, we’ll look at what the new NIPT involves and why experts are worried about the gender reveal aspect of the test.

What is this pregnancy test used for?

The NIPT is a blood test which was first made available in the UK in 2012. Carried out as early as ten weeks, it is largely used to test baby’s risk of Down’s Syndrome, Patau’s Syndrome and Edward’s Syndrome.

Compared to other existing tests, NIPT is much more accurate and it’s known to present no risk of a miscarriage. A little blood is taken from the arm, in which traces of your baby’s DNA can be found. The DNA is then tested for potential chromosomal abnormalities. Results of the test typically take up to three weeks.

While its ability to detect chromosomal abnormalities is extremely beneficial, the test can also reveal other information about the baby including gender. It is this aspect which experts are hoping to ban.

Gender reveal not considered medically useful

A report recently published by the National Council for Bioethics, recommends against using NIPT for gender reveal purposes, claiming it isn’t medically useful. The worry is that the information could be used as a gender selection process.

For example, in some cultures, there is a preference for baby boys. So, if a woman discovers she is having a baby girl at ten weeks, she could be more inclined to have an abortion and try again for a baby boy. Usually at the 20-week scan, women are much less inclined to have an abortion due to how much their baby has grown. However, at ten weeks, the decision becomes much easier, which is what experts are largely concerned about.

The worry over designer babies

It isn’t just the gender reveal part of the test which worries experts. It can also potentially detect baby’s eye colour and hair colour. So, there is also a risk it could be used as a designer baby tool.

This has caused a great deal of controversy with many arguing that denying women the right to know the sex of their baby does women a disservice. As Clare Murphy from the British Pregnancy Advisory Service explains: “In the circumstances where a woman is under pressure to produce a child of a particular sex the ethical answer is not to deny every pregnant woman the right to find out information about her own pregnancy, but to do our utmost to challenge misogynistic attitudes, ensure gender equality and access to comprehensive women’s support services so that women can make their own choice about their pregnancy free from coercion.”

When is the best time to discover baby’s sex?

The best time to discover the sex of your baby is at your 20-week ultrasound scan. However, if you’re struggling to wait that long, you could undergo a private scan anywhere from 14 weeks. Any earlier than that and baby may not be developed enough to tell the gender.

The fact the NHS is going to offer NIPT to detect for early chromosomal abnormalities is great news; especially for women who are considered to be having a higher risk pregnancy.