A Little Bit Pregnant — A Primer

So you’ve peed on a stick and seen two lines or a + or a dubiously-scientific “2-3 weeks pregnant” note on an insane piece of instant electronic waste (whyyyyyyy did we manufacture and dispose of a battery for this).

Are you pregnant?

Trigger warning.

This pregnancy and labor book has got to be joking. What kind of nonsense is this.


Note: I sound pretty technical in here which is a bit silly since most of this is gleaned from second-hand anecdotal experience in all my online forums, and maybe double checked on Wikipedia. It’s likely there’s an actual error, or that terminology is different in other places.

What causes a positive home pregnancy test? Two things: 1) an error in the test, or 2) the presence of hCG in your urine, usually the amount present around 10 days after you ovulate*.

* Fun fact: due to the Hook effect, too-high a concentration of hCG will actually not set off a home test! The phenomenon where women don’t know they are pregnant can be exacerbated by them taking a home test later in pregnancy and it being negative because their hormone levels are too high.

Tests are very accurate these days. Of the very rare “false positives”, many of these are errors in reading the test, from reading the results outside the valid testing window of time, or reading an extremely faint shadow (an evap line) as a positive line (which usually has color to it). Also, occasionally there are bad batches of tests. And more of the “false positives” or “I must have read the test wrong” cases are early miscarriages, sometimes called chemical pregnancies or biochemical pregnancies (to distinguish from a clinical miscarriage, which involves having confirmed a developing pregnancy on ultrasound before the loss).

What causes hCG in your urine? The three ways I know are: you were administered hCG as part of treatment; the presence of Products of Conception* having implanted** in your uterus; or rarely, another biological process, like at least one kind of cancer.

* Why a euphemism here? We’re going to get into this; it’s basically the reason for this post

** Implantation is a term commonly misused by those with a passing knowledge of reproductive technologies. Implantation as I’ve always heard it used “in the biz” is something you cannot control — a fertilized egg (it’s not even an embryo yet) managing to latch on. The process that IS controlled where fertilized eggs (often colloquially called embryos even though they’re not at that stage yet) are reintroduced to the uterus is more accurately called “a transfer” and inaccurately but usually called “an embryo transfer”.

Transfers only happen in assisted reproductive technologies and don’t necessarily result in implantation. Implantation is the step the fertilized egg hopefully makes on its own either after any unassisted attempt at conception or any ART.

(Transfers also put us in the absolutely agonizing realm of knowing that a dividing fertilized egg is present (something usually unknowable) without knowing if it will latch on. Are we pregnant in this case? We’re more pregnant than if we didn’t know, but we still don’t have any hCG because it’s still not implanted.)

So, you have a positive test and we’re assuming it’s because of the implantation of Products of Conception and not cancer or traces of meds from your ART cycle. Why have this term and not call it an embryo yet? The reasons might horrify you.

When I think of whether a pregnancy is “really real” I tend to think of it more as passing a series of hurdles rather than a goal you reach. First hurdle is either a missed period or a positive test at home, depending on how sensitive of tests you’re using. If you’re in the care of a clinic they do a quantitative blood test around now which gives them a better view of how “strong” the pregnancy is instead of just yes/no on the presence of the right hormone.

Depending on standards where you live there are then some number of ultrasounds. At each one they are looking for something that tells them things are progressing, and if you have no idea of how pregnant you might be or you are in the care of a clinic, you might be starting very early. Is there a gestational sac very early? A “fetal pole” visible shortly after that? A heartbeat after that? At subsequent scans, if you opt for them, they start checking general anatomy for general development and watch for physical signs of conditions which would allow the pregnancy to be carried to term but would not allow the baby to live outside the womb, and of course we hope for a heartbeat at each of those too. Optionally you might sample the baby’s DNA in one of a few different ways to look for conditions which would show up in their genes (but some congenital defects do not).

First thing that can be detected as wrong is if the embryo (technically still a fertilized egg) implants not in the uterus: in a tube or even outside a tube. There is no widely available procedure to “move” it (although I remember a time public consciousness thought there was) and termination is absolutely necessary to save the life of the person carrying it.

Next, do we actually see a fetal pole and then embryo? Sperm must have met egg but for whatever reason, you don’t even have an embryo in there — only an empty gestational sac. Or you see a fetal pole but never see a heartbeat.

In one terrifying twist, a molar pregnancy, the Products of Conception start growing out of control, and have to be treated as a very serious condition, with termination required AND more pregnancies put on hold until it’s confirmed no small amounts remain to grow out of control again, basically like a tumor. If it spreads it is literally cancer. Almost unbelievably, this cruel twist of fate can even coexist with a heartbeat, in a partial molar pregnancy; the pregnancy is not salvageable regardless of the embryo’s apparent state.

And of course, sometimes you see a heartbeat on one scan, and none on a future one. This can happen even without any physical symptoms in between, in a “missed miscarriage”.

When we’ve seen Products of Conception implant in the uterus and then miss a milestone doctors usually assume that we “simply” lost the genetic die roll. In the case of a series of miscarriages, or miscarriages after fertilized eggs had tested genetically normal in an IVF cycle which optioned this extra screening, we hope a reason can be found, but we’re at a stage in the science where one rarely is. We just don’t have all the knowledge yet.

So when I see two lines on a test, even if my period never comes, I don’t think of it as “I’m going to have a baby”. I hope that what’s in there has all the right pieces, and that I’m lucky enough that they grow right and no cruel randomness strikes.

But it takes me a long, long time to think “there’s a baby in there”. And I hate, HATE it when people use “pregnant” as the ultimate binary thing. “Saying you are [partly something] is ridiculous, that’s like saying you are a little pregnant” SHUT UP

Post script: Does it help to keep this emotional distance? Knowing what I know now, personally, just me, I would be more heartbroken the further down the list of milestones I got before a loss, and therefore sort of less heartbroken the earlier up the list. Knowing there *never was* an embryo to speak of would feel different to me than seeing a heartbeat and then losing the pregnancy. But that’s no way to comfort people and is a dubious way to talk about it ahead of time too. Some people have no knowledge of all this uncertainty and celebrate for those two blue lines and if tragedy strikes them, they are experiencing a real loss and real grieving of what they *thought* they had, no matter what they actually had.

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