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Fertility Awareness and Infertility
Understanding your monthly fertility pattern (days in the
month when you are fertile, days when you are infertile, and
days when fertility is unlikely, but possible) can help you
plan a pregnancy, or avoid pregnancy. But if you already understand
your menstrual cycle and fertility pattern, and are having
problems getting pregnant, there is help and support available.
In 1995, one in 10 U.S. women of reproductive age had a problem
with fertility. If you have a problem with fertility, learn
all you can about you and your partner's health, and your
options for treatments.
The Menstrual Cycle
Being aware of your menstrual cycle and the changes in your
body that happen during this time can be key to helping you
plan a pregnancy, or avoid pregnancy. During the menstrual
cycle (a total average of 28 days), there are two parts: before
ovulation and after ovulation.
Day 1 starts with the first day of your period.
Usually by Day 7, a woman's eggs start to prepare to be fertilized
Between Day 7 and 11, the lining of the uterus (womb) starts
to thicken, waiting for a fertilized egg to implant there.
Around Day 14 (in a 28-day cycle), hormones cause the egg
that is most ripe to be released, a process called ovulation.
The egg travels down the fallopian tube towards the uterus.
If a sperm unites with the egg here, the egg will attach to
the lining of the uterus, and pregnancy occurs.
If the egg is not fertilized, it will break apart.
Around Day 25 when hormone levels drop, it will be shed from
the body with the lining of the uterus as a menstrual period.
The first part of the menstrual cycle is different in every
woman, and even can be different from month-to-month in the
same woman, varying from 13 to 20 days long. This is the most
important part of the cycle to learn about, since this is
when ovulation and pregnancy can occur. After ovulation, every
woman (unless she has a health problem that affects her periods)
will have a period within 14 to 16 days.
Charting Your Fertility Pattern
If you are aware of when you are most fertile, this will
help you plan or prevent a pregnancy. There are three ways
that you can keep track of this time each month:
Basal body temperature method - This involves taking your
basal body temperature (your body's temperature when you're
at rest) every morning before you get out of bed, and recording
it on a chart. You will begin to know your own fertility pattern,
and you can see the changes from month to month. During the
menstrual cycle, your body temperature remains at a somewhat
steady, lower level, and begins to slightly rise with ovulation.
The rise can be a sudden jump or a gradual climb over a few
days. The rise in temperature can't predict exactly when the
egg is released, but your temperature rises between .4 to
.8 degrees Fahrenheit on the day of ovulation. You are most
fertile, and most likely to get pregnant during the two to
three days just before your temperature hits the highest point
(ovulation), and for about 12 to 24 hours after ovulation.
A man's sperm can live for up to three days in your body and
is able to fertilize an egg during that time. So, if you have
unprotected sex several days before ovulation, there is a
chance of becoming pregnant then. Once your temperature spikes
and stays at a higher level for about three days, you can
be sure that ovulation has occurred. Your temperature will
remain at the higher level until your period starts. Basal
body temperature differs slightly from woman to woman, but
anywhere from 96 to 98 degrees orally is normal before ovulation,
and anywhere from 97 to 99 degrees orally after ovulation.
So, any changes that you chart are very small and are in 1/10
degree. You can buy an oral basal body temperature thermometer
or an easy-to-read thermometer, which has the degrees marked
in these small fractions, at a drug store. If you can't find
it easily, ask the pharmacist to help you.
Calendar method - This involves keeping a written record
of each menstrual cycle on a regular calendar. The first day
of your period is Day 1, which you can circle on the calendar.
Continue doing this for eight to 12 months so you know how
many days are in your cycle. The length of your cycle can
vary from month to month, so write down the total number of
days it lasts each time in a list. To find out the first day
when you are most fertile, check your list and find the cycle
with the fewest days. Then subtract 18 from that number. Take
this new number and count ahead that many days on the calendar.
Draw an X through this date. The X marks the first day you're
likely to be fertile. To find out the last day when you are
fertile, subtract 11 days from your longest cycle and draw
an X through this date. This method always should be used
with other fertility awareness methods, especially if your
cycles are not always the same lengths.
Cervical mucus method (also known as the ovulation method)
- This involves being aware of the changes in your cervical
mucus throughout the month. The hormones that control the
menstrual cycle also cause changes in the kind and how much
mucus you have just before and during ovulation. Right after
your period, you usually have a few days when there is no
mucus present or "dry days." As the egg starts to
mature, mucus increases in the vagina, appears at the vaginal
opening, and is usually white or yellow and cloudy and sticky.
The greatest amount of mucus appears just before ovulation,
during the "wet days," when it becomes clear and
slippery, like raw egg whites. Sometimes it can be stretched
apart. This is when you are most fertile. About four days
after the wet days begin, the mucus changes again. There is
now much less and it becomes sticky and cloudy. You might
have a few more dry days before your period returns. You can
describe changes in your mucus on a calendar. Label the days,
"Sticky," "Dry," or "Wet." You
are most fertile at the first sign of wetness after your period,
but maybe also a day or two before wetness begins. This method
is less reliable for women whose mucus pattern is changed
because of breastfeeding, use of oral contraceptives or feminine
hygiene products, having vaginitis, sexually transmitted diseases
(STDs), or surgery on the cervix.
To most accurately track your fertility, it is best to use
a combination of all three methods, which is called the symptothermal
It is not uncommon to have trouble becoming pregnant or experience
infertility. Infertility is defined as not being able to become
pregnant, despite trying for one year, in women under 35,
or after six months in women 35 and over. Pregnancy is the
result of a chain of events. As described in the Fertility
Awareness section, a woman must release an egg from one of
her ovaries (ovulation). The egg must travel through a fallopian
tube toward her uterus. A man's sperm must join with (fertilize)
the egg along the way. The fertilized egg must then become
attached to the inside of the uterus. While this may seem
simple, in fact many things can happen to prevent pregnancy.
Reasons for Infertility
There are many different reasons why a couple might have
infertility. One is age-related. Women today are often delaying
having children until later in life, when they are in their
30s and 40s. A couple of things add to this trend. Birth control
is easy to obtain and use, more women are in the work force,
women are marrying at an older age, the divorce rate remains
high, and married couples are delaying pregnancy until they
are more financially secure. But the older you are, the harder
it is to become pregnant. Women generally have some decrease
in fertility starting in their early 30s. And while many women
in their 30s and 40s have no problems getting pregnant, fertility
especially declines after age 35.
As a woman ages, there are normal changes that occur in her
ovaries and eggs. All women are born with over a million eggs
in their ovaries (all the eggs that they will ever have),
but only have about 300,000 left by puberty. Then of these,
only about 300 eggs will be ovulated during the reproductive
years. Even though menstrual cycles continue to be regular
in a woman's 30s and 40s, the eggs that ovulate each month
are of poorer quality than those from the 20s. It is harder
to get pregnant when the eggs are poorer in quality. Ovarian
reserve is the number and quality of eggs in your ovaries
and how well the ovarian follicles respond to hormones in
your body. As you approach menopause, your ovaries don't respond
as well to your hormones, and in time they may not release
an egg each month. A reduced ovarian reserve is natural as
a woman ages, but young women might have reduced ovarian reserve
due to smoking, a prior surgery on their ovaries, or a family
history of early menopause. Also, as a woman and her eggs
age, if she becomes pregnant, there is a greater chance of
having genetic problems, such as having a baby with Down syndrome.
Embryos formed from eggs in older women also are less likely
to fully develop, a main reason for miscarriage (early pregnancy
Couples also can have fertility problems because of health
problems, in either the woman or the man. Common problems
with a woman's reproductive organs, like uterine fibroids,
endometriosis, and pelvic inflammatory disease can worsen
with age and also affect fertility. These conditions might
cause the fallopian tubes to be blocked, so the egg can't
travel through the tubes into the uterus. Certain lifestyle
choices also can have a negative effect on a woman's fertility,
such as smoking, alcohol use, weighing much more or much less
than an ideal body weight, a lot of strenuous exercise, and
having an eating disorder. Some people also have diseases
or conditions that affect their hormone levels, which can
cause infertility in women and impotence and infertility in
men. Polycystic ovarian syndrome (PCOS) is one such hormonal
condition that affects many women, and is the most common
cause of anovulation, or when a woman rarely or never ovulates.
Another hormonal condition that is a common cause of infertility
is when a woman has a luteal phase defect (LPD). A luteal
phase is the time in the menstrual cycle between ovulation
and the start of the next menstrual period. LPD is a failure
of the uterine lining to be fully prepared for a fertilized
egg to implant there. This happens either because a woman's
body is not producing enough progesterone, or the uterine
lining isn't responding to progesterone levels at some point
in the menstrual cycle. Since pregnancy depends on a fertilized
egg implanting in the uterine lining, LPD can interfere with
a woman getting pregnant and with carrying a pregnancy successfully.
Unlike women, some men remain fertile into their 60s and
70s. But as men age, they might begin to have problems with
the shape and movement of their sperm, and have a slightly
higher risk of sperm gene defects. They also might produce
no sperm, or too few sperm. Lifestyle choices also can affect
the number and quality of a man's sperm. Alcohol and drugs
can temporarily reduce sperm quality. And researchers are
looking at whether environmental toxins, such as pesticides
and lead, also may be to blame for some cases of infertility.
Men also can have other health problems that affect their
sexual and reproductive function. These can include sexually
transmitted diseases (STDs), diabetes, surgery on the prostate
gland, or a severe testicle injury or problem. If you or your
partner has a problem with sexual function or libido, don't
delay seeing your health care provider for help.
You should talk to your health care provider about your fertility
are under 35 and, after a year of frequent sex without birth
control, you are having problems getting pregnant, or
are 35 or over and, after six months of frequent sex without
birth control, you are having problems getting pregnant, or
believe you or your partner might have fertility problems
in the future (even before you begin trying to get pregnant).
Your health care provider can refer you to a fertility specialist,
a doctor who focuses in treating infertility. This doctor
can recommend treatments such as drugs, surgery, or assisted
reproductive technology. Don't delay seeing your health care
provider because age also affects the success rates of these
The first step to treat infertility is to see a health care
provider for a fertility evaluation. He or she will test both
the woman and the man, to find out where the problem is. Testing
on the man focuses on the number and health of his sperm.
The lab will look at a sample of his sperm under a microscope
to check sperm number, shape, and movement. Blood tests also
can be done to check hormone levels. More tests might be needed
to look for infection, or problems with hormones. These tests
an x-ray (to look at his reproductive organs)
a mucus penetrance test (to see if sperm can swim through
a hamster-egg penetrance assay (to see if sperm can go through
hamster egg cells, somewhat showing their power to fertilize
Testing for the woman first looks at whether she is ovulating
each month. This can be done by having her chart changes in
her morning body temperature, by using an FDA-approved home
ovulation test kit (which she can buy at a drug store), or
by looking at her cervical mucus, which changes throughout
her menstrual cycle. Ovulation also can be checked in her
health care provider's office with an ultrasound test of the
ovaries, or simple blood tests that check hormone levels,
like the follicle-stimulating hormone (FSH) test. FSH is produced
by the pituitary gland. In women, it helps control the menstrual
cycle and the production of eggs by the ovaries. The amount
of FSH varies throughout the menstrual cycle and is highest
just before an egg is released. The amounts of FSH and other
hormones (luteinizing hormone, estrogen, and progesterone)
are measured in both a man and a woman to determine why the
couple cannot achieve pregnancy. If the woman is ovulating,
more testing will need to be done. These tests can include:
an hysterosalpingogram (an x-ray to check if the fallopian
tubes are open and to show the shape of the uterus)
a laparoscopy (an exam of the tubes and other female organs
an endometrial biopsy (an exam of a small shred of the uterine
lining to see if monthly changes in it are normal)
Other tests can be done to show whether the sperm and mucus
are interacting in the right way, or if the man or woman is
forming antibodies that are attacking the sperm and stopping
them from getting to the egg.
Drugs and Surgery
Different treatments for infertility are recommended depending
on what the problem is. About 90 percent of cases are treated
with drugs or surgery. Various fertility drugs may be used
for women with ovulation problems. It is important to talk
with your health care provider about the drug to be used.
You should understand the drug's benefits and side effects.
Depending on the type of fertility drug and the dosage of
the drug used, multiple births (such as twins) can occur in
some women. If needed, surgery can be done to repair damage
to a woman's ovaries, fallopian tubes, or uterus. Sometimes
a man has an infertility problem that can be corrected by
Assisted Reproductive Technology (ART)
Assisted reproductive technology (ART) uses special methods
to help infertile couples, and involves handling both the
woman's eggs and the man's sperm. Success rates vary and depend
on many factors. But ART has made it possible for many couples
to have children that otherwise would not have been conceived.
ART can be expensive and time-consuming. Many health insurance
companies do not provide coverage for infertility or provide
only limited coverage. Check your health insurance contract
carefully to learn about what is covered. Also, some states
have laws for infertility insurance coverage. Some of these
include Arkansas, California, Connecticut, Hawaii, Illinois,
Maryland, Massachusetts, Rhode Island, Texas, and West Virginia.
In vitro fertilization (IVF) is a type of ART that is often
used when a woman's fallopian tubes are blocked or when a
man has low sperm counts. A drug is used to stimulate the
ovaries to produce multiple eggs. Once mature, the eggs are
removed and placed in a culture dish with the man's sperm
for fertilization. After about 40 hours, the eggs are examined
to see if they have become fertilized by the sperm and are
dividing into cells. These fertilized eggs (embryos) are then
placed in the woman's uterus, thus bypassing the fallopian
tubes. Gamete intrafallopian transfer (GIFT) is similar to
IVF, but used when the woman has at least one normal fallopian
tube. Three to five eggs are placed in the fallopian tube,
along with the man's sperm, for fertilization inside the woman's
body. Zygote intrafallopian transfer (ZIFT), also called tubal
embryo transfer, combines IVF and GIFT. The eggs retrieved
from the woman's ovaries are fertilized in the lab and placed
in the fallopian tubes rather than the uterus.
ART sometimes involves the use of donor eggs (eggs from another
woman) or previously frozen embryos. Donor eggs may be used
if a woman has impaired ovaries or has a genetic disease that
could be passed on to her baby. And if a woman does not have
any eggs, or her eggs are not of a good enough quality to
produce a pregnancy, she and her partner might want to consider
surrogacy. A surrogate is a woman who agrees to become pregnant
using the man's sperm and her own egg. The child will be genetically
related to the surrogate and the male partner, but the surrogate
will give the baby to the couple at birth.
A gestational carrier might be an option for women who do
not have a uterus, from having had a hysterectomy, but still
have their ovaries, or for women who shouldn't become pregnant
because of a serious health problem. In this case, the woman's
eggs are fertilized by the man's sperm and the embryo is placed
inside the carrier's uterus. In this case, the carrier will
not be related to the baby, and will give the baby to the
parents at birth.
Counseling and Support Groups
If you've been having problems getting pregnant, you know how
frustrating it can feel. Not being able to get pregnant can
be one of the most stressful experiences a couple has. Both
counseling and support groups can help you and your partner
talk about your feelings, and to help you meet other couples
like you in the same situation. You will learn that anger, grief,
blame, guilt, and depression are all normal. Couples do survive
infertility, and can become closer and stronger in the process.
Ask your health care provider for the names of counselors or
therapists with an interest in fertility.