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.

Fertility Awareness

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 by sperm.

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 method.

Infertility

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

Age

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 loss).

Health Problems

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.

Treating Infertility

You should talk to your health care provider about your fertility if you:

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 treatments.

Tests

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 can include:

an x-ray (to look at his reproductive organs)

a mucus penetrance test (to see if sperm can swim through mucus)

a hamster-egg penetrance assay (to see if sperm can go through hamster egg cells, somewhat showing their power to fertilize human eggs)

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 for disease)

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 surgery.

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.

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