 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.
View the printable version of Fertility
Awareness and Infertility
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.
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.
Check out the following resources for more information on fertility awareness
and infertility:
This page last updated: June 2003 |
