Taking Charge of Your Fertility

by Toni Weschler

  Why People Are Often Misled to Believe They Are Infertile

  Before discussing the impact on a couple of being inappropriately labeled “infertile,” let’s look at why people are often misled in the first place. (For most of the points below, I will use the Day 14 myth as a point of reference.)

  1. Infertility is assumed if pregnancy has not occurred within a year.

  If a couple has been unable to get pregnant after a year of unprotected intercourse, the standard wisdom is to assume that there is probably a fertility issue, when in reality there may be no medical issue whatsoever.

  2. Irregular cycles are assumed to be potentially problematic.

  The belief that normal cycles are 28 days and ovulation occurs on Day 14 is so entrenched in the medical profession that when a woman’s cycles vary from that standard, the variation is often presumed to be a potential concern. “Irregular” cycles are seen as problematic in part because gynecologists often need to time fertility tests and procedures around when the egg was released. But if a woman is taught how to identify approaching ovulation to time intercourse appropriately, it’s irrelevant whether she ovulates on Day 14, 19, or 21. (Of course, if your cycle lengths vary dramatically, or are longer than about 38 days, it’s often an indication of a true hormonal disorder that warrants being checked by a doctor. see Medical Causes of Anovulation or Irregular Cycles.)

  One of my clients was clearly depressed when she first called me, because it had been over a year since she and her husband had started trying to get pregnant. She mentioned that she thought the reason she may not be getting pregnant was because her cycles were not a “normal” length. I learned that they were about 33 days, a normal period of time, but certainly longer than the proverbial 28 days. She went on to say that her husband got so frustrated with their apparent infertility that they would have intercourse only up to Day 14, then stop until the next cycle. No wonder they weren’t getting pregnant! If a woman has long cycles, by definition she ovulates later. Within a month of taking my fertility seminar, the couple got pregnant.

  3. Many doctors overlook the most obvious solutions.

  Physicians are trained to identify disease and illness, often by diagnosing and treating with high-tech procedures. The result is that the most obvious solutions are often overlooked. A good example of this is the relationship between frequency of intercourse and pregnancy. A couple may have sex twice a week for a year and wonder why they have not gotten pregnant. A doctor may proceed with a fertility workup (including invasive and potentially painful tests) on the assumption that the couple may have a fertility problem, without considering the most rudimentary question, namely, whether the couple is having intercourse at the right time in the woman’s cycle. It’s quite possible to have intercourse twice a week for a year and still be missing the fertile phase in each cycle, especially if the woman has only a day or so of fertile cervical fluid, or the man’s sperm count is marginal. This is clearly not a fertility problem but an education problem.

  This concept of overlooking fundamental principles is exemplified by Abraham Kaplan’s theory, The Law of the Instrument:

  Give a small boy a hammer,

  and he will find that everything

  he encounters needs pounding.

  Doctors have a vested interest in using the tools that they have perfected through years of study. It should come as no surprise, then, that infertility specialists initially apply the high-tech tools of the trade. This is very helpful for scores of couples dealing with actual infertility. However, there are many couples for whom the use of these tests and procedures is simply unnecessary. Before any high-tech tests or treatments are employed, the man should have a semen analysis. In addition, the couple should chart the woman’s fertility signs to both identify when she is the most fertile and to determine any possible impediments to achieving pregnancy.

  4. Many clinicians tend to focus on basal body temperatures rather than cervical fluid.

  Doctors will usually focus on basal body temps to the exclusion of the most important fertility sign for timing intercourse effectively, which is cervical fluid. In fact, physicians may unintentionally create a fertility problem by advising their patients to time intercourse for either the drop or rise in temperature.

  This advice is not only misleading, it can actually impede getting pregnant! In short, cervical fluid is the key sign for timing intercourse to get pregnant.

  One of the most glaring examples of a doctor reinforcing the notion of depending on past temps to indicate future fertility took place at, of all places, a conference of the infertility organization RESOLVE. The doctor’s keynote address was about all the myths surrounding fertility. She was making the correct point that basal body temps only indicate fertility after it’s too late, after ovulation has already occurred. While sitting in the audience, I remember thinking how gratifying it was to finally hear a physician stress the point that temps are ineffective for timing intercourse. Imagine my surprise, then, when she continued: “Therefore, to predict impending fertility, you must look back at your previous thermal shifts to predict your upcoming fertile time.”

  I was stunned. Here she was, reinforcing the idea of looking at past cycles to predict future fertility, without so much as mentioning the most important fertility sign for getting pregnant: cervical fluid. The irony of the moment would have been amusing if it wasn’t such blatantly bad advice, and addressed to such a vulnerable group of people.

  The reason temps don’t help determine the best time to achieve pregnancy is that by the time the temperatures shift up, the egg is typically already dead and gone. However, the temperature is still very useful in terms of determining several facts about the woman’s cycle, including: 1) whether she is ovulating at all, 2) whether the second phase of her cycle (from ovulation until her period) is long enough for the egg to implant in her uterus, and 3) whether she has conceived in that particular cycle.

  5. Many fertility tests are timed inappropriately (or simply performed unnecessarily).

  If infertility is suspected, doctors may perform a postcoital test to determine if the man’s sperm are swimming freely in the woman’s cervical fluid. For this test, the couple has intercourse, then the woman visits the clinic within several hours. A few drops of semen are removed from her vagina and examined under a microscope to determine if sperm are alive and moving in the fluid. The purpose is basically to determine two facts: whether the woman’s cervical fluid is conducive to sperm viability, and whether her partner’s own sperm will survive in it.

  One of the most common mistakes made is in the procedure’s timing. Many doctors continue to perform it around Day 14 of the woman’s cycle, regardless of when she actually ovulates. Unless the woman does ovulate close to that day, the test is usually invalid, and leads many couples to believe they have a fertility problem when they actually don’t.

  I will never forget a lecture I gave to a group of nurse practitioners experienced in infertility treatment. As I explained that tests are useless if performed at the wrong time in a woman’s cycle (for numerous women, Day 14 is simply too early), I could feel the anger build. Finally, one nurse blurted out sarcastically: “And just who do you expect us to refer our patients to for postcoitals where they will be willing to test them based on the woman’s cycle rather than the availability of the staff?” All I could think of at that point was that I was not there to tell them what they wanted to hear, but rather what works.

  There are certain medical events over which we simply have no control. Childbirth does not occur merely between the hours of 9 to 5, Monday through Friday. Certainly trauma is treated when it happens, not just when the clinic is open. To the extent possible, a woman’s ovulation should be no different.

  A test is useful only if it’s both reliable and valid. In the case of the postcoital test, the only information to be obtained from performing it on Day 14 on a woman who ovulates on Day 20, for example, is to prove that Fertility Awareness can also be effecti
vely used as a method of birth control! Sperm die within a few hours of intercourse when a woman is not in her fertile phase, and that phase is only the few days surrounding ovulation. If performed at any other time, the test is useless.

  Another frequently mistimed test is the endometrial biopsy, which involves removing a small segment of the uterine lining close to the estimated time of menstruation. This is done in order to determine if the woman is ovulating and producing a suitable lining for implantation. But here too, practitioners will often simply assume a Day 14 ovulation, whether this really occurred or not, and thus the procedure’s accuracy and relevance are questionable. (Had ovulation actually taken place on Day 21, for example, one would expect both endometrial development and the next period to be a week behind.) Clearly, women undergoing these procedures deserve useful information, which is possible only if they are appropriately timed.

  Finally, some tests are performed well before it’s appropriate to do so, especially given how painful and intrusive they can be. For example, the hysterosalpingogram (HSG) is a dye test used to determine if the woman’s fallopian tubes are open. It’s actually quite revealing, but given its potential discomfort and cost, it should be performed only after it has been determined that possible ovulatory and cervical fluid problems have been ruled out. And, needless to say, it’s completely useless if the fertility problem is determined in fact to be due to miscarriages. Charting would have revealed all of these problems.

  6. Women are often needlessly prescribed an ovulatory drug such as Clomid (clomiphene citrate).

  If a couple is presumed to be infertile, the woman is often put on an ovulatory drug whether or not she is actually ovulating. Its purpose is to stimulate egg development in the ovaries. But what the couple is often not told is that it has a paradoxical side effect: it can dry up the very cervical fluid that is vital for sperm transport through the cervix. So, while this potent medication is given to increase a woman’s fertility, it can, ironically, act to prevent a pregnancy. (Sometimes, the only way to remedy this problem is through intrauterine insemination, where the sperm is deposited directly in the uterus, bypassing the cervix altogether.) I have had many clients achieve a pregnancy specifically after discontinuing Clomid.

  This is not to suggest that Clomid does not have a role in infertility treatment. Certainly many women do get pregnant by using it, and indeed, it may be possible to alleviate some of the side effects. The one benefit of Clomid for women who already ovulate is to increase the luteal phase, the postovulatory phase. However, the use of Clomid should be an informed decision, rather than a routine first step. Women should ask their doctors why they think a prescription would be beneficial in their particular case, especially if they already know from charting that they are ovulating normally.

  7. The commonly used ovulation predictor kits can be misleading.

  With the advent of ovulation predictor kits so readily available in drugstores, many women are led to believe they have a fertility problem if the kits do not show the expected color surge indicating ovulation is about to occur. But even if the kits do show a color surge, it does not necessarily mean the woman is fertile. The reasons they can be misleading are all discussed on For more click here.

  8. Women are often led to believe they are not getting pregnant, when they are actually having miscarriages.

  There is a huge difference between a woman who has never achieved a pregnancy and one who gets pregnant but then miscarries. I do not mean to imply that women who continually miscarry do not have a fertility problem. However, the diagnostic steps taken for the two women should be dramatically different.

  Miscarriages can be difficult to diagnose, since they often happen so early in the woman’s cycle. They may be mistaken for nothing more than a menstrual period. But a woman trained in Fertility Awareness knows that she needs a phase of at least 10 days from ovulation to menstruation for implantation to later occur, and that 18 consecutive high temps after ovulation almost always indicates a pregnancy. She would therefore be able to determine with a high degree of accuracy whether or not she was indeed pregnant before she bled. But since most women are not taught how to take control of their cycles, they are unable to interpret what is occurring in their bodies. Thus, they may needlessly subject themselves to painful and invasive diagnostic procedures to rule out an infertility problem that may not exist.

  My client Kisha thought she might finally be pregnant because she had taken my class and knew that 18 high temps most likely indicated a pregnancy. Upon hearing from her, I suggested she come in to the clinic to get a blood test to confirm it. Sure enough, she was pregnant. In fact, she had conceived so early in her cycle (about Day 11) that by the time 18 high temps had been recorded, she was only on Day 29, not a day that most women typically associate with pregnancy! But she knew she was pregnant earlier than most women would know because she had educated herself through Fertility Awareness. Unfortunately, within a few days of her positive test, she had a miscarriage. Although it was sad that this happened, the fact that she conceived was nevertheless very helpful in terms of what it told her about her fertility at the time:

  a.She was ovulating.

  b.Her fallopian tubes were open.

  c.Her cervical fluid was suitable for sperm penetration.

  d.Her partner’s sperm count was fine.

  What Kisha learned from this experience is that she had undoubtedly been having other miscarriages while trying to get pregnant, but would never have known had she not learned how to identify pregnancy through charting. FAM taught her that her problem may have been related to a shortened phase of progesterone in the second part of her cycle (the luteal phase). Rather than start the infertility workup from square one, with all of the inherently intrusive tests, she was able to show her charts to her doctor and immediately address the problem. Several months later, after being treated for a short luteal phase, she got pregnant and carried her baby daughter to term.

  The Infertility Diagnosis: Staying in Control

  As you can see, there are a number of reasons people are led to believe they are infertile when they actually may not be. The physical and emotional ramifications of this misdiagnosis are far-reaching and hard to overstate. The cost of infertility diagnosis and treatment is not covered by most insurance companies. Many couples struggling with infertility feel that it’s grossly unfair to have years of their insurance fees cover the maternity care of other couples, only to have their own infertility treatment not included. The cost of even a minimal infertility workup can be thousands of dollars, and a comprehensive workup including treatment can amount to tens of thousands of dollars, usually out of pocket. It’s especially disheartening that these exorbitant costs are so often unnecessary.

  While men feel the impact to a certain extent, the woman is usually the partner most affected by the whole process. Because a woman’s fertility is integrally related to her menstrual cycle, she must visit the doctor several times a cycle to determine potential fertility problems. Since doctors’ offices are rarely open at night or on weekends, many must make arrangements to miss work numerous times or, in some cases, quit their jobs, in order to pursue fertility diagnosis and treatment.

  As you’ve read, many of the diagnostic tests are quite uncomfortable or even painful. Even worse, they are often mistimed and simply not needed. But by charting their three primary fertility signs, women can inform their doctors of numerous facts about their fertility, which can quickly narrow the range of possible diagnoses. In so doing, they can help exclude those procedures that would serve no purpose, and help to most appropriately time those tests that could reveal valuable information.

  Indeed, imagine how much more confident a woman would feel if she could say to her physician:

  Hi, Dr. Smith. Yes, I am basically fine, thank you. But I do have a couple of concerns I wanted to discuss with you. I practice Fertility Awareness and have noticed that my luteal phase is a little short. We plan to get pregnant this spring and woul
d like to try to lengthen it to avoid risking a miscarriage. What would you suggest?

  In other words, women and couples can become active participants in their health care. By charting, couples facing fertility issues can reduce their feelings of vulnerability, and most important, increase their chances of pregnancy, whether medical intervention is required or not.

  Knowing When: Identifying the Date If Conception Occurs

  Interestingly enough, some clinicians may inadvertently lead couples who have gotten pregnant to believe there is a problem when there is not. Once again, it all reverts back to the erroneous assumption that women usually have 28-day cycles and ovulate on Day 14.

  Dana was a 25-year-old woman who had recently come off the pill, so her cycles had not yet returned to normal. Because she and her husband wanted to get pregnant, they practiced Fertility Awareness to determine her fertile phase. After she became pregnant, her doctor asked her the date of her last menstrual period to apply the standard pregnancy wheel (shown on A Typical Pregnancy Wheel in the color insert). Dana mentioned that the pregnancy wheel would be inaccurate in her particular case since it assumes ovulation on Day 14. She explained that she practiced FAM and knew that she didn’t ovulate until about Day 37, so it would inaccurately predict her due date a full three weeks earlier than it really should be.

  You can imagine Dana’s surprise when the doctor not only did not give credence to her charts, but also expressed great concern when his pelvic exam revealed that the fetus was “extremely small for dates.” Had she not been practicing Fertility Awareness, she would have undoubtedly been distressed to be told that there was something wrong with her fetus, all because he was estimating her date of conception on the average woman’s day of ovulation, rather than on her own cycle. As if that wasn’t enough, he even red-flagged her chart with a “medical alert” tag, indicating that her pregnancy was high-risk and needed to be carefully monitored!