Taking Charge of Your Fertility

by Toni Weschler

  A common mistake in trying to diagnose a luteal phase problem is that the woman’s blood is routinely tested only on Day 21, or she is given an endometrial biopsy around Day 26—both tests being done without regard for when she actually ovulated that particular cycle. Ideally, in order to diagnose a potential problem, you should have a Pooled Progesterone Test. With this, you have your blood drawn every other day on Peak Day plus 3, 5, 7, 9, and 11. (Alternatively, you could get it on Thermal Shift Days 2, 4, 6, 8, and 10.) The key point is that luteal phase testing should be done based on when you ovulated that particular cycle.

  Dr. Thomas Hilgers, one of the foremost OB/GYNs in the field, provides one of the following protocols for progesterone support, but only after he has established that his patient is definitely in her luteal phase. I have chosen not to include the dosages because doctors differ on their protocols, but you may want to at least familiarize yourself with these therapies:

  •Oral micronized progesterone capsules (standard or sustained release)

  •Micronized progesterone vaginal capsules

  •Intramuscular progesterone injections

  •Human chorionic gonadotropin (HCG)

  If you are diagnosed with luteal phase insufficiency (sometimes called inadequacy), there is one more option you may want to explore before relying on the traditional medical remedy of progesterone supplementation, Clomid, or HCG injections. This is to have your prolactin tested, because an elevated level can lead to this problem.

  A BRIEF LOOK AT TRADITIONAL CHINESE MEDICINE AND ACUPUNCTURE

  As you read in Chapter 9, Traditional Chinese Medicine and other alternative or complementary therapies such as naturopathy and herbs have garnered increasing public interest and acceptance. As applied to getting pregnant, such approaches are more intensive than the other strategies discussed in this chapter, in part because they require consulting with professional clinicians in the field. Still, they are much less invasive than the drugs and high-tech procedures that you may need and that are discussed in the next chapter, and thus I would encourage you to consider them before moving on to those more mainstream but invasive strategies.

  Of all the alternative therapies, the most promising one for getting pregnant appears to be Traditional Chinese Medicine (TCM). The general goal of TCM is not only to cure specific ailments, but to maintain optimal health so that you prevent disorders from occurring in the first place. In addition, it’s considered a holistic therapy because it views the whole person, not just the individual ailment.

  TCM draws on many centuries of study of acupuncture, medicinal herbs, nutritional therapy, massage, and therapeutic exercise. The principle behind this form of medicine is to look for the underlying causes of imbalance in the yin and yang, which lead to disharmony in the qi energy in the body (qi is pronounced “chee”). TCM addresses how illness evolves in a patient, and then treats the whole person.

  The therapy that I would single out as being most strongly supported by scientific studies is acupuncture. The theory behind it for fertility enhancement is that it stimulates the production of hormones and immune system cells, as well as stimulating pelvic blood flow through a relaxation of the blood supply to the ovaries and uterus. It has not only been shown to enhance fertility in both women and men when used alone, but when it’s used in combination with IVF treatment, pregnancy rates appear to increase significantly.

  Still, a few caveats are worth mentioning here if you are considering acupuncture or any of the other alternative therapies to get pregnant:

  •It’s unlikely that they alone could help you conceive if you have a structural problem such as blocked tubes, a large fibroid, or anatomical defects. (Of course, if you have had surgery to rectify such issues, they could help promote your fertility following the surgery.)

  •Like the more common fertility drugs, these alternatives are powerful therapies. However, they typically take longer to accomplish the same goals, so if you haven’t conceived using FAM and time is of the essence (especially if you are older), then you should probably consider the more widely used reproductive technologies in combination with TCM (the former are all discussed in the next chapter).

  •If you do try acupuncture or any complementary therapy, it’s imperative that you inform your reproductive physician that you are doing so. Although these therapies are relatively noninvasive, as I said, they can be very powerful (for example, some medicinal herbs can actually disrupt a pregnancy!). Therefore, they should never be used in combination with other therapies without your entire team of professionals being apprised. Having said all that, though, if you do have the luxury of time, if you have an aversion to fertility drugs, if you don’t want to increase the risk of multiple ovulation, or if you simply want to improve your chances of conception through less invasive means, then I would encourage you to explore these options with a trained clinician in the field.

  FOR MEN: HOT TUBS, SAUNAS, BICYCLES, TIGHT CLOTHING, AND SUPPLEMENTS

  Unless clearly dealing with a case of physical obstruction that is treatable only by surgery, there are several noninvasive treatments that men with subfertile sperm counts may want to consider before moving on to more serious medical procedures. Just remember that most everything a man tries on his own will probably not be detected in the ejaculate for two to three months. This is because it takes that long for newly created sperm to reach maturity.

  The first is, ah, yes, the age-old weight issue. If it’s any consolation to women, men also must deal with it when it comes to fertility. A man’s sperm count can be compromised if he is either too thin or too heavy. So, if a man’s sperm analysis is not within a normal range, he can at least try to improve it through achieving his ideal weight.

  As you know, sperm are very sensitive to heat. While it’s not clear how much is too much, it’s wise if you’re having problems conceiving to avoid anything that exposes the testes to excess heat. Hot tubs and saunas can be enjoyable, but from the sperm’s perspective, it’s basically saying “Life’s a fish and then you fry.” Laptop computers have also become implicated as a potential cause of overly heated testes. Not only does the computer itself generate a lot of heat, but the position of balancing it on thighs that are pushed together can further cook them, as it were.

  Bicycling is another activity that may affect sperm counts. The constant bumping of the testes, combined with the added heat generated from sweating, may contribute to diminished sperm counts. If the man’s sperm analysis is fine, then by all means, enjoy the daily bike rides. But if the sperm count is marginal, it’s one more practical change he might consider making.

  Even hot work environments may have a harmful effect on sperm production. It should come as no surprise that standing in front of a pizza oven eight hours a day may not be the most efficient way to build up a sperm count. And finally, as far as the common folk wisdom of avoiding tight underwear and pants—it certainly can’t hurt. Obviously, if bikini briefs on your guy rock your boat, and your partner wants to wear them occasionally to seduce you, more power to both of you. But he would be wise not to wear them every day.

  The bottom line is that until you achieve the pregnancy you desire, you may want to avoid anything that causes the sperm to get too hot. And remember that it may take as long as 2 to 3 months after reducing such exposure for a new generation of healthy sperm to mature.

  Finally, for men with marginal counts, perhaps the most overlooked change is to try to keep ejaculations to a maximum frequency of once every 48 hours, since this may be all that is necessary to increase it. (Please don’t shoot the messenger!)

  OTHER FACTORS TO CONSIDER

  Age

  One of the major reasons for the prevalence of subfertility is the relatively late age at which many people today attempt to start having children. The reality is that as women reach their mid to late 30s, their fertility begins to decrease substantially.

  There are several reasons why couples in their 30s face lower fertility. Some factors are ea
sily remedied through simple education, while others are a regrettable function of biology. One of the most fundamental and easily rectified reasons for impaired fertility is that as people age together, they tend to have intercourse less frequently, obviously decreasing their odds of conception. Of course, charting would help them time their lovemaking to fully compensate for their decline in sexual frequency. Two acts of intercourse on perfectly timed days is much more likely to result in pregnancy than a dozen randomly performed acts throughout the cycle.

  There are physiological changes that also affect overall fertility rates. As women age, the quantity and quality of fertile cervical fluid tends to decline. I’ve noticed that women in their 20s will generally have 2 to 4 days of eggwhite, while women approaching their late 30s will often have a day or less. This decline can lead to impaired fertility if intercourse is not timed well. In addition, as women approach their late 30s, they tend to have more anovulatory cycles, and often when they do ovulate, their luteal phases are shorter. Finally, the quantity and quality of women’s eggs also decline, but as discussed in Chapter 10, there are at least effective ways to predict the pace of the decline.

  In any case, you should know that while it’s definitely easier to conceive a child and carry it to term in your 20s than it is in your mid-30s and later, it’s also true that both FAM and various high-tech strategies can help shift the odds back in your favor.

  Stress

  One of the most commonly held axioms is that stress leads to infertility. While there is no doubt that stress is associated with diminished fertility, the opposite appears to be more accurate—that is, infertility leads to stress! So the old adage “just relax and you’ll get pregnant” is well-meaning but often misguided.

  There are several ways, though, in which stress can indirectly influence fertility. One is simply that leading a busy life and all the stress that entails may leave little time or energy for the average couple to have intercourse frequently enough to achieve pregnancy. Of course, as you know by now, intercourse doesn’t need to be frequent as long as it’s well-timed.

  A second way is that stress itself may affect when ovulation occurs. In fact, one of the most common causes of delayed ovulation is both physiological and psychological stress. This is because stress can have a dramatic effect on the functioning of the hypothalamus. It is the hypothalamus that is responsible for the regulation of appetite, temperature, and most important, emotions. It also regulates the pituitary gland, which in turn is responsible for the release of FSH and LH. When stress affects the hypothalamus, the end result can be delayed secretion of these reproductive hormones, which are necessary for the release of a mature ovum. (It’s not known what triggers an early ovulation, but stress does not appear to play a role.)

  As you know, the timing of ovulation will determine the length of the cycle—the later it occurs, the longer the cycle will be. Occasionally, if stress is severe, it can prevent ovulation from occurring altogether. If stress were to affect your cycle, then, one of two things would probably happen:

  1. You would have a longer-than-average cycle, with ovulation occurring later than usual and menstruation following 12 to 16 days afterward, assuming pregnancy didn’t occur. You can see this on Lily’s chart below.

  2. You would have a long cycle, but wouldn’t release an egg (an anovulatory cycle). If this were the case, the cycle could theoretically extend for months. Or you would have a long cycle followed by anovulatory bleeding, which is the result of a drop in estrogen, as opposed to progesterone. Remember that in an ovulatory cycle, the corpus luteum dies, and the sudden drop in progesterone causes the uterine lining to shed. But with anovulatory cycles, it’s the drop in estrogen that usually causes the bleeding since there is no corpus luteum. For this situation, see Leslie’s chart below.

  Lily’s chart. A long cycle due to stress. With her in-laws arriving for a week, is it any wonder that Lily had a delayed ovulation leading to a long cycle? Note that she started to prepare to ovulate about the time they arrived, but didn’t actually do so until after they left, about Day 21.

  Leslie’s chart. Anovulatory cycle due to stress. Note that Leslie’s body started to prepare to ovulate about Day 15, but then she broke her leg skiing. A couple of weeks later, as she was finally starting to recover and prepare again to ovulate, her basement flooded. At this point, her body decided to throw in the towel and not release an egg at all. On Day 40, Leslie had anovulatory bleeding rather than a true menstrual period.

  While it’s true that stress can prevent ovulation, it’s my professional experience that it more commonly delays it. For this reason, it’s especially important to learn to focus on the signs that indicate approaching ovulation. That way, if stress is causing a delayed ovulation, you can at least take control by identifying when you are about to ovulate, and thus take advantage of the most fertile time. Of course, the sign that indicates impending ovulation is progressively wetter cervical fluid, especially eggwhite, that develops just before you release an egg.

  One of the ironies of how stress and the desire to get pregnant can interact is that couples may inadvertently fail to get pregnant by focusing on the mythical Day 14. So, for example, in women who usually have average-length cycles, a vicious circle can develop in which the stress of continually not achieving pregnancy may only delay ovulation. This in itself wouldn’t be a problem, if the couple were aware of how to identify when the woman was about to ovulate.

  In women who typically have longer cycles, stress may not be delaying ovulation at all. However, if the couple is unaware of when the woman does ovulate, they may be having intercourse too early for conception to occur, thus subjecting themselves to the needless anxiety of misperceived infertility. For both couples, the most constructive advice is to have them chart their cycles, and then time their lovemaking accordingly, or face the frustration Mariah is having, as seen in the chart below.

  Mariah’s chart. Mistimed intercourse during a long cycle. Note that Mariah’s ovulation didn’t occur until about Day 20. Whether caused by stress or just typical of her cycles, the end result is that intercourse the week before could not result in the conception they sought.

  Stress is also notorious for causing cervical fluid either to disappear altogether or to form patches of wetness interspersed with dryer days. It’s as if the body keeps making noble attempts to ovulate, but stress continues to delay it. If this should happen, remember that your temps will usually ultimately indicate when you have finally ovulated. So if you observe patches of slippery or eggwhite, take advantage of those days until you see the confirmation from a thermal shift that ovulation has indeed taken place.

  The fact is that stress may not necessarily affect a cycle at all, or it will affect individual women differently. You should also know that chronic stress may tend to normalize over time, so that the woman’s body eventually stops perceiving it as stress, and thus cycles may revert to the way they were before.

  Avoiding Ovarian Surgery

  If you are ever in a situation where your doctor recommends surgery on your ovary to rectify a problem such as an ovarian cyst or endometriosis, insist on discussing alternatives to surgery. If he says there aren’t any, consider getting a second opinion, because one of the quickest ways to diminish your fertility is through ovarian surgery that either removes an ovary altogether (the most drastic way to decrease your fertility) or removes even a part of your ovary. This is because all your mature eggs rise to the ovarian surface, so it’s crucial to preserve that outer shell if at all possible.

  However, if you absolutely must undergo ovarian surgery, there is a new generation of surgeons who are being trained in a new technique that decreases the extensive scarring that is usually inherent in this type of procedure. This procedure is further discussed in the next chapter, Click here.

  The Jewish Practice of Niddah

  If you are an observant Jew who practices niddah, you certainly know that you are prohibited from having intercourse for 7 days
following the last day of your period. Alas, if you meet any of the following three conditions, it may be affecting your ability to conceive:

  •your cycles tend to be fairly short (i.e., less than 25 days or so)

  •your cycles are average length but you bleed for at least 7 days

  •you have midcycle spotting

  The reason the practice may be impeding your ability to get pregnant is that it prevents you from having intercourse during what may be your most fertile phase. For example, if you have cycles of about 24 days, you are probably ovulating about Day 10, but you’re not allowed to resume intercourse again until about Day 13. And even if you have average-length cycles but your periods last 7 days or more, you would again find yourself abstaining until about Day 14 or so, possibly a bit too late for your particular ovulation. Finally, if you happen to be a woman who has occasional midcycle spotting, niddah rules would again require you to abstain at the time that you are most likely ovulating.

  Needless to say, if you practice niddah and you would like to conceive, I would highly recommend charting to determine whether this may be the reason you aren’t getting pregnant. Then discuss it with your rabbi to see what modifications are acceptable according to Jewish law.

  The Logical Road to Parenthood

  As you can see, there is a fairly diverse list of possible impediments to a successful pregnancy, but fortunately, you can address many of these problems on your own, before resorting to the more intensive approaches discussed in the next chapter. Charting your cycles, of course, should always be the first step. By doing so, you can at least determine that your problem is more than just a question of bad timing, and if necessary, beyond that, you could then choose a potential remedy or alternative solution that makes the most sense for your particular situation.