Regardless, try not to be discouraged in your quest for a baby. For even if self-education and these simple noninvasive steps don’t result in success, many of you can still reach your dreams through the latest advances in assisted reproductive technologies.
LOVEMAKING VERSUS BABYMAKING
When I had my baby, I screamed and screamed. And that was just during conception.
—JOAN RIVERS
Although a person’s sexuality is separate from their fertility, society often equates them, leaving many people dealing with infertility feeling that they are also somehow diminished sexually. This in turn may lead to emotions ranging from unresolved anger and fear to anxiety or guilt. Even worse, communication between the couple often deteriorates just when they need to be more supportive than ever. Sexual problems often arise between couples touched by infertility because sex has taken on one main function, procreation, rather than making love.
It may reassure you to know that what you are experiencing is absolutely normal. But so much of the anxiety associated with trying to conceive could be eliminated if you knew exactly when in your cycle you could get pregnant. Of course, some couples’ fertility problems will require high-tech treatment, but ironically, those procedures may actually free them to enjoy lovemaking for what it is—and not as a means of only conceiving.
Having a sense of humor during this trying time can help pull you through the rough times, as this couple so poignantly conveyed to me:
Diana had very irregular cycles, having ovulated only about eight times in the prior four years. Because she had excessively high levels of prolactin (the hormone that is normally present in breastfeeding women), she was prescribed Parlodel and Clomid to regulate her cycles. Along with the drugs and FSH shots, she had several ultrasounds taken. In addition, she would put her legs up on the wall for about an hour after intercourse. After about six months of trying, nothing worked. On the advice of her gynecologist, Diana and Steve tried using fresh eggwhites to simulate fertile-quality cervical fluid.
Before making love, they removed an egg from the refrigerator, separated it, and inserted the eggwhite into a pastry bag. After Diana comfortably positioned herself, Steve blew the ice-cold eggwhite into her vagina through the nozzle. Diana laughed so hard that the eggwhite squirted out in one fell swoop. So much for that cycle.*
During the next cycle they decided to try things a little differently. Having learned their lesson from the first time, they let the egg sit at room temperature first. Then they used a vaginal-cream applicator to insert the eggwhite. They conceived that day—Mother’s Day. Today, 22 years later, their daughter Tessa is graduating from college.
Who knows? When you finally achieve your dream of the pitter-patter of little feet, whether it be the old-fashioned way, through assisted reproductive technologies, or through adoption, you might just find yourself trying to remember what it was like to have so much time for sex in the first place.
CHAPTER 15
What Next? Tests and Treatments That May Be Necessary to Get Pregnant
The world is moving so fast these days that the man who says it can’t be done is generally interrupted by someone doing it.
—ELBERT HUBBARD
As you know by now, the most important advice for a couple trying to get pregnant is to chart the woman’s cycle as the first step. It’s astounding that something so fundamental is routinely ignored. Of course, there will be individuals for whom FAM won’t be enough to get pregnant, but even then, charting will help determine what tests or treatment are needed, often allowing them to bypass inappropriate or unnecessary interventions.
When first beginning to chart, you should be able to verify that there are no obstacles to pregnancy that you can clearly identify. This would include issues like anovulation, lack of fertile-quality cervical fluid, excessively short luteal phases, and recurrent miscarriages. If your charting reveals nothing wrong, but you are still unable to get pregnant after optimally timing intercourse for about 4 cycles, your partner should get a semen analysis.
If his sperm count is low, try timing intercourse by the FAM guidelines discussed here for another few cycles. If, however, his sperm analysis is normal, both of you should be given a comprehensive fertility workup to determine if there might be a physical impediment to getting pregnant. (His workup, which is much simpler than yours, is discussed here near the end of this chapter.)
A FEW IMPORTANT CONDITIONS THAT MAY AFFECT YOUR FERTILITY
There are four conditions, any one of which you may have, that are discussed extensively in different chapters in this book. I’ve listed them below on the off chance that you might have skipped ahead and missed that crucial information if you are trying to conceive. The first two below will typically give you obvious signs, even if you are not charting. The last two may be asymptomatic. In all four cases, treatment is often needed before you can get pregnant.
Endometriosis
A common problem in which the cells that normally line the uterus are displaced and attach elsewhere in the pelvic cavity, possibly affecting ovulation and even the ability of the fallopian tubes to grasp the egg.
Polycystic Ovarian Syndrome, or PCOS
A common disorder in which a woman has an imbalance of sex hormones that frequently leads to anovulation and irregular menstrual cycles as well as more general health problems.
Luteinized Unruptured Follicle Syndrome
A condition that prevents ovulation altogether, but on your fertility charts may mislead you to believe you are ovulating normally.
Premature Ovarian Aging
A condition in which the woman’s ovaries age much sooner than average, making it more difficult to conceive.
THE WOMAN’S FERTILITY WORKUP
Generally speaking, your fertility workup will involve most or all of the following steps:
A. Medical History Review
The clinician will take a comprehensive medical history and review any previous fertility tests before performing a standard pelvic exam. The exam is to rule out any obvious physical problems of the uterus, ovaries, and cervix, such as fibroids, cysts, and infections.
B. Diagnostic Tests
There are a number of fairly noninvasive means of determining potential problems. In women, the four general areas of concern in the reproductive system are:
•dysfunctional ovulatory cycles
•cervical problems
•uterine and fallopian tube abnormalities
•endometriosis
The tests and procedures discussed below are used to detect problems in any of these areas. They are listed in approximate order, from least to most invasive. However, be aware that if you go straight to a reproductive endocrinologist or other fertility specialist, they will undoubtedly bypass the first three altogether.
Waking (Basal Body) Temperature Charting
As I’m sure you can recite in your sleep by now, this is the sign that is easiest to identify and puts a sense of control in your hands. Taking your waking temps will help you determine whether:
•you are ovulating
•your luteal phase is long enough for implantation (at least 10 days)
•your progesterone levels are high enough in your luteal phase
•you have a thyroid problem (either hypo- or hyperthyroid)
•you are still fertile in any given cycle as reflected by preovulatory temps
•you may have gotten pregnant, as reflected by more than 18 high temps
•you are in danger of having a miscarriage, as determined by a sudden or gradual drop in temps after an apparent conception
•you were pregnant before having what seemed to be just a “late period”
Cervical-Fluid Ferning Test
In this test, cervical fluid is removed from the woman’s vagina and observed under a microscope to determine if she is indeed fertile that day. If she is, it will reveal a beautiful ferning pattern like the one here in the color insert. But be aware that the test will b
e invalid if it is done at the wrong time in your cycle. Of course, you yourself should be able to tell when you are fertile by simply observing when it’s stretchy, clear, or lubricative, and you know that it doesn’t matter whether that’s on Day 9, 14, or 20.
Postcoital Test
This test determines whether the couple’s sperm and cervical fluid are compatible. To determine this, a sample of cervical fluid is taken from the woman’s vagina within two hours of intercourse (again, for the test to be valid, it has to be done at the right time, when the woman has fertile-quality cervical fluid, and not necessarily on Day 14!). If the two are compatible, the clinician will be able to observe the live sperm swimming forward.
Hormone Blood Tests
Blood tests are a fundamental means of determining if the woman is producing normal reproductive hormones or has a hormonal imbalance. They can determine levels of FSH, LH, estrogen, progesterone, and thyroid-stimulating hormone (TSH). They can help ascertain some vital facts, such as whether the woman is ovulating, has a normal luteal phase, or is possibly entering menopause. The table below summarizes the most commonly performed blood tests.
Special Pap Tests
These are fertility screening swabs or Pap smears that test for a number of potentially problematic conditions such as pelvic inflammatory disease (PID) and sexually transmitted infections (STIs), all of which could adversely impact your fertility.
HORMONE BLOOD TESTS*
In order of day of cycle it is usually drawn. All test results vary depending on the laboratory used.
Hormone Best Time to Take Test Purpose of Hormone
Follicle Stimulating Hormone (FSH) Day 3 and Day 10, if part of Clomid Challenge Test Stimulates follicle development. If FSH levels are too high, it could indicate possible menopause or declining fertility.
Estradiol Day 3 and possibly mid-luteal phase (7 to 10 days after your LH surge) Stimulates egg maturation and endometrial maturation for the implantation of a fertilized egg. Responsible for the fertile quality of the cervical fluid around ovulation.
Inhibin B Day 3 A protein hormone that inhibits FSH and is tested to predict ovarian reserve, including egg quality and quantity.
Luteinizing Hormone (LH) Around ovulation Triggers ovulation when it surges.
Progesterone Mid-luteal phase (7 to 10 days after your LH surge) Necessary for sustaining the uterine lining and maintaining early pregnancy. Causes the rise in BBT and drying of cervical fluid in the postovulatory infertile phase.†
Pooled Progesterone Thermal shift Days 2, 4, 6, 8, and 10, or Peak Day plus 3, 5, 7, 9, and 11 Since the progression of progesterone levels during the luteal phase is so important, it is more accurate to test several alternating days than just one mid-luteal phase.
Prolactin Any cycle day Stimulates the production of breast milk and inhibits the ovarian production of estrogen. Occasionally present in excessive levels in non-breastfeeding women, potentially causing fertility problems.
Thyroid Stimulating Hormone (TSH) Any cycle day Stimulates the production of thyroxine in the thyroid gland, the endocrine gland that regulates hormones in the body. Excessively high or low levels may affect fertility.
Testosterone Any cycle day Necessary for the production of estrogen. When produced in high levels, may impact fertility.
Dehydroepian-drosterone sulfate (DHEAS) Any cycle day Produces the same effects as male hormones (androgens). When produced at high levels in both men and women, may cause fertility problems.
C. Diagnostic Procedures
Ultrasound
The only way to definitively determine if ovulation has occurred is with an ultrasound, which is usually done vaginally. This procedure offers a means of being able to know if and when ovulation occurred. It’s especially useful in detecting the condition LUFS (luteinized unruptured follicle syndrome), in which the woman’s body produces all the signs of ovulation, including a Peak Day and thermal shift, but without releasing an egg (click here).
The obvious disadvantage of ultrasound is that it’s not practical on a daily basis. However, if you are charting, you should be able to help your doctor know when to schedule it by observing when you are starting to produce fertile-quality cervical fluid.
As always, if you are told to come in for an ultrasound on a particular cycle day, such as the infamous Day 14, rather than one based on your individual cycle, the ultrasound could be completely invalid. The one exception is if you are taking fertility drugs, which control your cycle artificially.
Endometrial Biopsy
This procedure sounds ominous but is in fact routine and fairly simple. We tend to associate the word “biopsy” with cancer, but the test has nothing to do with that. Its purpose is to determine if the uterine lining (endometrium) is sufficiently developed during the luteal phase of the cycle. The lining must be mature enough to be able to sustain the implantation of a fertilized egg.
The test is usually done a couple of days before the woman’s expected period. A tiny piece of the uterine lining is removed and biopsied. Unfortunately, it can be fairly uncomfortable, because it may cause cramping or a sharp pain from partially dilating the cervix. So you’ll probably want to take a pain reliever about 30 minutes before the procedure.
The timing of this test is crucial, because if it’s done too soon after the egg is released (especially in the case of delayed ovulations), it can deceptively appear as if the woman has an undeveloped endometrium. Likewise, if it’s done too late after ovulation, the woman may start her period before the test has been completed. Thus, charting and/or an ultrasound is necessary in order to time this test appropriately.
Fallopian Tube Tests
The hysterosalpingogram, with the thankfully short acronym HSG, is an X-ray procedure that involves inserting dye through the cervix and uterus to see whether it spills out the fallopian tubes and into the pelvic cavity. Although it can be quite useful, the procedure can be uncomfortable and does have its limitations.
For one thing, the tubes occasionally spasm during the procedure, giving the appearance of being blocked, when in reality it may have been the test itself that caused them to appear closed. Another problem is that if the tubes are only scarred but not blocked, the HSG would not necessarily reveal that. The concern with scarring is that it could lead to a dangerous tubal pregnancy, in which the fertilized egg begins to burrow into the tube rather than the uterine lining.
The other purpose of an HSG is to evaluate the uterine cavity for the presence of any type of surface lesion, such as polyps, fibroid tumors, or scar tissue. However, it could miss some of these, and thus some clinicians may also want to perform one of the tests in the bulleted list below.
There are a number of procedures that are designed to not only determine if your fallopian tubes are open, but to test if they are functioning properly. Indeed, one of the most interesting things about fallopian tubes is that they are more than just tubes! The fimbria at the end are more like delicate folds, which, when working properly, capture the eggs that have been released from the ovary with gentle sweeping motions. If the tube is diseased, however, this function is compromised, so that even if it’s seemingly open, it can no longer serve its purpose (see picture of the fimbria here in the color insert).
As with everything in the fertility world, there are numerous variations of this procedure:
•FUS (Fluid ultrasonography)
A sterile saline solution using a vaginal ultrasound.
•Tuboscopy
A thin telescope which is passed through the fimbriae of the fallopian tubes to evaluate their inner structure. It’s a more accurate way of identifying various tubal issues, such as polyps and scar tissue.
•Falloscopy
A fiber optic tube which is guided through the cervix and uterus and into the fallopian tubes.
•Selective Hysterosalpingogram
A thinner, flexible catheter which is run inside the HSG catheter. It’s able to also clear a tube that has an obstruction, so it’
s both a diagnostic and therapeutic procedure.
•HyCoSy (Hysterosalpingo-contrast sonography)
Needless to say, this exam’s official name would be a killer in any spelling bee. A procedure in which a small amount of fluid is injected into the uterus through the cervix. This procedure has the advantage of not using radiation or iodinated contrast material.
•Tubal Perfusion Pressure (TPP) Measurements
The most recently developed of these technologies, this procedure tests for the functioning of tubes, because those that are rigid and diseased need higher pressures to push dye through.
Hysteroscopy
The best “window into the womb” is through hysteroscopy, a procedure performed specifically to view inside the uterus. In the context of fertility, it’s done primarily to determine if the woman has fibroids or other conditions that may affect her ability to carry a pregnancy to term.
Laparoscopy
This is exploratory surgery that is used to view the internal pelvic area, especially the outside of the ovaries and fallopian tubes. It usually involves a couple of tiny incisions, including one in the navel, through which a lighted tube is inserted to view the pelvic region. Although the procedure is fairly routine, it’s typically done with general anesthesia.
It is most commonly used to detect endometriosis. There is a specific type called “near-contact laparoscopy” that is considered the gold standard for treating endometriosis. You can learn more about it here.
THE WOMAN’S FERTILITY WORKUP: COMMON DIAGNOSTIC TESTS AND EXPLORATORY SURGICAL PROCEDURES
(in alphabetical order)
Test Best Time to Take Test Purpose of Test
Basal body temperature charts Throughout cycle To determine whether you are ovulating and how long your postovulatory phase is.
Cervical fluid ferning slide The few days leading up to ovulation, when your cervical fluid is slippery and wet To determine if your cervical fluid forms the characteristic ferning pattern indicating that it is fertile enough for sperm to survive within it or if you are making adequate estrogen. Note, though, that the test is not quantitative and does not predict if the sperm can swim in it.
Taking Charge of Your Fertility Page 23