 	        			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. 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
          o The Menstrual Cycle
          o Charting Your Fertility Pattern
          o Sample Basal Body Temperature (BBT)
Chart
          o Blank BBT Chart to print and use each
month
    * Infertility
    * Reasons for Infertility
          o Age
          o Health Problems
    * Treating Infertility
          o Tests
          o Drugs and Surgery
          o Assisted Reproductive Technology
(ART)
          o Counseling and Support Groups
    * Frequently Asked Questions about
Infertility
    * Resources

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

ThermometerIf 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 to experience infertility. Infertility
is defined as not being able to become pregnant,
despite trying for one year, in women under age
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 her 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 reserves 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

Man and woman smilingCouples 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.

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.

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.

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 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
doctor for help.

Treating Infertility

You should talk to your doctor about your
fertility if you:

    *

      are under age 35 and, after a year of
frequent sex without birth control, you are having
problems getting pregnant, or
    *

      are age 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 doctor 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 doctor
because age also affects the success rates of
these treatments.

Tests

The first step to treat infertility is to see a
doctor 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 doctor'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 doctor 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
doctor for the names of counselors or therapists
with an interest in fertility.

This page last updated: October 2004
Source: Womenshealth.gov