The decision to start a family is scary and exciting and when you have decided that it is time to become parents you assume that that is all it takes. For over 80% of fertile couples that is the case; most become pregnant within 6 months of trying. However, for approximately 15% of couples, they can find that they are still not pregnant despite trying for over 12 months. This is the medical definition of “infertility”; however I prefer to call it “delayed conception” as most of those couples do eventually become pregnant; 50% of them with conceive spontaneously in the next 12 months of trying. Although this is somewhat reassuring, couples who are experiencing delayed conception want to be pregnant now! After 12 months of trying, if a couple has not become pregnant then it is appropriate to do an evaluation to see if there are any treatable causes for their problem.
Infertility is a “couple” problem; it should not be thought if as only a woman’s issue. As high as 40-50% of sub fertile couples are found to have abnormal semen analysis results and it is extremely important to have a semen analysis done as a first step in the evaluation of delayed conception. The semen analysis should be done in a specialized laboratory to obtain the best clinically important information.
Evaluation of the woman is much more complicated. Not surprising huh? I find it easiest to break down the evaluation into specific areas. The first step is to make sure that the woman is ovulating regularly. Most women who have regular menstrual periods that occur every 28-30 days do ovulate and urine ovulation predictor kits do work to help anticipate when that will happen. A good rule of thumb is to get a 5 day kit, start testing day 11 of your menstrual cycle (day 1 is the first day of menstrual bleeding), and when you get a positive result then you will release an egg within 24-48 hrs after the positive result. That is the best time to have intercourse! If there is no obvious positive then that could definitely be the problem. Ovulation problems can have many causes and the first step in figuring out what might be going on is to have some basic blood work. Of course if you have not had a complete physical exam within the last 6 months then that should be done as well. Thyroid abnormalities and other glandular abnormalities such as Polycystic Ovarian Syndrome may be present; other medical problems and or medications can also be a potential cause. The next step in the evaluation is to make sure that the pelvic organs are healthy and that there are no abnormalities that could be interfering with pregnancy. A pelvic ultrasound and a specific radiological study called a Hystrosalpingiogram (HSG) can be done to evaluate the uterus and fallopian tubes. An office pelvic exam can be done to make sure that the cervix is normal in appearance and healthy. Other procedures can also be done, including a minor outpatient procedure called a laparoscopy, to evaluate the pelvis.
Of course, it would be much better if a couple never has to be in the position of having an “infertility work-up” and at Women’s Wellness we feel it is of the utmost importance to prevent problems when we can. There are some things that you can do that have been proven to help in achieving that desired pregnancy.
Some of the most common questions that I get relates to the most ideal timing and frequency of intercourse to achieve pregnancy. Forget what your best friend or your mom told you (unless either one is an OB/GYN!). The most fertile time in a woman’s menstrual cycle is approximately 6 days long and includes the 5 days prior to ovulation and the actual day of ovulation. This is not affected by age. The highest probability of conception occurs in the two days prior to ovulation and the day of ovulation. With a normal menstrual interval (occurring every month) then ovulation occurs approximately 13 days from the first day you started bleeding. Frequency of intercourse should be approximately every 1-2 days during this fertile time and to assure the best quality sperm will be present when needed, there is evidence that it is best if there is a less than 3 day period of abstinence prior to this time of optimum fertility. There is also some concern about the use of lubricants; it is recommended that if lubricants are necessary then it is best to use natural lubricants such as mineral oil or the brand “Pre-Seed”. Other concerns such as position during intercourse, elevating the pelvis and whether or not a woman has an orgasm all have no effect on conception.
Personal lifestyle choices can affect your chances of conception. Tobacco use is associated with delayed fertility in woman and with reduction in sperm quality in men. Alcohol use in women and men of greater than 2 drinks per day is associated with delayed conception. Moderate consumption of caffeine (1-2 8 oz cups/day) is not associated with any difficulties with conception. Although there is no definitive evidence that recreational drug use is associated with delay in conception, it does carry health risks and it is discouraged.
One of the most significant issues that can impact conception is being overweight and/or obese. For women the optimum BMI for conception and healthy pregnancy is 18.5 to 25; a BMI of less than 17 and over 27 is associated with problems with ovulation. Even in women who ovulate regularly, a BMI over 27 is associated with increased time to become pregnant. Obesity is also associated with increase risk for pregnancy complications. There is something that you can do about it. In women who do not ovulate regularly and have a high BMI, weight loss has been shown to help achieve spontaneous ovulation and conception. I am a firm believer that a healthy diet is if the utmost importance for all and at Women’s Wellness we have made it a priority to help you get the guidance that you need to optimize your chances for success! A quality multi-vitamin is also very important to take for at least 3 months before you attempt pregnancy as well as the time that you are trying and during your pregnancy. A recent study showed that taking a prenatal vitamin for 3 months before attempting pregnancy decreased the time it took to become pregnant and also reduced the incidence of significant nausea and vomiting in the first trimester of pregnancy. Not all vitamins are created equal however; it is important to make sure that you are getting what you need.
A couple of other things to consider; environmental exposure to certain toxins such as BPA (present in certain plastics, especially water bottles) and phthalates (DEHP; present in shampoos/lotions) have been shown to have effects on fertility as they can affect the action of natural hormones and should be avoided. Ways to avoid these toxins are to avoid high fat foods (cream/whole milk/fatty meats), avoid canned fruits and vegetables, use glass/stainless steel/ceramic and wood containers for food instead of plastic and do NOT microwave in plastic containers. Avoid plastic with the number 3, 6 or 7 on the bottom and minimize the handling of receipts (email is much easier to keep track of anyway!). I also recommend that the majority of your diet should be REAL FOOD; no processed food, organic as much as possible and limit sugar. Diets high in sugar cause inflammation and inflammation leads to organ dysfunction; you really are better off without it!
Exercise is also important for general good health and moderate regular physical activity is best. However if you are a vigorous and dedicated athlete there is no reason for concern as long as your BMI is greater than 25; if it is less than this you might want to consider reducing the intensity to allow for a BMI around 25 if you are experiencing a delay in conception. This recommendation is based upon a very well-designed Danish study. Of course for those women who have a BMI of greater than 27, incorporating more exercise will help you to reduce your weight and hopefully assist you in achieving pregnancy. Even 30 minutes of vigorous walking 3 times a week can help considerably.
Once you have finally achieved that positive pregnancy test the healthy habits that you have practiced before will help you to have the healthiest pregnancy possible for you and your baby!