Infertility Is Not Just A Woman’s Issue
The decision to start a family is scary and exciting and when you decide it is time to become parents you assume that making that decision is all it takes and it will happen naturally right away. 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 some prefer to call it “delayed conception” as most of those couples do eventually become pregnant with 50% of them conceiving 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 this delay.
Infertility is a “couple” problem; it should not be thought of as only a woman’s issue. It is extremely important to have a semen analysis done as a first step in the evaluation of delayed conception. As high as 40-50% of sub-fertile couples are found to have abnormal semen analysis results so the semen analysis should be done in a specialized laboratory to obtain crucial and accurate clinical information.
Not surprisingly, evaluations for women is much more complicated. It is 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 occurring every 28-30 days do ovulate and using urine ovulation predictor kits will help anticipate when that will happen. A good rule of thumb is to use a 5 day kit and start testing day 11 of your menstrual cycle (day 1 is the first day of menstrual bleeding). When you get a positive result then you will release an egg within 24-48 hours after that. This is the best time frame to have intercourse! If there is no obvious positive result, then that could indicate where the problem lies. 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 or 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 there are no abnormalities that could be interfering with pregnancy. A pelvic ultrasound and a specific radiological study called a Hysterosalpingogram (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.
There are some things you can do that have proven to help in achieving that desired pregnancy. Some of the most common questions people have relate to what the ideal timing and frequency of intercourse is in order 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, there is evidence to show it is best if there is a less than 3 day period of abstinence prior to this time of optimum fertility. If the use of lubricants is necessary, it is recommended to use natural lubricants such as mineral oil or the brand “Pre-Seed”. Other common questions such as what the best sexual position is to use during intercourse, whether or not to elevate the pelvis and ensuring a woman has an orgasm has no effect on conception.
Personal lifestyle choices can also affect how quickly you conceive. Tobacco use is associated with delayed fertility in woman and a reduction in sperm quality in men. Alcohol use in women and men of greater than 2 drinks per day is also associated with delayed conception. Contrary to what some people believe, moderate consumption of caffeine (1 to 2 – 8 oz. cups/day) is not associated with conception difficulties and although there is no definitive evidence that recreational drug use is associated with a delay in conception it does carry health risks and 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 ovulation problems. Even in women who ovulate regularly, a BMI over 27 is associated with an increased delay in becoming pregnant. Obesity is also associated with increased risk for pregnancy complications. The good news is there is something 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. A quality multi-vitamin is also very important to take for at least 3 months before you attempt pregnancy, as well as while you are trying to conceive 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 by consulting with a knowledgeable authority.
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) and 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 recycling number 3, 6 or 7 on the bottom and minimize the handling of paper receipts since the majority of them are coated in BPA. Another recommendation is for the majority of your diet to be from REAL FOOD meaning no processed food, limiting your intake of sugar and eating organic as much as possible. Diets high in sugar cause inflammation and inflammation leads to organ dysfunction so 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 and you are experiencing a delay in conception, you might want to consider reducing the intensity to allow your BMI to increase. 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.
If you are experiencing delayed conception, you are not alone and you should discuss the various options available with your provider to determine the root cause and best course of treatment. Being proactive with your health by following these guidelines may help you on your path to finally achieving that positive pregnancy test and once you become pregnant then adopting these healthy habits will help you to have the healthiest pregnancy possible for you and your baby!
Anne Rainville, MD, FACOG is a highly trained, board certified OB/GYN specializing in women’s health. She recognizes that a close partnership between doctor and patient is essential to exceptional healthcare and is one of the reasons she practices in a small, private office setting to give you the time and attention you deserve. Dr. Rainville has special interests in fertility evaluation and treatment, minimally invasive surgery, urinary disorders, ultrasound services, adolescent gynecology and menopause. She is also the only OB/GYN in Maine trained in acupuncture. For more information, visit: www.womenswellnesscare.com.
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