Guest Post by Ann Korkidakis, MD MPH
For most beginning on their fertility journey, the end goal is obvious (and adorable!), but the path to get there can be a big unknown. Whether you’re at the starting line or somewhere along the road, it is always helpful to brush up on the basics. A lot of biology goes into getting those double lines to appear on a pregnancy test. Understanding how it all works, and when to reach out for help, can optimize your chance of conceiving and carrying a healthy pregnancy.
It’s all in the numbers
Before you were ready to start a family, it is likely that you put a lot of effort into not getting pregnant. Perhaps this is why the pregnancy rate per month (known as cycle fecundability) is often thought to be much higher than it actually is. Research shows that the truth of the matter is that couples in their thirties have a 15-20% chance of getting pregnant every month. That is why infertility is typically diagnosed only after a full year of unprotected intercourse without conception. Somewhere between 85-90% of couples will get pregnant within that time frame.
How to track your cycle
In order for a pregnancy to occur, the sperm and egg must meet at precisely the right time. Once an egg is released from the ovary (known as ovulation), it is viable for up to 24 hours. Sperm can live in the female reproductive tract for a maximum of 5 days. That is a pretty narrow fertile window! Of course, monitoring for this ovulatory period is not essential. Many couples will conceive without paying too close attention to timing. If you want to take a proactive approach, however, cycle tracking can help identify your fertile window and maximize the chance of pregnancy.
The simplest method of ovulation tracking is the “calendar method”. If you have regular cycles, ovulation generally occurs 14 days before the expected first day of your next period (first day of period = cycle day 1). For cycles that tend to be 30 days long, ovulation would occur around day 14. In general, the most fertile period starts 5 days before and ends 1 day after ovulation. If you are looking to conceive, you should time intercourse to this 6-day window. The ideal frequency of intercourse is less clearly defined, but most experts recommend having intercourse at least every other day during this period.
There are many more options for detecting ovulation. Charting basal body temperature and cervical mucous characteristics can help you pick up on physiologic changes that occur with ovulation. Cervical mucous tends to be thin and white in the ovulatory period. On the other hand, basal body temperature rises after ovulation, making it a better option for planning around upcoming cycles. Both of these methods do have low accuracy and can be quite tedious to keep up over several cycles. For these reasons, ovulation prediction kits (OPK) are often favored. These tests detect urinary LH, a hormone that surges mid-cycle to signal to the ovary that it is time to release an egg. The surge lasts up to 36 hours, meaning that the test is generally only positive for 1-2 days. Targeting intercourse to the day of the first positive test and the subsequent day is ideal. Notably, OPKs can be misleading in some women, particularly in those with polycystic ovarian syndrome.
As we all get more tech-savvy, it is increasingly common for women to rely on a fertility app for cycle tracking. These apps estimate the fertile window based on prior cycle length trends. Having a record of past menstrual cycles with built-in reminders right at your fingertips can certainly help with organization and cycle awareness. However, it is important to point out that recent studies have raised concerns about the accuracy of these applications. In fact, all of the fertility tracking modalities have their limitations, and a fertility specialist can help determine which method is best suited for you.
Why age matters
When it comes to fertility, a lot of emphasis is placed on a woman’s age. Healthy males are constantly producing sperm; approximately 1,500 sperm are made in the testicles every second. In contrast, women are born with all of the eggs that they will ever have. There are about a million of these eggs, each within a fluid-filled cavity called a follicle, in the ovaries of a newborn girl. This number steadily diminishes, leaving girls entering puberty with a stockpile of 300,000 to 400,000 eggs. The decline in egg quantity is accelerated once a woman reaches her mid-30s and at that point, there also starts to be a compromise in egg quality. These age-related changes make it more difficult to become pregnant after 35 and increase the risk of pregnancy loss. Of course, age is just one of the many considerations that go into deciding when to start a family. Speaking to a fertility doctor about your options when it comes to delayed childbearing can help empower you to make informed decisions about your timeline.
When you should seek help
Sometimes, the hardest step is recognizing when you need help. Infertility is typically diagnosed when a couple is unable to achieve a pregnancy after 12 months of regular, unprotected intercourse. For women over 35 years old, it’s actually recommended to seek help after 6 months of attempts. Importantly, there are circumstances when it is reasonable to consult with a professional right from the beginning.
You may benefit from an early fertility assessment if:
- You often have irregular cycles with less than 21-day or more than 35-day intervals (from the start of one cycle to the start of the next cycle). This may indicate that you have an ovulatory disorder, and fertility can certainly be complicated when an egg is not being released in a predictable and regular manner. A fertility specialist can help identify the underlying problem and suggest appropriate treatment.
- You have very painful periods that interfere with your daily functioning. You may have moderate-to-severe endometriosis, which can negatively impact fertility. It may still be reasonable to try on your own, but a specialist can help provide some guidance.
- You have experienced 2 or more pregnancy losses. Having a history of multiple losses may warrant further testing to exclude possible endocrine, anatomic, auto-immune, or genetic causes.
- You are single or a member of the LGBTQ community and would like to know more about your family-building options. We are privileged to work closely with individuals in personalizing care around their unique fertility needs and goals.
- You have been previously exposed to chemotherapy or pelvic radiation. These treatments can significantly impact both female and male fertility. Assessing your current fertility status can assist with planning.
- Intercourse just isn’t working well; whether it’s painful or there is difficulty with achieving an erection or ejaculation. It is common for couples to experience sexual dysfunction at some point of their fertility journey. Managing these concerns can improve overall well-being and facilitate future attempts at conception.
- You or your partner have a history of a serious genetic disorder. Technological advancements have allowed for the selection of embryos that do not carry these known disorders. If this applies to you, it is certainly worth knowing more about this option before attempting a pregnancy.
It’s important to remember that consulting with a fertility specialist doesn’t commit you to complex treatments. Early assessments may uncover treatable conditions or offer simple techniques that may boost chances for pregnancy. Wherever you are on your journey, having a better understanding of your fertility status, as well as the possible paths ahead, can assist you in navigating these challenging times.
Dr. Ann Korkidakis is a fellow physician in the Division of Reproductive Endocrinology and Infertility at Beth Israel Deaconess Medical Center and Boston IVF.