Step 3 – Getting Pregnant
When I meet an infertile couple, the first things I want to know are the age of the woman, her past reproductive history and how long this couple has been having intercourse without contraception.
Make an Appointment
I’m generally not as interested in how long they’ve been “trying” to get pregnant. The reason I say this is because if couple has been “trying” to get pregnant for 6 months but have not used any form of birth control in six years, then they have 6.5 years of infertility. Their prognosis is frequently much worse than another couple that quit birth control 12 months ago and is not pregnant.
Areas of Concern
When we give talks about getting pregnant, we frequently discuss six areas of concern: duration of infertility, adequate intercourse, adequate ovulation, adequate sperm, anatomy and ovarian reserve.
Of the six areas of concern, three are essential to conception and these are: a woman must produce an egg (ovulation), the man must have sperm, and the sperm and the egg must be able to meet (adequate anatomy).
Many couples that are trying to conceive fixate on exact timing of intercourse, when in truth exact timing is not particularly important. What is essential is that a couple has intercourse on, or prior to, the day of ovulation.
Sex on a single day of the month has virtually the same chance of pregnancy if the sex occurs on the day of ovulation, the day before ovulation or even the day before that.
Sperm can live up to five or six days and still fertilize. This means, for most couples, intercourse every two to three days is adequate.
Intercourse 24 hours after ovulation has a very low chance of pregnancy. After ovulation, the egg lives only about 12-24 hours. So make sure you have sex prior to ovulation if you want to conceive.
Ideally, adequate intercourse would mean satisfactory intercourse for both partners. Unfortunately, for the purpose of getting pregnant, it really only has to be satisfactory for the male – as he must deposit sperm into his partner. Female orgasm has no significant role in fertility. I know, it’s not fair.
Ovulation (producing an egg) is essential to getting pregnant. Most women who have regular predictable menses are ovulating. Ovulation is even more likely in regularly cycling women who reliably predict their menses because of breast tenderness or bloating or mood changes that precede the menses by a few days.
Ovulation can be confirmed various ways, with basal body temperatures, ovulation predictor kits, or even a blood test. Ovulation is generally deemed adequate when the luteal phase is 11 days or longer based on basal body temperature charts or 12 days or longer based on ovulation predictor kits.
Normal menstrual cycles are between 24-35 days. Shorter cycles frequently mean a woman’s ovarian reserve is declining and should be evaluated. Longer cycles can mean a woman is not ovulating and also should be evaluated.
If a man has any sperm, it is possible to get pregnant; however, once sperm counts go below 15 million per ml, the chances of pregnancy can plummet significantly. Of course, we don’t recommend home sperm testing, because there are many facets of sperm that may affect fertility. Because it is a painless test, this should be the first test sought by a couple.
If there is a history of frequent sauna or hot tubbing, significant testicular trauma, testicular surgery, undescended testicle, prior radiation or chemotherapy, low libido, erectile dysfunction or low volume ejaculations then a more immediate evaluation should be pursued.
The fallopian tubes serve as a transit system for sperm and eggs. When a woman ovulates, the tube picks up the egg and holds it there for sperm to fertilize. For their part, the sperm are deposited in the vagina and have to swim through the cervical mucus, up through the uterus and out to the tube. Only 1 in a million sperm will eventually make it to the egg with intercourse.
- If the cervical opening is small or scarred due to prior surgery it may not produce the needed cervical mucus which assists in the transport of sperm.
- If the tubes are blocked, the egg and the sperm cannot meet.
- If sheets of adhesions (scar tissue) separate the ovary from the tubes, getting pregnant can be a real challenge.
- If benign tumors such as fibroids are growing in the uterus, this may prevent a pregnancy from taking hold.
Women with infertility for more than one year should have an x-ray called a hysterosalpingogram performed.
Endometriosis, a condition in which uterine lining grows outside the uterus, can sometimes distort the anatomy. Even when it doesn’t distort the anatomy, endometriosis can make getting pregnant more difficult.
If you are just starting to get pregnant and you have a history of endometriosis, ask your physician if yours is so severe that you should do something about it.
This is the biological clock. The best predictor of the biological clock is a woman’s age. By age 35, nearly 30 percent of women will be sterile. By age 40, nearly 70 percent will be sterile.
In a study of women who never used any birth control and stayed married their entire lives, the last average pregnancy occurred at age 42. Many of these pregnancies ended in miscarriage because the embryos have a higher rate of being abnormal the older women get.
The biologic clock, or ovarian reserve, is determined by several factors: how many eggs a woman had at birth, how much damage has occurred to her ovary or eggs throughout her life, and how quickly she has lost her eggs.
Smoking, ovarian surgery, radiation and chemotherapy can all lead to premature depletion of eggs. Genetics can also cause early loss of eggs. We find that many women with unexplained infertility and with endometriosis have findings consistent with diminished ovarian reserve.
A sign that ovarian reserve is decreasing is a shortening of the menstrual cycle. Women who were regularly menstruating every 28 days may find themselves having cycles every 24 days. This can be evidence of diminished ovarian reserve.
The same goes for women who had PCOS and who never or rarely ovulated on their own who suddenly find themselves having normal menses.
If you have any of the risk factors above, strongly consider having your physician, or us, evaluate your ovarian reserve.