What does it mean to be infertile?

The definition of infertility is very difficult since it is the absence of an event. For example, how long should it take to conceive when there is no infertility? Does a person have any chance of conceiving? Consider a woman 55 years old who is menopausal. It doesn’t take a genius to figure out that she will not conceive on her own (with her own eggs).  

This fact gets a bit muddled when the media reports on a 55 year old woman delivering twins or triplets…without including the ‘tiny detail’ involving the use of donor eggs. But what about a 47 year old woman who still has regular menses? Or a 41 year old female with regular menses? Are they infertile? Studies suggest that the 47 year old is highly unlikely to conceive with her own eggs and the 41 year old has a 50-50 chance of conceiving with her own eggs. When should these women get concerned about getting pregnant on their own?

So, what is “fertile”? A fertile woman is defined as a woman who conceives and delivers a child. Studies have shown that if you evaluate the time to conception for fertile women, 65% are pregnant within 3 months of trying and 85% are pregnant within 6 months of trying. These figures are true almost independent of age, meaning that a  fertile 41 year old female will achieve a pregnancy within the same timeframe as a fertile 21 year old female.   However, keep in mind that there are, by definition, fewer 41 year old fertile females than 21 year old fertile females.   And the quality of eggs between a 41 year old female, fertile or not, also will differ dramatically from her 21 year old fertile counterpart.

The American Society for Reproductive Medicine (ASRM) has defined infertility as a disease where a successful pregnancy has not been achieved within the first 12 months or more of regular unprotected intercourse. Treatment and evaluation may be indicated sooner than the one year definition if the woman is over the age of 35. (Fertil.Steril. 2008: 90; S60)

Nature’s Way

Maximizing the chance to conceive begins with sufficient “pregnancy exposure” (read: enough sexual intercourse at the right time.) Therefore, the first question becomes: “What is enough?” Men and women usually disagree on this topic. But for many couples, trying to conceive and not being immediately successful produces significant stress such that intercourse becomes more of a chore than a pleasure. The question becomes not how often can we have intercourse, but how often do we need to have intercourse.  In general, having intercourse every other day around the time of ovulation will produce the highest spontaneous pregnancy rates.

But when does ovulation occur?

To begin with, for a fertile female with regular cycles, ovulation usually occurs 12-14 days prior to her expected menses.  This is calculated based on the first day of FLOW being day one (not spotting).  For women with regular 28 days cycles, calculating backwards, this means ovulation occurs somewhere around day 14.

For 30 day cycles, that would mean around day 16. Cycles which have become shorter than 26 days are a concern, and for women over the age of 35, this should prompt a visit to the doctor to evaluate ovarian reserve. Longer cycles may be OK, but the longer the interval – the lower the pregnancy rates and the more likely a problem exists – usually easily treated. Thus for the average fertile female, having intercourse on days 12-14-16 or 13-15-17 (again, depending on the length of her cycle overall) will maximize the chance for getting pregnant. Having done this for 6 months (not necessarily consecutively) without success makes it far more likely that a problem exists and an evaluation may be indicated.

Have I ovulated yet?

Monitoring ovulation has become both an obsession and a large business.  Most of this is unnecessary, but other than creating more hassle and stress, it probably will not reduce a person’s chance of conceiving. Both basal body temperature charts and cervical mucous testing are time consuming, inaccurate and unnecessary. Again, if a woman is fertile and having regular cycles, she is likely ovulating, making testing unnecessary. If she has irregular cycles, then an evaluation needs to be done to answer the question as to why the cycles are irregular and which treatments will be effective in achieving a pregnancy.

However, if a woman wants to predict her time of ovulation, the home urinary ovulation predictor kits are accurate.  The way to use them however, is sometimes different than the instructions on the kit. Two types of home predictor kits are popular- those for detecting ovulation and those for detecting pregnancy. The underlying principles behind these kits are quite different.  

The kits for pregnancy testing are designed to detect very low amounts of the pregnancy hormone HCG, which is only present in a woman when she is pregnant. So the idea is to have as concentrated a urine sample as possible since this hormone will not be present if she is not pregnant. The first morning urine sample is generally the most concentrated and this is the one best used for home pregnancy detection. But the ovulation kits detect the hormone LH which is always being produced. The kit is designed to detect a rise in the LH level which occurs about 36 hours prior to the release of an egg (ovulation).  

For this test, a concentrated specimen might give the false impression that ovulation is about to occur. Thus,  a first morning specimen is not the one to use.  One way to use these kits (and there are many suggestions) is to urinate at around 4 PM. Then urinate at 6 PM and perform the test on this specimen. The testing needs to start before any color change has occurred and the test is valuable when the first color change occurs. The color does not have to match the test strip, only that there is a color change which should be occurring based upon the predicted day of ovulation. The best time to have intercourse is the following two nights, but having intercourse on the night of the first color change is perfectly OK.  Once there is any color change, stop performing the test because after that there is no useful information to be obtained. A very important point is that these tests are designed to detect the LH surge prior to ovulation which is the release of an egg. This obviously is crucial, but of greater importance is the quality of the egg released, which cannot be predicted by these tests.   So a 44 year old woman may have perfect ovulation by these kits but have no chance of pregnancy because all her remaining eggs are structurally damaged by age.

How do the Birds and the Bees do it?

What about sexual positions or lying supine or with hips elevated after intercourse?  The best answer is that it’s not that complicated.  Any sexual position whereby vaginal intercourse occurs is OK. Semen always leaks out of the vagina and lying around after intercourse will not increase the chance for conception.

Other myths relate to boxers vs. briefs for men’s underwear, dietary supplements, saunas, and hot baths. None of these will significantly influence a fertile woman’s chance to achieve a pregnancy. Alcohol and caffeine consumption may have an influence on pregnancy and they certainly have an influence on an established pregnancy. Limiting each of these is probably a wise decision, but there is no need to absolutely stop all caffeine. Once pregnant, alcohol is a fetal toxin so even a small amount is not helping the child. Smoking does have a negative effect on achieving a pregnancy. This becomes an issue for women who smoke and are of advanced maternal age.

Simply put, fertile women should achieve a successful pregnancy within the first six months of pregnancy exposure. For women where this has not happened an inquiry to a physician might help detect a problem that could lead to successful treatment.  And remember, even the birds and the bees don’t get it right every time.