Updated: Jun 15
Now that you have been trying to conceive (TTC) for 6 to 12 months, and you have been deemed suffering from infertility, what do you do next? Your doctor's orders were: have sex every 48 hours from the end of your period to the start of the next, but the woman's fertile window is much shorter than that - about 6-7 days in one cycle. If you are like me, or any other over-achieving working professional, then you may not have the time or energy to set aside the time to connect with your partner. Of course, once you know the 'why' of why are you not conceiving, then your doctor or fertility specialist can assist you, but as mentioned, during COVID-19, all non-essential businesses have closed their doors. The things I have included in this post are things that I hope can help you determine of clues to why you may not be conceiving.
This is day two of my posts for National Infertility Awareness Week (NIAW). While this is part of my series for NIAW, this was actually the first post I started writing - bringing to you some basics.
Having self-awareness is important. Understanding when you are stressed, anxious, depressed, often you can 'feel' that in your body, but you can sometimes 'feel' when you are fertile. For women with limited time, with limited energy, or those who just want to know their bodies better, I hope this is helpful for you.
Tracking Your Cycle
There are several mobile applications for tracking your cycle and predicting ovulation when you are TTC. The Natural Cycles App is the one that I started with. A friend of mine was using it as a natural contraceptive, so I started tracking my cycle long before I was TTC. I already knew I had a short cycle length (23-24 days), but I didn't track my ovulation until recently. I first started tracking my basal body temperature (BBT - first thing in the morning). Then the app told me the average length of my follicular phase (when the follicles are growing towards ovulation) and my luteal phase (after ovulation when the corpus luteum is growing). My luteal phase length averages 10 days. I honestly thought nothing of this previously, as with a background in reproduction in cattle, cows have 2 or 3 follicular waves, and therefore have variable lengths of their cycles - this is natural. As a refresher, below is an image of the menstrual cycle of a woman.
They say an average length of a woman's cycle is 27-28 days, but some women have a shorter length (~24 days) and some have a longer length (~34 days), and similar to cattle, women can have 2 or 3 follicular waves.
What do I track?
There are a few changes that occur during your cycle, outside of your menses. For most women, we know roughly when our next menses is going to occur. We've been keeping track of this for a while. However, when you are trying to conceive, or are struggling to conceive, then you may wish to include tracking additional markers. As estrogen increases, then your cervix will change. The mucous it produces can be thinner or thicker, or none at all. The thinner, clear mucous makes it easier for the sperm to swim in. Your body temperature changes with the level of progesterone, due to an increased metabolic rate of the structure in the ovary called the corpus luteum. And the level of hormones can be tracked as well - specifically LH (luteinizing hormone).
Otherwise known as CM in the fertility world, cervical mucous is a marker of fertility. When estrogen is high, this is highest right before ovulation, then the cervical mucous is more clear, and people refer this to egg-white consistency. Tracking your CM and when you have EWCM (egg-white cervical mucous) can help you understand when your estrogen is high. Being a veterinarian, this is a marker of fertility in cattle as well! When we go to check a cow or do artificial insemination, noting the amount of clear mucous tells us that we are insemination at the right time in the cow's cycle.
What have I been tracking?
Now that I have been unsuccessfully TTC for 7 months, I am doing more reading about what is 'normal' versus abnormal, and different causes of infertility in women (other than increased maternal age and decreased AMH). A luteal phase that is 11 days or shorter is considered abnormal, or gives the woman are poorer prognosis of natural conception. In additional to having a shorter luteal phase, some woman may experience a luteal phase deficiency (lower levels of progesterone and potentially bleeding or spotting during their luteal phase). AMH is not predictive of luteal phase defect. Stay tuned for a future post on addressing a short luteal phase with supplements.
The second mobile app that I started using more recently was the PreMom app. I started using ovulation prediction kits (OPK; these measure your LH concentration) so that I could predict my ovulation better, in combination with my BBT which confirms ovulation. The easy home OPK is the one I have been using with this app. I like the app because it can take a photo and measure your relative LH levels based on the ratio of your test line versus the control line. I find that the Natural Cycles app is a better predictor of your cycle - and changes as your cycles vary - but the PreMom app is great for getting that peak. So once I get peak LH, then I enter that as a positive test in the Natural Cycles app. Seems complicated, but hey, I like to have some control over what is going on.
Natural Cycles and monitoring BBT
Take a look at the graphs below (screenshot from the Natural Cycles app). What you can see is that the day of my ovulation is not consistent. In those three consecutive cycles I ovulated on Cycle Day 10, 12 and 14. That means if you predict that you ovulate on Day 14 (which is the middle of the average 28 day cycle), and you wait until day 12 to get between the sheets, then you have already missed your fertile window. What you can also see to the right is that my luteal phase is very consistent. This is the case for most women.
PreMom app and monitoring LH peak
In general, the sperm needs to be there before ovulation. Therefore, if you are only tracking your BBT it is not sufficient enough when you are TTC.
I have only been consistently tracking my LH for about three cycles. I used to do it sporadically, but now I have more experience with this.
The first full cycle I tracked the LH 'peak' was still below a ratio of 1.0. Then I had an anovulatory cycle where my LH was consistently high and I didn't ovulate at all (as confirmed by a lack of increase in BBT before menses occurred). This past cycle (the image below) you can see that my LH peak occurred on Cycle Day 10. When tracking your LH, it is going to be very individualistic, but roughly around CD8 (Cycle Day 8) I take one LH first thing in the morning. If it's low, then I take it again the next day. If it's starting to increase and says High, then I will take it multiple times in a day. Maybe 2-3 times. The highest test to control (T/C) ratio is considered your peak. So on that peak day, I then mark it as a positive LH test result in the Natural Cycles app.
The Natural Cycles app has predicted my cycle better than the PreMom app. Some women in the TTC online community haven't been super happy with the PreMom app. But I like the T/C ratio part and it's a free app, so why not!
Short Luteal Phase
So what does it mean when you have a short luteal phase? When you ovulate the egg goes in the fallopian tube and you hope that sperm have made their way to this location. Inside the oviduct is where fertilization occurs. After fertilization, the baby is starting to develop - first as a zygote, then a multicellular morula, then a blastocyst - which is the stage of early development of the placenta prior to implantation. The embryo at this stage enters the uterus and you have to have a blastocyst to get implantation. The embryo enters the uterus around 6 to 12 days after fertilization/ovulation.
Two Week Wait
The other time frame that women who are trying to conceive will be anxious about is called the two week wait (TWW). This is a generalized time frame from ovulation (think of day 14) and when menses starts (think of day 28). During this time frame is when women will be waiting to take a pregnancy test. The First Response test is supposed to be one of the more sensitive over-the-counter tests as it can measure the amount of hCG (human chorionic gonadotropin) in the urine at a lower detection limit. However, most women will use the cheap hCG strips (like the ones in the easy home kit) if they have been trying for a while. Then use one of the expensive ones to confirm. Also, most women don't trust the tests with blue dye.
This TWW however may not be two weeks if you are like me and have a short luteal phase. The luteal phase is less variable - remaining fairly consistent cycle to cycle. If you ovulate earlier, then your menses will start earlier than you anticipate. The early pregnancy tests may be able to detect hCG 5 days before your scheduled period (but not for all women).
Now, if you have a longer luteal phase, the blastocyst has a longer time to implant, then signal with hCG to the ovary to keep the progesterone levels high for early maintenance of pregnancy. It is a signal called maternal recognition of pregnancy. In brief, the growing baby needs to tell the mother's body to not regress the corpus luteum - the progesterone producing structure in the ovary. If the embryo does not have time to send the signal before the mother's endocrine system tells the ovary to shrink the corpus luteum, then menses will begin and the embryo will be sloughed off with the uterine lining. This is the ultimate problem for women with a poor production of progesterone, or a short luteal phase. In the next few posts I will discuss a few things that may help women with a short luteal phase. Until then, stay positive! Stay safe!
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