Trying To Conceive ‘TTC’
"People who are concerned about their fertility should be informed that vaginal sexual intercourse every 2-3 days optimises the chance of pregnancy" (NICE 2013)
Many women have unrealistic expectations about a normal time to pregnancy and may feel pressures in view of their age. For most couples, conceiving is easy. It simply takes time and opportunities for sex. Biologically, the optimum age for natural conception is between 25-35 years.
The National Institute for Health and Care Excellence (NICE) guidelines suggest that "People who are concerned about their fertility should be informed that over 80% of couples in the general population will conceive within one year if the woman is aged under 40, they do not use contraception and have regular intercourse (every 2-3 days). Of those who do not conceive in the first year, about half will do so in the second year - that means that 90% of couples will conceive within two years.
"People who are concerned about their fertility should be informed that vaginal sexual intercourse every 2-3 days optimises the chance of pregnancy" (NICE 2013)
Preconception health and lifestyle
Women who are planning pregnancy should discuss their preconception health with their fertility awareness practitioner, GP or practice nurse. This provides an opportunity to discuss any lifestyle factors including alcohol, smoking, weight, diet and exercise, all of which can adversely affect fertility.
All women should start taking 400 mcg of folic acid three months before conception (and for the first three months of pregnancy).
Supplements
Folic acid reduces the incidence of neural tube defects such as spina bifida. Some women may require a higher dose of folic acid. The medical consultant may want to test vitamin D levels and advise on supplementation with vitamin D or a multivitamin supplement. A preconception consultation should also include a blood test to confirm immunity to rubella. Infection with rubella in early pregnancy has serious consequences for the unborn baby. For more information on preconception care see the WHO Preconception Care Brief.
Immunizations
The Advisory Committee on Immunization Practices of ACOG and the American Academy of Family Physicians have identified that assessment of immunity and appropriate protection should be provided to all women of reproductive age. All women should have their immunization status for tetanus, diphtheria, pertussis; measles, mumps, and rubella; and varicella reviewed annually and updated as indicated. Infection with rubella in early pregnancy has serious consequences for an unborn baby.
Body Mass Index (BMI)
A woman’s nutritional status has a profound impact on her own health and can impact fertility and reproductive outcomes. All women should have their BMI calculated at least annually. Women with BMIs greater than 26 kg/m should be counselled about the risks to their own health, the risks for exceeding the overweight category, and the risks to future pregnancies, including infertility. Obesity, defined as a BMI of greater than 30 kg/m2 is associated with elevated risks of type 2 diabetes mellitus, hypertension, infertility, heart disease, gallbladder disease, immobility, osteoarthritis, sleep apnea, respiratory impairment, social stigmatization, and a variety of cancers that include breast, uterine, and colon. Losing 5-10% of total body weight over a 6-month period has been shown to help with hormonal imbalances and often times, women who previously had difficulty conceiving - conceive more easily.
Optimising Natural Conception
Understanding the importance of Cervical Secretions:
Cervical mucus is fluid that the cervix releases into the vagina. It has several functions, including keeping the vagina lubricated, preventing or allowing sperm to travel into the uterus and preventing infection. Throughout the menstrual cycle, hormonal shifts influence the amount, texture, and appearance of cervical mucus. Secretions change from a sticky, thick mesh-type secretion that previously prevented sperm penetration (in the first stage of the cycle) to a more wetter, transparent and stretchy, highly fertile mucus (at the time of ovulation).
The menstrual cycle is beautifully orchestrated with the monthly goal of achieving a pregnancy. The body really is a wonderful thing.
The ovarian hormone estrogen rises during the follicular phase of the cycle, peaking around day 14 (of a typical 28 day cycle). This estrogen peak causes a leutenizing hormone (LH) surge which causes ovulation as well as the cervical mucus to change from a sticky, thick mesh-type secretion that previously prevented sperm penetration to a more wetter, transparent and stretchy, highly fertile mucus.
‘Peak day’ is your most fertile day when the cervical mucus opens like a channel for sperm to swim through.
There are a limited number of days when secretions allow sperm to penetrate through the cervix. The appearance of the secretions changes during the menstrual cycle from sticky white to wetter, transparent and stretchy (highly fertile secretions). The last day of this highly fertile secretion is peak day. The day after peak the secretions change back to stickiness or to dryness again. The fertile time starts as soon as there is a possibility of sperm survival - this is shown by the first sign of secretions. The fertile time ends when the egg is no longer fertilisable - that is about three days after peak day. Remember, sperm can live in the cervix and uterus for 5 days. The egg can survive for a maximum of 24 hour (usually only 18 hours).
How do I check my cervical mucus?
Sensation: Sensation is important and often the most difficult to learn. Throughout the day the presence or absence of secretions is recognised by the sensation at the vulva (the vaginal opening), the way the beginning of a period is noticed. The sensation may be a distinct feeling of dryness, of dampness or moistness, stickiness, wetness, slipperiness or lubrication.
Appearance: Soft white toilet tissue is used to blot or wipe the vulva. There may be dampness only on the tissue resulting from vaginal moistness. This moistness soaks into the tissue and any cervical secretions appear raised as a blob on the tissue. It may be white, creamy, opaque, or transparent (clear). Secretions observed on underclothing may have dried slightly causing some alteration in characteristics.
Finger Testing: A finger-tip lightly applied to the secretion on the tissue and then gently pulled away tests its capacity to stretch. It may feel sticky and break easily, or it may feel smoother and slippery like raw egg white and stretch between the thumb and first finger, from a little up to several inches before it breaks. This stretchiness is known as the spinnbarkeit effect, and shows that the secretions are highly fertile.
Take Home - As soon as you see the creamy and watery ‘egg white’ mucus, have sex!
2. Optimizing Intercourse Timing
Knowing when to do it……..
The timing of the cervical secretions will vary dependent on the length of the menstrual cycle. A very broad estimate of the likely fertile time can be made by looking back at the length of the last 12 menstrual cycles (it can be useful to track your cycle length on a fertility app or fertility chart). The follicular phase of a cycle is at the beginning, when the follicles are growing. It is phase of the cycle that can fluctuate the most. It can last anywhere from 7 to 21 days. The best way to determine your most fertile window is by counting backwards from your last period. Ovulation usually occurs approximately 10-16 days before you started last period. Timing intercourse by using this approach as well as monitoring changes in cervical mucus can help you to optimise intercourse timing. As per NICE recommendations, couples should practice vaginal sexual intercourse every 2-3 days to optimise their chance of pregnancy. This approach will mean that your probability of conceiving is high. It is not always possible however for couples to have sex every 2-3 days, whether this is due to travel or work commitments, and so using other methods such as cervical mucus monitoring and basal body temperature monitoring, which we will discuss below, is a great approach.
3. Basal Body Temperature ‘BBT’
Should you be monitoring your daily temperature?
There are mixed reviews about the usefulness of waking temperature for women trying to conceive. It does not give any useful information about intercourse timing, because the temperature does not go up to the higher level until after ovulation.
Therefore it’s too late. You’ve missed the boat. However, this method can be useful to confirm the occurrence of ovulation and the length of the luteal phase. Basal body temperature (BBT or BTP) is the lowest body temperature attained during rest. It is usually estimated by a temperature measurement immediately after awakening and before any physical activity has been undertaken. Once a rise has been seen for three consecutive days - ovulation can be confirmed (it occurred on the first day of the temperature rise).
4. Ovulation predictor kits
Ovulation predictor kits are great at detecting the LH surge however they don’t absolutely confirm ovulation - they predict that ovulation is likely to occur (by detecting the surge in luteinising hormone ‘LH’). Some kits only identify two days of maximum fertility whilst others typically identify four days (using estrogen metabolites as well as LH). These kits (and monitors) may be of value if women are unable to distinguish their cervical secretions, but they are costly and can often place added pressure on a relationship.
Proof of ovulation
It’s really important to know that the presence highly fertile secretions (wetter, slippery, stretchy secretions) is an encouraging sign reflecting the growing follicles and higher levels of estrogen, but these secretions do not prove the occurrence of ovulation. Similarly hormone monitoring and a rise in temperature only provide presumptive evidence. Ultrasound scans which monitor the growth of follicles and observe the corpus luteum provide strong evidence of ovulation, but the only definitive proof of ovulation is pregnancy.
When to seek further help
A couple under the age of 35, who have not conceived after 12 months of trying should seek medical advice with a view to referral for further investigations. Although it may take longer for women over 35 to conceive, investigations (on both partners) should normally be started after six months. NICE guidelines provide information on the diagnosis and management of fertility problems and the criteria for access to assisted fertility treatments such as IVF.