by Kim Christopher Mackey, MD, OBGYN at The Women’s Center at Southwest Health
Women often ask me if it’s okay they’re not pregnant yet. Typically they’ll ask after six or nine months or even a year of trying, wondering whether everything is normal. We can approach this by figuring out whether things are normal and just need more time, or whether it’s time to do some tests and figure out if there’s a problem. Often, if we find problems, we also have solutions.
In order to get pregnant, a woman needs a few basic things. She needs to ovulate, she needs to have sex, she needs a partner with adequate sperm, and all of her anatomy needs to be working properly – fallopian tubes, uterus, vagina, and cervix. We take a pretty simple and straightforward approach to this by starting with some basic questions: 1) are the periods coming monthly, 2) are there symptoms, 3) how long is the bleeding. We’ll also perform a physical exam to make sure that the vagina and cervix are normal and that the uterus and ovaries are a normal size.
We start with talking about her periods. Periods should come monthly, every 27 to 29 days. There should be some breast tenderness, cramps, and maybe a little mood change before the period comes. Each of the bleeding episodes should be about the same length – three to five days. This is the typical pattern for regular, monthly periods. When periods are irregular, they might come every 24 or 31 days, for example, without any other associated symptoms. This can suggest a problem that is usually related to ovulation.
The most common problem with getting pregnant is usually that the woman isn’t ovulating, either monthly or sometimes at all. How can you know if you’re ovulating? There are lots of tests we can do to tell for sure, but one of the most accurate ways of knowing whether you’re ovulating is by keeping a calendar of your periods. They should be regular, monthly, and roughly 27-29 days in between. There should be some physical warning signs that let you know it’s coming. These warning signs include breast tenderness, cramps, and mood change. If a woman is getting these symptoms, having regular periods, and the bleeding about the same amount from month to month, then she’s most likely ovulating. The accuracy of body temperature measurements and ovulation predictor kits is close, but it’s not quite as valuable as a good calendar to keep track of symptoms.
Some women will ask how we can prove that she’s ovulating. That’s a really important question! We can prove ovulation with a blood progesterone test. Progesterone is a hormone that is only in a woman’s blood for three reasons – ovulation, pregnancy, or she’s taking progesterone pills. The progesterone that comes with ovulation comes in the middle of the second half of the cycle. If her cycle is 28 days, we have to time that blood tests really carefully to get it on day 21. If it’s done at the wrong time, the progesterone level can be too low, and we can miss it. If we find that the progesterone level is over ten, it proves ovulation even more than body temperature or an ovulation predictor kit.
The next thing we do is make sure the couple is having intercourse at the right time. One of the common questions about getting pregnant is when to have sex. We don’t recommend timing intercourse based on basal body temperature or ovulation predictor kits. Just keep a calendar. Sex should be daily or every other day. Sex shouldn’t be less than every other day, and it shouldn’t be more than once per day as the sperm count goes down a little bit if you have intercourse more than once per day.
Here’s how to time sex: If her period is coming every 28 days, then if we count day one as the first day of bleeding and day 29 as the first day of the next period, then day 14 is the typical ovulation day. So couples should be having sex around day 14. For example, sex should take place on days 12, 14, and 16 of a 28-day cycle. If her cycles are 31 days then sex should take place on days 14, 16, and 18. So the first of your period is day 1 and the first day of your next period is day one again, and that’s the cycle length. The second half of the cycle is always 14 days. If a woman’s cycle is 35 days, then she ovulates on day 21, and that’s how you can time intercourse.
For couples who are having regular intercourse and the woman is having regular periods, we usually wait about 12 months before we think that there’s a problem. At the nine to twelve month mark or for women who are not getting regular periods, we need to do some investigation.
The next part of the evaluation is focused on sperm count or semen analysis. This is an important step when we know a woman is ovulating and that she’s having regular intercourse. It is a very simple test and it can be done anytime. There’s one number that’s really important to us and that is called Total Model. That number is the total number of swimming sperm. It’s important for that number to the over 10 million per ejaculation to be considered normal. There are other criteria that are tested as well, but the only number that matters to us is Total Model. This is a test that we can order for couples, or a man’s physician can order for him. Typically it’s ordered through our office and is part of the full evaluation process and treatment of fertility problems.
Could Something Be Wrong?
You need to have a normal uterus and open fallopian tubes to get pregnant; we have tests for that, too. There are a number of ways of evaluating the uterus. Those tests include a traditional ultrasound, a saline ultrasound, and a hysterosalpingogram (HSG). These are all different x-ray tests to make sure that the uterus is a normal shape and a normal-size and to know there’s nothing abnormal inside like a polyp or a fibroid or something that might get in the way of getting or staying pregnant.
One of the most reliable ways to find out where the fallopian tubes are opened is something called a hysterosalpingogram. This is an x-ray test done with a die injected through the cervix into the uterus and a simultaneous x-ray. This test is performed in the hospital by the gynecologist and radiologist together. It’s a very accurate test to find out whether the fallopian tubes are open. There are some other tests to find out whether her fallopian tubes are open but they’re not quite accurate. Either a saline sonogram or surgery can give an idea, but typically those are not as accurate or necessary. If we find the fallopian tubes are blocked or there is some change in the uterus, we can often fix that with surgery.
If we find that the uterus is normal, the fallopian tubes are open, the sperm count is sufficient; then the most likely problem is that she isn’t ovulating properly. At that point, we have medication to help her ovulate. There are pills, shots, and a combination of the two. The more you take the higher chance that a couple will get pregnant. Of course, the more you take the more costly things are, and the more trips you have to make to the doctor and the laboratory. Typically we start with medicine in pill form, and there are two medicines on the market. The first is called clomiphene citrate. The other is called Letrozole. Clomiphene citrate has been on the market for over 30 years, while Letrozole is a little bit newer. Letrozole actually came to the market has a breast cancer medicine, but we found that has very good, effective, and safe effects in helping with fertility.
What we know is that 75-percent of young healthy couples that are having regular intercourse will end up pregnant within six months. Eighty-five percent of those couples will get pregnant within a year. There will always be 10-15% of couples not getting pregnant. Women who are not ovulating appropriately and who we can help with medication will get back to those numbers. The small percentage of couples that still have trouble getting pregnant should not give up. With everything being normal, we have more treatments available. Aside from the pills and shots, there are higher level treatments such as in vitro fertilization (IVF). What’s necessary and what’s appropriate for each couple is really a personal decision – that’s a discussion that starts here in our office.
There’s also the discussion about women who are able to get pregnant but keep having miscarriages. The evaluation and management of women who have consecutive miscarriages is a really important topic and something that we can also treat.
Many women also ask when they should first come to the doctor after a positive home pregnancy test. Many offices suggest that you wait up to three months. Here at the Women’s Center at Southwest Health, we recommend that as soon as you have a positive urine test you come see us. There are often many questions early on. We want to make sure that the pregnancy is starting off right and that all the early questions are answered. So as soon as you have a positive pregnancy test, pick up the phone, give us a call, and come in to make sure that everything’s getting started healthy and normal for a great pregnancy.
Learn more about Dr. Kim Christopher Mackey, MD, OB/GYN and the team at the Women’s Center at Southwest Health by visiting womens-health-center.org – a site which is a helpful online guide to women’s health.