Couples often ask doctors what they can do to help their chances of conceiving naturally. We are well aware of the decline in fertility with age and need our patients to know this.
However sometimes couples are just not ready for medical intervention.
Their preference is understandably to conceive naturally and they will often say they are ‘not ready for IVF’. Often we hear that they have not been using contraception for some time but have not really been ‘trying’. It may be that before they are willing to accept fertility treatment, they need to be confident they have done everything they can naturally.
We know that 80% of couples achieve pregnancy after six ovulations. So when the duration of trying to conceive falls outside this timeframe they may require referral to a gynaecologist with expertise in fertility. Of course there may be issues that need addressing sooner such as infrequent periods signifying uncertain ovulation or painful periods which could be a sign of several things but endometriosis related infertility is a differential diagnosis. But there may also be issues with timing and coital frequency or lifestyle factors that need correcting that may justify a longer period of trying naturally.
Early evaluation at any time on request or by the six month mark would be of benefit to our patients. At this time, regular menses, a normal semen analysis and a normal pelvic ultrasound would be reassuring. Women over the age of 35 years need to be reminded of the decline in their chances with age. Lifestyle issues and timing can be addressed with review after a short time frame of a few months would be reasonable.
It is a commonly held misconception that increasing coital frequency will decrease sperm concentrations. In fact, the evidence supports the opposite. Abstinence of greater than five days may reduce sperm counts. Men with low sperm counts record the highest measurements of sperm motility after daily ejaculation. There is also an improvement in sperm quality (shape) with frequent ejaculation. But we need to balance this recommendation with the fact that couples that have been trying for some time are often under stress and may have a reduced desire for intercourse. For some couples, ovulation predictor kits can be helpful and for others they can lead to anxiety by having to ‘perform’ on certain days.
Knowledge of the ‘fertile window’ is key to helping couples understand timing. In contrast to sperm which can stay alive for 3 to 7 days, the egg is only viable for 24 hours. Having sex alternate days over a broad range will help cover this fertile window. However pregnancy is most likely to occur if intercourse happens in the 2 days leading up to and the day of ovulation. Detection of the luteinizing hormone surge by urine ovulation predictor kits will predict this timeframe. They may be useful for couples having infrequent intercourse to narrow down the days needed to try. However some women have persistently positive urine ovulation tests due to high baseline luteinizing hormone levels which preclude the utility of this test. Basal body temperature rise is a retrospective test to confirm ovulation, as progesterone, which is thermogenic, is released after the egg is non-viable. Some women can detect ovulation from changes in cervical mucous with an accuracy on par to urine ovulation tests and some find this assessment very difficult. Couples often ask whether remaining supine after intercourse will help. We know that sperm can be seen in the fallopian tubes within minutes of ejaculation. We also know that the ejaculate must liquefy after half an hour so leakage is a normal process. It has been suggested that female orgasm assists in sperm movement and increases cervical mucous which allows for sperm transport. For women, urination shortly after intercourse will decrease the risk of urinary tract infections.
Another commonly asked question is whether vaginal lubricants are spermicidal. Water based lubricants such as K-Y jelly and even saliva can inhibit sperm motility so should be used sparingly. Arousal prior to penetration is likely to aid cervical mucous production.
Some lubricants have no effect on sperm motility such as Pre-Seed.
The chance of conception decreases in both very thin or obese patients. Aiming for a normal weight range should be the aim. Folic acid supplementation to reduce neural tube defect risk is important. Smoking has a negative effect on time to pregnancy and increased risk of miscarriage. High alcohol intake is best avoided when trying to conceive and alcohol consumption should cease once pregnant. With regards to caffeine, high intake has been associated with an increased time to pregnancy and > 3 cups/day may increase the risk of miscarriage. It is probably safest to recommend no more than one cup of day in women. In men, the evidence is not clear.
After identification of factors that can be addressed to assist natural conception, a follow up appointment for general discussion would be helpful. A progesterone level performed a week after a positive urine ovulation test may help confirm ovulation occurred and can be added to the information gained from cycle length, ovulation tests and temperature charts if used. Issues with intercourse or coital frequency may be more readily disclosed in a follow up appointment. Lifestyle factors can be reinforced. Patients will appreciate the guidance and support from a trusted GP.