Stronger Than Infertility

Infertility 101
Chapter 1

I remember my preconception appointment like it was yesterday. After 6 years of marriage, building our careers, and developing some semblance of financial security, my husband and I were finally ready to expand our family.

"Be careful," my doctor warned me. "You're only just starting prenatal vitamins, and they won't have had time to build up in your system if you get pregnant quickly."

Oh, the irony!

The months flew by, but my period continued to show up.

I was traveling with my husband when I noticed I hadn't used the pads I had packed. I looked at my calendar. I was late. Definitely late.

I took a pregnancy test. The three minutes I spent waiting for the results were among the longest of my entire life. The incredibly faint line that appeared—most would call it a "squinter"—indicated a positive.

The next day, Mother's Day, I began bleeding. I was devastated.

Five months later, I still wasn't pregnant. It was time to get serious. I started meticulously tracking my cycles. I bought ovulation prediction kits (OPKs) and began taking my basal body temperature (BBT) every morning.

It was September and we were on another trip, this time to Germany. I brought an enormous stash of pads. When I hit day 35 of my cycle without breaking into them, I sent my husband out for a pregnancy test. The instructions were, of course, in German. I had no clue how to read the results, but according to the pictures on the back of the box, the first test appeared invalid.

Before using the second test in the box, I sent my husband back to the pharmacy for further instruction. He returned triumphant, and back to the bathroom I went. This time, we waited together—only to have another squinter. We took it as a win. Here we were, on this amazing trip, and I was pregnant! It was time to sit back, relax, and let the embryo settle in.

I woke up one morning near the end of our trip in agonizing pain. I was weak, dizzy, and confused. It was all I could do to make it onto our flight home.

Back in the United States, after catching a few hours of much-needed sleep, we headed to the ER. I was seen quickly and instructed to pee in a cup. Despite the pain and dizziness, I'd not had any bleeding. Imagine my surprise when the urine in the cup was black.

But the ER doctor took one look at the cup, rolled his eyes, and told me all of my symptoms were PMS and I should go home. He discharged me with no evaluation. He didn't even test the urine. I left in a haze of red-hot anger, confusion, and overwhelming sadness—not to mention pain.

I'd had enough of trying to conceive on our own. It was time to get help. Probably way past time. I made an appointment with the reproductive endocrinologist that Google Maps told me was closest to our house. (Seriously, I did no other research.) We met her exactly 1 year after our preconception appointment. It was the first time someone told me I had infertility.

That was the day I became one of 48.5 million people who experience infertility. At the time, I felt isolated and alone. But now I know that a lot of people hoping to get pregnant— 15 percent, according to the CDC—were right there with me.

Every infertility journey is different. And learning that you have or will have trouble conceiving happens in different ways. For some, it comes after an unexpected medical event. Lindsey from Wyoming had been trying to conceive for 6 months until she blacked out in the shower. She and her husband, Grant, went to the ER.

"They found seven cysts on my ovaries, and I was encouraged to follow up with my ob-gyn," says Lindsey. "I truly believe that if I hadn't blacked out, we probably would've tried on our own for years not knowing any better."

Her ob-gyn suggested laparoscopic surgery, which confirmed that Lindsey had endometriosis—a common, painful, chronic disease where the uterine lining grows in areas other than the uterus, such as the ovaries, where it can cause cysts to form. Her cysts were drained and her endometriosis lesions were removed. But, as Lindsey found out, the disease carries long-term fertility risks. "My ob-gyn told me there is a chance I could have issues conceiving on my own," she says.

Three months later and still not pregnant, she went back to her ob-gyn, who ordered blood work for a fertility workup. "As soon as the results came in, she called me to explain that I had signs of diminished ovarian reserve. She suggested I go to a reproductive endocrinologist."

For others, it's a miscarriage—and especially recurrent pregnancy loss—that leads to a diagnosis. Rachel of North Carolina experienced two miscarriages in a year.

"After the second miscarriage, we started taking more active steps to discover the problem," she explains. "We found a fertility clinic and started with basic blood work and genetic tests, as well as testing hormone levels at various stages of my cycle."

Age is another factor that drives many people to seek help with their fertility. We live in a time when celebrities such as Alanis Morissette, Gwen Stefani, Marcia Cross, and many more have announced pregnancies in their mid- to late-40s (Janet Jackson gave birth at 50!), it can sometimes come as a surprise to people that age is still very much a factor in fertility.

Melinda from New York began trying to conceive with her partner when she was 34 but didn't visit a fertility clinic until she was 38.

"We tried for about 4 years on our own," she says. "I had always heard about women my age getting pregnant, so I did not think too hard about it—except that it was always so heartbreaking and frustrating to get my period each month."

Eventually she felt it was time to consult a reproductive endocrinologist. "She warned me to not wait too long because the likelihood of getting pregnant on my own—seeing as how I was not successful to that point—was getting lower with each passing day."

However you found your way to dealing with infertility, I believe that knowledge is power and a firm understanding of the science of fertility will give you a strong foundation to navigate your journey with confidence. You are your own best self-advocate!

What Is Infertility?

Simply put, infertility is defined as the inability to get pregnant after 12 months of regular unprotected sexual intercourse. But what about infertility is ever simple?

Many official definitions of infertility don't take into account what infertility may look like for the LGBTQ+ couples or single people who are struggling to conceive through methods other than sexual intercourse, or folks like me who can get pregnant but not stay pregnant. In 2017, an international group of medical organizations hammered out a more expansive and inclusive definition of infertility:

Failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or due to an impairment of a person's capacity to reproduce either as an individual or with a partner. Fertility interventions may be initiated in less than 1 year based on medical, sexual, and reproductive history, age, physical findings, and diagnostic testing. Infertility is a disease, which generates disability as an impairment of function.

Infertility can also be broken down into two different categories (though these definitions aren't as inclusive as the one above):

Primary infertility. A condition in which pregnancy has not been achieved after at least 1 year (6 months for females 35 or older) of having sex without any form of birth control.

Secondary infertility. A condition in which pregnancy has been achieved in the past but can no longer be achieved after at least 1 year (6 months for females 35 or older) of having sex without any form of birth control.

Understanding Female Fertility

Let's take a trip down memory lane to junior-high health class. If you want to understand your infertility, you need to understand how the female reproductive system is supposed to work. This information will help you ask good questions and better understand your doctor. You may want to return to it as a glossary once you read future chapters.

The Female Reproductive System

The female reproductive organs are exclusively internal and are made up of the following organs:

• Vagina. A muscular tube located between the external genitals and the cervix.

• Cervix. The lowest region of the uterus that attaches to and provides a passageway between the uterus and vagina.

• Uterus. A pear-shaped, hollow, expandable organ located in the lower abdomen between the rectum and bladder. This is where fertilized eggs implant and gestate before birth. Also known as a womb.

• Oocytes. Female sex cells, also known as eggs. (Sex cells—whether female or male—are sometimes also called gametes.) A person is born with one to two million eggs but starts losing them immediately. By puberty, only 300,000 to 500,000 remain.

• Ovaries. The small, internal glands located on both sides of the uterus that produce eggs.

• Follicle. A small, fluid-filled sac in the ovary that contains one immature egg.

• Ovum. A mature egg ready for ovulation. Once the menstruation cycle begins, eggs grow slowly—approximately 1 to 2 mm per day—until one takes the lead and matures, eventually reaching 17 to 20 mm.

•Ovulation. Release of an ovum. But before the ovum releases, the body has a lot of work to do. It needs to produce and increase levels of luteinizing hormone (LH). Then, just a few hours before ovulation, the lead egg is divided in a process called meiosis, which gives it twenty-three chromosomes.

•Corpus luteum. A temporary cyst that develops after ovulation from the follicle that releases an egg. It quickly degenerates unless pregnancy has begun. Follicles that do not release an egg are absorbed back into the ovary until every egg is gone and menopause occurs.

• Cumulus. A circular, mucous-based barrier created by the egg-releasing follicle to protect and support the egg.

• Zona pellucida. The membrane just beneath the cumulus. A sperm must fight its way through the cumulus and the zona pellucida to fertilize an egg—usually 12 to 24 hours after ovulation—in the fallopian tube.

•Fallopian tubes. A pair of tubes attached to the upper part of the uterus. Fertilized eggs journey through them from the ovaries to the uterus.

•Endometrium. The mucous membrane that thickens during the first half of the menstrual cycle to prepare for possible implantation. Also known as the uterine lining.

Female Reproductive Hormones

A healthy female reproductive system must continuously produce five important hormones to maintain that system: estrogens (E1, E2, E3), progesterone (P4), gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH).

•Estradiol (E2). The most important of the three estrogens during the reproductive years. It's secreted from follicles on the ovaries and impacts the growth of reproductive organs, such as the vagina, fallopian tubes, uterine lining, and cervical glands.

•Estrone (E1). Produced by both the ovaries and fat cells. When estrone levels are high, they promote weight gain, which then causes more estrone production, and so on.

•Estriol (E3). The weakest of the three estrogens. It's released by the placenta—the organ that develops around a fetus—and thus is present only during pregnancy.

•Progesterone (P4). Produced by the ovaries. During the menstrual cycle, levels of this hormone fluctuate. When the corpus luteum forms after ovulation, it produces progesterone to enable implantation and support pregnancy until the placenta can take over production.

•Gonadotropin-releasing hormone (GnRH). Secreted by the brain. The release of GnRH stimulates the production of FSH and LH.

•Follicle-stimulating hormone (FSH). Produced in the pituitary gland at the base of the brain. Together with LH, it regulates follicular function in the ovary. FSH stimulates follicles to increase estrogen and progesterone levels during the follicular phase of the menstrual cycle. Follicles grow until one takes the lead, secreting the most estrogen. Rising estrogen levels eventually signal to the brain that it's time for ovulation and to stop producing FSH.

•Luteinizing hormone (LH). Produced in the pituitary gland at the base of the brain. Together with FSH, it regulates follicular function in the ovary. Rising estrogen levels signal to the pituitary gland when it's time to release LH, which initiates ovulation.

The Menstrual Cycle

The menstrual cycle is, on average, 28 days, although cycles can be longer or shorter. Many people turn their attention to their cycle only when their period arrives—or doesn't. However, understanding the significance of each day in your cycle is important when it comes to understanding your body and recognizing when there's an issue.

Menstrual Phase

Days 1–5. Enter the period—also known as "Aunt Flo" (AF) within the infertility community—when your uterine lining breaks down and leaves your body. You must have a full flow, as opposed to spotting, to be considered on cycle day 1 (CD1). Normal bleeding can last anywhere from 4 to 7 days. Both estrogen and progesterone levels are low. Follicles, each containing one egg, begin to develop in the ovaries during this time.

Early Follicular Phase

Days 6–7. One—or sometimes two and very rarely three—lead or dominant follicle continues growing to maturity. The others stop and are absorbed back into the ovary as estrogen rises.

Late Follicular Phase

Days 8–13. By the time day 8 arrives, that dominant follicle has grown much larger, period bleeding has subsided, and the increased estrogen levels cause your uterine lining to thicken in preparation for implantation.

Ovulatory Phase

Day 14. Estrogen levels peak, causing LH levels to rise. LH then causes the mature follicle to burst open and release an egg. Women who have intercourse in the 3 days before, the day of, and/or the day after ovulation are most likely to get pregnant because sperm can live for 3 to 5 days in a woman's reproductive organs when estrogen levels are at their highest.

Luteal Phase

Days 15–24. The newly released egg travels away from the ovary, through the fallopian tube, and toward the uterus. The corpus luteum produces progesterone, further supporting uterine lining development. If the egg is fertilized by a sperm in the fallopian tube, its cells begin dividing and it eventually becomes a blastocyst—a ball of hundreds of cells. Meanwhile, it continues its journey through the fallopian tube and attempts to attach to the uterus; this process is also known as implantation. If an egg remains unfertilized, it breaks apart.

Days 24–28. If implantation doesn't take place, the blastocyst doesn't remain attached, or the blastocyst doesn't continue to develop, and estrogen and progesterone levels drop. This change can impact your mood, causing irritability, anxiety, or feelings of depression. The menstrual cycle comes to an end when the unfertilized egg exits the body with the uterine lining, which takes us back to day 1, and a new period begins.

Remember that everyone is different—and so is each cycle. Your cycle is still considered "regular" if your period comes every 25 to 35 days (counting from the first day of your last period to the start of your next).

Some people's periods function like clockwork, making it easy to predict the day it'll arrive. Others are still regular but know only a general range of days when they might expect their period to begin. Many people battling infertility, however, have erratic or even nonexistent periods.

What You Need to Know About Egg Health

Typically, between 300 and 400 eggs—approximately one per menstrual cycle, though that number declines with age—will reach ovulation during a person's reproductive lifetime. But what's going on with those eggs prior to ovulation? It all starts before you're even born.

Approximately 95 percent of embryo health is derived from the egg, according to Dr. Allison K. Rodgers, a board-certified reproductive endocrinologist with Fertility Centers of Illinois in Chicago. There are a number of factors that can lead to poor egg health.

Age

As much as we hate to admit it, a biological clock does exist. As Dr. Rodgers explains, when we talk about age and fertility, "we're talking about the percentage of eggs that have the ability to do their job of making a baby."

When a woman is in her 20s, between 50 and 75 percent of her eggs should be of good quality. That percentage goes down to between 25 and 50 percent by her mid-30s and 15 percent by the time she's 40 years old. (For more information, see the advanced reproductive age "diagnosis" in the appendix.)

Perhaps not surprisingly, research conducted by RESOLVE: The National Infertility Association and Shady Grove Fertility found that 87 percent of respondents younger than 35 and 81 percent older than 35 wish they had better understood the link between age and fertility earlier.

Dr. Shruti Malik, a board-certified reproductive endocrinologist with Shady Grove Fertility in Fair Oaks, Virginia, explains, "As [people] age, hormonal changes begin to take place. There is a lot going on, but of particular interest are the two main hormones controlling the development and release of the egg each month. These are follicle-stimulating hormone (FSH) and luteinizing hormone (LH)."

If age has begun to impact your egg health, one of the first symptoms you might notice is your cycles shortening. Dr. Rodgers says, "If they were always 28 days and now they're 24 days, that's something that can happen when quality declines. Additionally, you might have true menopausal symptoms, such as hot flashes and vaginal dryness. But that's not until things get really severe."

Dr. Rodgers adds, "There's so much variability, and that's why it's really important to meet with a doctor if you're having trouble conceiving." In other words, if you are older than 35 and are having trouble conceiving, the sooner you visit your doctor, the better.

Busted

Myth: I've got time.

Dr. Lynn Westphal, a reproductive endocrinologist and chief medical officer at Kindbody in New York, says it's not uncommon to see stories of people giving birth in their late 40s or early 50s and think, "If they can get pregnant, I've got plenty of time." But the truth is these people are the exception, not the rule. And most likely, they did not get pregnant easily.

"Many people are not aware of the decline in fertility with aging," says Dr. Westphal. "Also, many lose track of time and don't realize that there is a big difference even between ages 35 and 40."

Poor Blood Flow

Healthy eggs require oxygen-rich blood flowing to your ovaries. Low oxygen levels may result in immature eggs that don't fertilize, implant, or develop properly. Lack of exercise, dehydration, and thick blood can all reduce blood flow.

Hormonal Imbalance

An imbalance of any of the five crucial hormones—estrogens (E1, E2, E3), progesterone (P4), gonadotropin-releasing hormone (GnRH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH)—can result in poor-quality eggs or no ovulation at all.

Although some over-the-counter supplements purport to help regulate these hormones to normal levels, be wary—and never take supplements or adjust dosages without your doctor's knowledge and ongoing monitoring. Sometimes they can do more harm than good.

Instead, it's good practice to receive a full fertility workup, once a year—and more often if diagnostics come back showing something abnormal. Work with your doctor to develop a plan to regulate abnormal hormone levels through a combination of prescription medication and approved supplements.

Lifestyle Factors

A variety of lifestyle factors may impact your egg quality:

• Smoking and using recreational drugs
• Exposure to environmental chemicals (parabens, phthalates, bisphenol A, bisphenol S, flame retardants, and pesticides)
• High caffeine and/or alcohol intake
• Being underweight or overweight (BMI of less than 18.5 or more than 25)
• An unbalanced diet, especially one low in fertility-fueling foods (see chapter 8)
• Not getting enough sleep on a regular basis

Just remember: Your actions are one aspect over which you have control throughout this journey. Feel empowered by that!

Certain Health Conditions

Certain health conditions can impact your fertility. In fact, you may already have been diagnosed with a condition—such as polycystic ovary syndrome (PCOS) or endometriosis—earlier in life and weren't told at the time how it would impact your future fertility.

Not all people who have PCOS produce unhealthy eggs. However, if you have elevated male hormone (predominantly testosterone) levels, you are likely to have poor egg quality.

Endometriosis is often associated with higher levels of inflammation from macrophages (a type of white blood cell) and cytokines (secreted by cells in the immune system). Some believe the presence of this inflammation is toxic to eggs, impacting their quality and ability to develop into healthy embryos.

Those of us with endometriosis, myself included, often develop ovarian cysts called endometriomas. These cysts are filled with a combination of menstrual debris, endometrial tissue, blood, and more. Their dark brown pigment has earned them the nickname "chocolate cysts." Endometriomas cause hormonal imbalances that impact egg development, quality, and even overall count.

Endometriosis can also leave scar tissue throughout your reproductive system, blocking blood flow to or within your ovaries. And remember, your ovaries need plenty of blood flow to produce healthy eggs.

There are many other medical conditions that can cause infertility. In the appendix, you'll find the nitty-gritty on each.

Warrior Wisdom

Don't Wait If You Have a Known Condition

Sarah, Ontario, Canada

Sarah knew she had an autoimmune disease. What she didn't know, however, is how this disorder needlessly extended her journey to pregnancy. "I wish I had known then that you don't have to wait a year if you have an existing medical condition that impairs fertility."

Signs and Symptoms of Female Infertility

Let's look at some general signs that might indicate a fertility issue.

• Irregular cycles
• Rarely or never menstruating
• Periods lasting longer than 7 days
• Short luteal phase
• Hormonal imbalance
• Pain during sex
• Recurrent miscarriages
• Chronic health issues and past illnesses
• Certain medications

Irregular Cycles

If your menstrual cycle is less than 25 days or longer than 35 days, it's considered irregular.

Cycles lasting less than 25 days indicate you likely are not ovulating.