How conception takes place and why it may not be happening
Many women and couples spend years vigilantly controlling their reproductive lives, only to discover that, when at last they are ready to have children, they cannot conceive. Some studies suggest that 20 to 35 per cent of couples will have some trouble conceiving at some point in their lives. Only half of those couples actually seek medical help. Of these some will resort to alternative therapies and some conventional medicine and some may be offered treatment using ‘Assisted Reproductive Technology’.
To have any understanding of how these methods work it helps to have a rudimentary understanding of how pregnancy occurs, particularly in respect of the chemicals which are produced by the body both before, during and after conception. Most forms of Assisted Reproduction work by substantially altering the (usually female) natural reproductive cycle, both with chemicals and, in some cases, surgery.
The female cycle
The menstrual cycle is usually taken to be a regular 28 days, and divided into two phases of activity. The first two weeks is the oestrogen/follicular phase, where everything is geared toward production of the egg (ovulation). The second two weeks is the progesterone/luteal phase, where ovulation has occurred and the uterus (womb) prepares for a possible pregnancy.
The menstrual cycle is controlled by three glands, the hypothalamus, the pituitary and the ovaries. These glands secrete hormones into the blood stream which act as chemical messengers, telling the reproductive organs what to do, and when.
Day 1 of the cycle is the first day of real bleeding, meaning a flow of red blood, not brownish discharge.
On about Day 1, the hypothalamus produces a chemical called gonadatrophin releasing hormone (GNRH), also known as lutenizing hormone releasing hormone (LH-RH). This chemical travels to the pituitary, and stimulates it to produce a further substance, follicle-stimulating hormone (FSH) an egg-maturing hormone which acts on the ovaries, stimulating them into action. Under the influence of FSH, the ovaries grow and mature about 20 follicles, which are tiny fluid filled sacs surrounding the eggs. Whilst these follicles grow, the ovaries start to prepare and release the hormone oestrogen. Oestrogen instructs the endometrium (the lining of the uterus) to grow and thicken, so that it will be able to nourish a potential pregnancy.
Oestrogen levels gradually rise until about Day 11/12, when the brain recognises that enough FSH has been secreted, and starts to decrease levels, releasing only enough to mature one follicle and the egg within it. Rising oestrogen stimulates the pituitary to produce lutenizing hormone (LH), an egg-releasing hormone.
LH levels surge on about Day 12/13, and cause the ovaries to produce more oestrogen, which in turn causes ovulation. This is when a mature egg bursts out of its follicle and is wafted into the Fallopian tube, beginning the journey to the uterus. The ends of the Fallopian tubes consist of tiny waving tentacles called fimbria, which are designed to ‘catch’ the egg as it emerges from its follicle. However, it has been estimated that the fimbria catch only about 60% of eggs.
This is the end of the first phase of the cycle. The second phase begins. The empty follicle now begins to produce the hormone progesterone, which signals the endometrium to stop growing and to become receptive to a prospective embryo. Progesterone levels peak at around Day 21.
If the egg has not been fertilised, it is absorbed by the body. Progesterone and oestrogen levels fall, and the blood vessels in the endometrium break down, filling the uterus with blood and broken tissue. This menstrual debris is expelled by mild uterine contractions out via the vagina, as the menstrual bleed. The cycle begins over again.
For the egg to be fertilised, both it and the sperm must be in the right place – the top half of the 4 inch fallopian tube – at the right time. After fertilisation, the embryo begins the 4-5 day journey down the tube to the uterus, all the time being nourished by the fallopian tube. During this time the embryo’s cells divide so that when it eventually reaches the uterus, it consists of 32 cells.
About 7-8 days after fertilisation, the embryo begins to implant itself into the endometrium. It has been estimated that around 40% of pregnancies are lost at this vital stage, where the embryo either fails to implant, or is lost after implantation. This may show as a period that is slightly late, or heavier than usual. As soon as the embryo begins to attach itself to the endometrium, it releases a hormone called human chorionic gonadatrophin (HGC), the so called pregnancy hormone. This signals the empty follicle to continue producing progesterone; oestrogen levels also continue to rise.
By 14 days after fertilisation, the embryo is secure in the endometrium. Miscarriage becomes less and less likely as the pregnancy progresses.
Problems with women
The main symptoms are no period, infrequent period, too frequent period, very light period.
The main causes are;
- malfunction of hypothalamus/pituitary/ovaries
- malfunction of adrenal glands or thyroid gland
- tumour or cysts in any of the above glands.
The biggest cause of ovulation failure is Polycystic Ovarian Syndrome (PCOS). One in five women suffer from multiple cysts on their ovaries, but this should not be confused with PCOS, where the cysts are caused by a hormone imbalance, and are accompanied by other symptoms. Obesity is a significant factor in this disease, and consequently PCOS is often treated with hormone treatment and weight reduction.
Damage to Fallopian tubes
It has been estimated that around 25% in Britain, and almost 50% in USA, of female infertility is caused by tubal damage.
The main causes are:
- pelvic inflammatory disease (PID), usually as a result of sexually transmitted disease (particularly chlamydia), infection after pelvic surgery (i.e. abortion), infection related to IUD contraceptive device, infection from naturally occurring micro-organisms migrating from anus or urethra
- pelvic and abdominal surgery, where adhesions and scarring block part of the fallopian tube
- abdominal disease, for example appendicitis, peritonitis, colitis
- ectopic pregnancy
- endometriosis resulting in scar tissue and adhesions
- Problems with other reproductive organs:
- cervix, including hostile mucus, ‘incompetent’ cervix, damage sustained in childbirth/miscarriage
- womb, including fibroids (non-cancerous tumours) which distort the shape of the uterus and can interfere with implantation, or block the opening to the fallopian tubes
This accounts for a fifth of female infertility, and is prevalent in women aged between 30 and 40 who have not had children. In can be asymptomatic, with the woman unaware that she has the condition until, for example, it is revealed by a laparoscopy investigating other problems. In other woman, the symptoms can be severe, giving, amongst other things, extremely painful periods, pain during penetrative sex, and painful bowel movements. It will obviously interfere with fertility if it results in scarring and adhesions to the ovaries or fallopian tubes. However, little appears to be understood about how mild endometriosis can adversely affect conception. One argument is that the condition is related to a hormone imbalance, which somehow affects the chemical balance in the vagina, making it increasingly hostile to sperm. It is currently treated by surgery, where the affected areas are burned off by laser, depending on the severity of the condition, or hormone treatment preventing ovulation, or a combination of both.
One in five pregnancies end in miscarriage, or ‘spontaneous abortion’. 75% of these occur in the first twelve weeks. No one really knows why miscarriage of a pregnancy happens, but doctors suspect:
- abnormal egg or sperm
- damaged/incompetent cervix
- abnormally shaped uterus
- hormone deficiency
- immunity problems (woman’s body rejects the foetus as a foreign body)
- drugs/alcohol/radiation/smoking/other chemicals
This can happen at any age, and may be caused by serious damage to the ovaries from infection, radiation or drugs used in the treatment of cancer. It may also be caused by the sufferer being born with fewer eggs than normal, or a tendency to release a greater number of eggs than normal at ovulation. Doctors suspect that autoimmunity may be a significant factor in as many as half the cases, but this is not as yet properly understood.
- Peak fertility is early to mid twenties.
- By the age of 35, a woman will be half as fertile as she was at 21.
- At 40, she will have a 1 in 3 chance of being infertile.
- At 41 this will have risen to a 2 in 3 chance
The male cycle
The medical profession, which refers to men’s reproductive system as ‘plumbing’, understands far less about the male reproductive cycle than it does about the female cycle.
Unlike women, who are born replete with all their ova in situ, men do not begin to produce sperm until puberty. However, once sperm production has begun it does not stop, and new sperm are in production every day of the male’s life. The male cycle is governed by the same glands as the female cycle (substituting testicles for ovaries), but there is no ‘cycle’. Instead, the male produces all sex hormones simultaneously, and continually.
The hypothalamus sends LH-RH to the pituitary, signalling it to send out FSH and LH to the testicles, which in turn stimulate the testicles to make the male hormone testosterone. Although testosterone controls the sex drive and is often associated with virility, if it is produced in too great a quantity it can inhibit the production of FSH, which in turn will reduce sperm production. It is therefore a great misconception to associate high virility with high fertility.
Although seminal fluid contains only about 2% sperm, the average ejaculate can deposit up to one million sperm into the vagina. However, it is a long and difficult journey, and only around a few hundred remaining sperm will make it into the uterus. To begin, the vagina and the mucus which covers the cervix (the entrance to the uterus) can be extremely hostile to sperm, and many will die trying to get through the cervix. Once inside the uterus, sperm will continue to die or make the wrong decision, for example, turning up the wrong fallopian tube, when the egg is actually waiting in the other tube. Only a few dozen sperm will actually reach the waiting egg. If there is no egg yet, the sperm can survive inside the tube for up to three days until a ripe egg appears.
Problems with men
Sperm disorders account for almost 75% of male infertility problems. Due to various factors, average sperm counts have dropped dramatically since the 1960s, and now normal male fertility is assessed at 20 million sperm per millilitre of semen. In addition, it appears that quality and quantity are linked, and men with a low sperm count frequently produce poor quality sperm. Quality is assessed in terms of motility (the ability to swim) and morphology (the shape of the sperm cell).
A sperm must be able to swim quickly through the hostile vagina, and be able to penetrate the cervical mucus, so ability to move is obviously important. Morphology is important because abnormally shaped sperm may not be capable of fertilisation, or if they are, the pregnancy may miscarry, or result in birth defects.
Doctors suggest that sperm disorders may be connected to:
- Age, health and environment;
- Hormonal problems;
- Congenital conditions;
- Physical problems, i.e. tubal blockage, retrograde ejaculation.
Only 5% of men suffer from a complete lack of sperm.
Over a third of all couples seeking medical help will be diagnosed with ‘unexplained infertility’. This can mean one of three things:
- There is no problem, but the couple have been unlucky so far;
- There is a problem but tests have failed to pick it up;
- The problem is one which doctors don’t yet know about.
Although for mainstream medicine this problem remains much of a mystery, alternative practitioners tend to treat it as a product of imbalances of energy or malnutrition, a severe vitamin and mineral deficiency, allergy or the presence of harmful toxins.
What can be done?
Tests for the woman and the man
Most couples experiencing problems with conceiving approach their family doctor as their first port of call. The GP should be able to establish whether there is a problem, by carrying out a number of fairly routine tests. These are likely to include a basic sperm analysis, and simple blood tests taken on certain days of the woman’s cycle, to establish whether she is ovulating. In addition, the GP may examine the woman for any obvious problems, such as cysts, fibroids or other obvious damage to her reproductive organs, and to look at the man’s penis and testicles for any malformation, signs of infection, lumps or varicocele.
However, in the absence of any obvious problem, it may be the case that the GP will be reluctant to begin any investigation at this stage. As it can take the average couple anything up to a year to conceive, and longer if the woman is over thirty (when fertility levels begin to decline) the GP may well advise the couple to go away and try naturally for at least another year. Whilst this may be sound advice for many couples, it can be incredibly frustrating for those still experiencing problems, especially given that serious investigations might be delayed for anything up to 18 months. However, couples should insist on immediate investigation where there are past problems with:
- The woman has had no periods for some time/or very infrequent periods/ painful periods/ recently increasingly heavy periods;
- She experiences deep pain during penetrative sex;
- She has had an operation on her cervix;
- She has had prior surgery on ovarian cysts;
- She has had a previous burst appendix;
- She has suffered infection after pregnancy/labour/termination/miscarriage;
- She has experienced problems with the contraceptive coil;
- The man has had mumps during adulthood;
- He has suffered testicle injury, or has had past inflammation of testes;
- He has had a previous undescended testicle;
- He has had hernia operation in the past;
- He has had inflammation of the prostate;
- He is a heavy smoker or drinker.
Fertility Awareness Through The Basal Body Temperature Method
As a woman trying to conceive one of the most obvious methods is to chart your Basal Body Temperature. The basal body temperature is one of the indicators of ovulation. This is often the first to be suggested by doctors and even women who have been unable to conceive for years could be asked to chart their BBT when they approach a medical practitioner for help.
Fertility Awareness means understanding your reproductive system by observing and writing down fertility signs. These signs determine whether or not you can become pregnant on a given day. You are actually fertile during only about one-fourth of your menstrual cycle.
This is a great way to learn more about your body.
Worldwide, the basal body temperature method is the oldest and most widely practiced Fertility Awareness Method. Every woman is different and your temperature may vary from the norm, but most women ovulate (release an egg from the ovary) at about day 14 of their menstrual cycle, plus or minus 2 days. The egg is viable for about 1 day, and sperm can live for 2-3 days.
How to chart your basal body temperature
Make a chart and keep a daily calendar record of your temperature. Specifically, you should use a basal body temperature thermometer which reads your temperature in easily readable tenths of a degree. The first day of your period is considered day 1 of your cycle; and you place an “x” on the chart for each day of your period (not spotting). Take your temp by mouth, and make sure you do this for the same amount of time, around 5 minutes, each morning, immediately after waking and before getting out of your bed. Also at the same time write down your results. On the same record, chart your menstrual cycle, beginning with day 1 as the first day of your period. If possible, chart your temperature pattern for a few months before relying on it.
Your most fertile days are those just before your temperature begins to rise during ovulation. It’s difficult to predict this time, so practice the temperature method until you know your pattern.
A monthly change in your basal body temperature is one of the signals that all may be well with your ovulatory functions, as progesterone increases a slight increase in temp should occur. This change could be as slight as 0.5 to 1.0 degree elevation. Once that temp rise has occurred, a woman may have missed the opportunity to conceive This leads to the importance of charting for several cycles in a row, to suggest a pattern.
Most doctors would suggest a woman keep track of her BBT for a minimum of three months. The end chart will give you an idea of whether or not you are ovulating on a typically regular basis. It may also give you some idea of when your most fertile days are during the average month.
It is not uncommon for your BBT to be influenced by a number of factors: physical activity, alcohol intake, amount of rest, medicines, etc. So make a note of any and all of these factors when you are charting. Understanding this very basic fertility-prediction method is a simple, yet crucial step in empowering yourself on your journey.
Most doctors and family planning clinics can help you learn more about basal body temperature charting and other Fertility Awareness Methods and offer advice on charts and thermometers.
Acupuncture works towards optimum health for both partners to improve the chances of a natural conception. This includes hormonal balancing and the freeing of blocked energy that may be preventing conception or weakening the organs that support conception. Period problems and general health issues such as stress insomnia and digestive disorders are also addressed.
The ‘conception meridian’ and the energy supply to the womb may also be stimulated. And acupuncture can also be used to support other methods of fertility and to help reduce any side effects of IVF.
Massage techniques also claim success. As the muscles relax stress levels are reduced and the circulation of blood and lymphatic fluid improved. The nervous system and the endocrine system may also be influenced to bring about a hormonal balance and an increased nerve supply to the womb.
The use of essential oils can also be deeply soothing and contribute towards a balancing effect on the entire physiology. The motion of massage creates heat and friction which stimulates the circulation and helps cleanse the tissues of chemical impurities. The right essential oils cleanse and nourish the tissues to aid in their repair and development. Like acupuncture, massage can also be used as a supporting therapy alongside another or others to improve your ability to conceive.
Stress is a major factor in disease and is the root cause of many disorders, including infertility. This is due to hormonal changes and other biochemical responses that stress imposes upon the body which imbalances the nervous system, reduces the natural healing abilities of the body and can easily depress reproductive function.
A certain amount of stress is healthy and normal to our every day lives. The tension that builds towards an event say, the expectance of a loved one, or of work to be completed, which dissolves with their appearance or the works completion is natural. Unresolved tension is not natural and circumstances and relationships that place you in a constant state of anxiety are best avoided. All our emotional feelings are supported by deep changes in our bodies starting with our muscles and the sense of dis/ease becomes pathological disease when there is no relief.
There are two major means of dealing with stress and these are meditation to quieten the mind and yoga or relaxed stretching exercise to relieve inherent muscular tension. Contrary to popular belief yoga and meditation have more to do with science than eastern religion. Both can be practiced by people of all religious denominations. They are highly documented regimens for harmonious living, well tried and tested over generations.
A nutritional expert will also provide you with a more detailed understanding of foods to favour and avoid when trying to concieve. Generally foods to avoid are those that are hard to digest and foods to favour are those that are nourishing and being easy to digest demand less energy during digestion. A healthy nutritious diet to strengthen your digestive system will help balance your energy and support your body’s inner intelligence, encouraging a better chance of conception, either on its own or again as a supportive therapy.
According to Ayur-Vedic medicine a good digestion and proper diet is especially important for fertility as the sperm and ova are the end result of the proper nourishment of all the major tissues in the body. Poor nourishment of any single major tissue group could prevent the final product of their combined functioning, sperm and ova, from being produced properly.
Tibetan wisdom for conception
Life is ongoing, and the spirit seeking incarnation is attracted by the specific energetic quality of the parents, even as they engage in intercourse.The environment at conception is important; it is recommended that a couple meditate on love, compassion, consciousness, or gentleness and avoid anger, attachment, jealousy, aggression, or fantasies.
Many clinics will have their own preferred methods of testing, and will carry out at least some of the following range of tests.
Tests for the woman
These are simple blood tests, sometimes taken over several days and most usually on day 21, to measure the level of progesterone in the blood. Progesterone rises a few hours after ovulation and peaks about seven days later, so any increase would indicate that ovulation had taken place in that particular cycle.
The hormone prolactin stimulates milk-production following pregnancy and appears to prevent ovulation. It has long been recognised that women are less likely to conceive whilst they are breast-feeding, although this has been found to be an unreliable method of contraception.
These are blood tests to measure the reproductive hormones, including FSH, LH, testosterone, oestrogen and progesterone, etc.
Performed in the second half of the cycle, usually about 3 days before bleeding is expected to begin, this tests whether the endometrium has responded properly to progesterone, and developed sufficiently in expectation of pregnancy and implantation. The test involves inserting a fine pipe into the vagina and through the cervix into the uterus, taking a small sample of tissue from the uterine lining for biopsy. No anaesthetic is necessary, and the procedure causes brief, period-like cramps.
Tubal patency tests
There are two tests currently used to check the condition of the fallopian tubes and the uterus:
The HSG is an X-ray of the uterus and fallopian tubes, usually performed using local anaesthetic. This is reputed to be a painful procedure, but this depends very much on the skill of the practitioner. Dye is squirted through the cervix into the uterus and tubes, and its progress monitored on a TV screen. A good X-ray result will reveal any obstruction, swelling, spasm, adhesions or blockages in the tubes, as well as any fibroids, adhesions or other abnormality in the uterus.
This is deemed to be the most important test for female infertility. In The IVF Revolution, Professor Winston states that in his view it should almost always be considered before entering an IVF programme.
Laparoscopy is performed under general anaesthetic and short hospital admission. A small incision is made on the interior of the navel and a small amount of carbon dioxide is released into the abdominal cavity. This has the effect of separating the reproductive organs, so the doctor can get a clearer picture. A thin telescope the width of a fountain pen is inserted into the naval incision, and through this the doctor can not only get a full picture of the condition of the uterus, including the presence of endometriosis, fibroids, but will also be able to test the patency of the fallopian tubes by injecting coloured dye through them. The ovaries will also be inspected for cysts.
Laparoscopy is usually performed in the second half of the cycle, so that the surgeon can inspect the ovaries for signs of recent ovulation, and also so that an endometrial biopsy can be taken, if it has not already been carried out. The procedure takes 20-40 minutes.
Most women will be allowed to go home within 4-6 hours of the operation. Side effects may be unpleasant but not serious, mostly related to the anaesthetic. They might include pain in the shoulders, due to the carbon gas which can irritate the stomach lining. This is because the nerves which supply this area also supply the shoulder area. There may be vaginal bleeding, lasting 2-3 days. A particularly unpleasant side effect affects the bladder, making it difficult and painful to pass urine. Sufferers are advised to drink lots of water, which is not always easy advise to take under the circumstances!
The operation will leave a small scar just inside the navel. There may also have been a second incision just underneath the pubic hairline, where the surgeon inserted fine probes to get a better view of certain areas.
Professor Winston states the benefits of laparoscopy to be considerable, and the best investigative procedure to detect many conditions, including endometriosis and tubal damage.
This might be carried out at the same time as a laparoscopy, or separately using a light anaesthetic with mild sedation, or a quick general anaesthetic. The hysteroscope is a small telescope which is inserted into the uterus via the vagina, allowing detailed examination of the interior of the uterus. It can be an excellent means of detecting polyps, fibroids, adhesions or congenital abnormalities of the uterus which might have been indicated by a prior HSG.
There are two types of scan used in infertility investigation. Both work on the same principle of using high frequency sound waves which, when they hit tissue, give off an echo which shows as a black shape on a monitor. From this, organs inside the abdomen including the ovaries and any cysts or follicles growing on them, can be measured in detail. The ovarian ultrasound uses an external scanner which is passed over the abdomen. Water conducts sound well, and consequently better quality images are possible where the bladder is full, although this can become an uncomfortable experience for the woman. However, a full bladder is not necessary for the vaginal ultrasound, where a small probe covered with a rubber sheath is inserted directly into the vagina. The probe is then manipulated inside the vagina to pick up images of each ovary and follicular development. It is not painful although it can be uncomfortable. Better quality pictures are available using this type of scan, and most IVF units use them to monitor ovulation. It is also useful in detecting cysts on the ovaries and damage caused to the ovaries by disease, such as endometriosis.
Tests for the man
The three main causes of male infertility are hormonal, genetic or physical, and are usually identified with the following tests:
The man provides a sample by ejaculating into a sterile container, either at the clinic or at home (in which case it must be delivered to the clinic within two hours of its collection). Usually the clinic will provide an appropriate room for the man to produce his sample in comfort, if he prefers. Wherever the semen is produced, the man will be instructed to ensure that all of the ejaculate gets into the pot, otherwise the sample will be incomplete and will result in an abnormally low sperm count. Some men understandably find the process disturbing and embarrassing, and consequently are able to produce only a very small amount of ejaculate, if they can manage at all. However, good clinics are aware of these factors and assess a man’s fertility on the results of several tests.
A routine sperm analysis will calculate the following:
The average ejaculate is between 2 to 5 millilitres, which is approximately a teaspoon. Less than 2 millilitres may indicate that the man is not producing enough secretions or that part of the ejaculate may not have been collected.
This measures the number of sperm. The average fertile man will produce more than 40 million sperm per millilitre of semen. Fewer than 20 million per millilitre may indicate a problem.
This measures the number of sperm able to move properly. At least 40% should show normal forward progressive movements within one hour of ejaculation.
At least 65% of the sperm should look normal under microscopic inspection.
- ‘Clumping’ bacteria, white blood cells
The presence of either may indicate infection or that the man is producing antibodies to his own sperm.
Antibodies are usually produced as part of the body’s natural defence system, in response to injury or infection. They will prevent sperm from working normally.
As with the hormone tests on women, these will be blood tests to measure FSH, LH, testosterone and also prolactin. An abnormally raised -or lowered- level of FSH is particularly significant, because it can indicate that the testes are having problems with sperm production.
This is an exploratory operation, usually performed under general anaesthetic, often as a day case in hospital. An incision is made in the scrotum, and a small piece of tissue is taken from the testes and examined under a microscope. This will show whether the testes is capable of normal sperm production. Also the procedure can test whether any tubes are blocked, damaged, or diseased.
This measures the temperature in the testes.
This scan is external, with the probe placed directly on the scrotum, so there is no need for a full bladder. Small cysts and tumours may be identified, and other abnormalities such as blocked tubes.
Sometimes, infertility may be the result of a genetic abnormality. For example, Flinefelter’s Chromosome is a genetic abnormality which leads to low testosterone levels, and usually prevents the man from producing any sperm. This condition is extremely rare but untreatable where it does exist. Chromosome testing may be able to identify this, and other abnormalities which cause poor sperm production. Where some sperm are still being produced, IVF techniques may be an option, although the couple will have to be advised on the genetic implications. Testing is by blood test, and the results take up to four weeks.
Getting the results
It may seem like stating the obvious but the above tests may produce results which will have a devastating impact on some couples’ lives. For this reason, it seems advisable for both partners to be together when they receive test results. Couples should also consider how they can support each other in the event of bad news, and indeed how they will cope themselves.
Counselling may be an option.