Fertility and Conception

A woman’s internal reproductive system broadly consists of two ovaries, two fallopian tubes, uterus, cervix and vagina. See diagram above.

Functions of each part:

1. Ovaries: Located just below the fallopian tube on either side of the uterus, this organ is oval shaped and attached to the uterus via fibrous cords or ovarian ligaments.

This organ is responsible for release of female reproductive hormones – estrogen and progesterone, and contains female gametes (also known as ova (singular – ovum), female gametes, oocytes or eggs). These gametes are released periodically (the process is known as ovulation and occurs once in a month) towards the fallopian tubes.

The eggs are contained in the ovarian follicles. Usually, each ovary takes turns in releasing an egg every menstrual cycle. If one ovary is absent the other ovary takes the sole responsibility.

An Amazing Fact: The number of eggs in the ovaries reduces with age. The number of eggs in the ovaries at different stages of a woman’s life is:

Female Fetus – 7 to 8 Million

At Birth – 3 to 4 Million

At Puberty – 700000 to 800000

Number of eggs ovulated during the complete reproductive life span – 300000

2. Fallopian Tubes: Each fallopian tube is located on either side of the uterus above the ovaries and is about 10 cm in length. The ends of the tubes contain finger like projections called fimbriae. These collect the eggs from the ovaries and transport them to the fallopian tubes. Hair like projections inside the fallopian tubes move the eggs along the length of the tubes.

3. Uterus: A pear shaped organ supported by strong ligaments (A sheet or band of tough fibrous tissue connecting bones or cartilages or supporting muscles or organs – Source Wordweb). Its function is to provide a place and space for the fetus to grow during pregnancy. This muscular organ is the size of a fist and has the capacity to extend in size to accommodate the growing fetus. The lining of the uterus known as endometrium (greatly influenced by female hormones) is shed during the menstrual cycle and thickens during pregnancy to help embed the fertilized egg.

4. Cervix: Cervix separates the uterus from the vagina. A small narrow opening at the cervix widens up towards the uterus via cervical canal. Cervical mucus is secreted by glands located in the lining of the cervical canal. The mucus at opening of the cervix also protects the uterus from infections. During ovulation the mucus becomes thin and lets sperms enter the uterus for egg fertilization.

5. Vagina: A flexible and muscular passage starting from the external female reproductive organs till the cervix. The vagina also acts as a passage for childbirth and menstrual discharge. It also helps in holding the semen near the cervix. The inner surface is lined with moist membranes which secrete a watery and odorless discharge to keep it clean and free of infections. With changes in hormones during pregnancy and ovulation, or during intercourse, there is an increase in the watery discharge.

Menstrual Cycle:

A menstrual cycle is a process by which a female body prepares itself for a possible pregnancy, and normally lasts for a month (A normal menstrual cycle varies from 23 – 35 days). A menstrual period or blood flow through vagina (which lasts for 5-7 days) occurs due to shedding of the endometrium. If the female egg gets fertilized by a sperm after the ovulation (when egg is released by ovaries into the fallopian tube), then it is transferred to the uterus for fetal development, the endometrium is not shed, and menstrual blood flow does not occur.

Source – Wikimedia Commons

The menstrual cycle occurs in the given order:

1. Menstrual cycle begins (The first day of the menstrual period)
2. Lining of the uterus thickens and prepares for a possible pregnancy ( On the 5^th day)
3. Ovulation (On the 14^th day assuming 28 day cycle)
4. Lining of the uterus prepares to be shed in case of no pregnancy (on the last day of the menstrual cycle)

The female menstrual cycle begins during puberty, when the reproductive organs start maturing, and generally occurs two years after the beginning of secondary (postnatal) breast development. The first menstrual period is known as menarche. The percentage of menstrual cycles which involve ovulation after menarche are:

1^st year – 20%

3^rd year – 50%

6^th year – 90%

Regular and consistent menstrual periods are signs of good fertility, and also signal normal and regular ovulation.

Estrogen and Progesterone are the two female sex hormones which play a critical role in female fertility.

Source – Wikimedia Commons

Estrogen is responsible for the maturation of the female sexual organs (both internal and external) at the time of puberty and also performs maintenance of the reproductive organs throughout the woman’s life.

Progesterone (also known as the pregnancy hormone) helps in maintenance of the menstrual cycle by preparing the endometrium (uterus lining) for pregnancy and periodic shedding in case of no pregnancy. Once a woman is pregnant, this hormone decreases the allowance of pregnancy. During pregnancy, this hormone acts as a lactation inhibitor. A drop in progesterone level during the final stages of pregnancy indicates beginning of labor.

The levels of hormones vary during the menstrual cycle depending on their functions.

FSH and LH – Follicle Stimulating hormone and Luteinizing Hormone. These are responsible for stimulating the ovaries to produce estrogen and progesterone. These two hormones are released by the pituitary gland in the brain.

The process of release of an egg by ovaries to the fallopian tubes is known as ovulation. Ovulation occurs once a month and one egg is released by rupturing of a follicle in one of the ovaries. The next menstruation cycle would involve the other ovary for ovulation.

Hypothalamus located in the brain controls the complete process of ovulation. It signals the pituitary gland to secrete FSH and LH, which further control the release of estrogen and progesterone from the ovaries.

The time period in a menstrual cycle before occurrence of ovulation is called as the follicular phase. In this phase an ovarian follicle prepares itself for release of an egg by getting signals from the FSH and LH release. LH release triggers release of estradiol (estrogen). This release of estrogen, at the time near ovulation, triggers the further release of FSH and LH required for the pre-ovulatory phase.

The complete process of ovulation occurs in these phases:

1. Pre-ovulation: The FSH and LH concentration increases to a certain level, which triggers a follicle to expand in size via build up of a fluid (called the antrum) inside it. This forms a bulge on the surface of the ovary.
2. Ovulation: Enzymes are released in the swollen follicle that creates a hole known as stigma on the bulged area. Through this hole, the female gamete or egg comes out and is caught by fimbriae or the end of the fallopian tube. This egg then travels towards the uterus aided by the finger like projections or cilia found in the inner surface of the fallopian tubes. The endometrial glands and the mucus membranes of the uterus are now at their maximum size.
3. Post-Ovulation: Also known as the Luteal Phase. The follicle that released the egg now starts turning back to its normal size and releases estrogen and progesterone for the endometrium to thicken. The release of progesterone also increases the body temperature by 0.25 or 0.5^o Celsius. The follicle keeps releasing progesterone to keep the endometrium in this state till the end of the menstrual cycle.

Women may feel changes in the body during and near ovulation. Though increase of body temperature is rarely detected, changes in the cervical mucus and vaginal secretions can be more clear signs of ovulation. Some may also feel pain on one side of the pelvis and some may feel a heightened sense of smell. Women are also known to feel heightened sexual desires near and after ovulation.

Timing: Depending on the duration of menstrual cycle and the first day of the menstrual period, the time of ovulation can be calculated. For a 28 day cycle, the ovulation occurs on the 14^th day, and for a 30 day cycle, the ovulation occurs on the 16th day after the first day of the menstrual period.

Ovulation Calculator

The Most Fertile Time of the Menstrual Cycle: The fertile life time of the released egg is 12 – 24 hours. A sperm can live for 3 days after release. So the most fertile time to conceive in a menstrual cycle would be maximum 4 days before and after ovulation.

Conception or fertilization occurs when a sperm enters a female gamete or egg resulting into formation of an embryo.

The ejaculated semen in a female’s vagina during sex contains millions of sperms. These have to face the acidic environment in the vagina and the cervix, and travel a “long” distance from the cervix to the fallopian tubes to fertilize the egg. Only thousands or hundreds of these sperms survive, and reach the fallopian tubes.

Fertilization and formation of Embryo:

• The egg is finally surrounded by the sperms, which try to breach the wall of the egg. Sperms release enzymes to penetrate the jelly like wall of the egg, and one of the sperms enters the plasma membrane of the egg.

• This sperm sheds its tail and takes the genetic material inside its head to start fusing with the egg.

• As soon as this happens, the egg’s surface next to the plasma (called zona pellucida which is like the egg’s shell) hardens and makes it impossible for the other sperms to go any further. This also helps in penetration of the egg’s plasma by only one sperm.

• The fertilized egg now begins division and multiplies itself into many cells to form an embryo.

• The embryo starts moving towards the uterus to embed itself in the endometrium.

• Once embedded, the embryo gets in contact with the circulatory system. This forms the beginning of the development of placenta which provides nourishment to the embryo to grow further.

There’s no need to worry about fertile health if you observe:

• Regular and consistent menstrual periods.
• Normal duration of menstrual cycle (23-35 days).
• Changes in cervical mucus few days before ovulation – A healthy and fertile woman will have sticky, stretchy and egg-white like mucus secretion.
• Body weight in the normal range (BMI 18.5 to 24.9 ensures maximum fertility with highest near 22.5).
• Overall good health and healthy diet containing lots of fruits, vegetables, low salt and low sugar, milk products (no or little processed foods) and low caffeine intake.
• Low stress levels or positive mindset that help face stressful situations intelligently.
• Good and healthy lifestyle with minimum exposure to pollutants, chemicals and pesticides.
• No smoking, no drugs and no alcohol intake.

Having good fertility and keeping a track of your time of ovulation can boost the chances of conception. Though you can use the ovulation calculator for a fair idea, every woman has a unique pattern of ovulation. Keeping a track of it for a few months can help her get a more personalized data about the pattern of ovulation in her menstrual cycle.

How to track ovulation?

There are three factors that can be noted on a daily basis:

• Basal Body Temperature
• Cervical Mucus
• Noting down first days of two consecutive menstrual cycles

Tracking only one of the three factors can provide incomplete information. E.g. noting down basal body temperature only for the entire duration of the menstrual cycle ignores body temperature changes due to other factors like illness or tiredness etc. These temperature changes can be marked as special points on the basal body temperature chart which can be ignored and two normal body temperatures can be joined by a straight line for a rough idea. In short, ignore peaks in the chart if you know why that happened. But, even after doing this, you may not be convinced.

Second, changes in the cervical mucus may also depend on some medications or infections in the vagina.

To summarize, in case of medication, illness or any other factor that can bring changes in body temperature or other normal symptoms, one should stop tracking these factors and continue tracking later, once things go back to normal.

Tracking ovulation can only give you the idea of the most fertile days of the menstrual cycle to increase chances of conception. But you should also take the essential step of checking the fertility of your partner too.

Female fertility is dependent on many factors – age, nutrition, lifestyle, body weight, chronic diseases, medications, use of contraceptives and environment. Many factors that reduce fertility can be prevented and controlled, but age is one factor which is beyond control.  Maintaining good health helps maintaining good fertility as a person ages, but nature has designed our bodies to reproduce at a certain age.

The most fertile time for a woman on an average is 20 – 25 years of age. A woman has all the eggs preserved inside the ovaries, which reduce with age. The reproductive system also undergoes changes with advancing age. The quality of eggs, the functioning of parts of reproductive system, the release of reproductive hormones, all weaken with age, especially after 35.

Increasing age also leads to increases susceptibility of certain diseases which lead to reduced fertility, such as endometriosis, uterine fibroids, Down syndrome, high blood pressure and diabetes.

Smoking and Alcohol– Smoking increases body toxins. These toxins interfere with normal body functions and affect fertility by reducing the number of eggs in the ovaries. It also increases chances of miscarriage and stillbirth. Studies show more menstrual cycle abnormalities in women who consume alcohol.

Caffeine – Excess caffeine intake is known to reduce chances of conception. One or two cups of coffee a day are fine, but the intake should be minimized depending on body tolerance. Caffeine is present in coffee (the primary source), tea, soft drinks, ice creams, energy drinks and chocolates etc.

Age: Women have their peak reproductive health between the age of 20 – 25. With increasing age, the changes in the reproductive system make the chances of conceiving lesser. As you might have read earlier, the number of eggs in the ovaries reduces with age. The ovarian follicles also become less productive with age and release of reproductive hormones also reduces. With increasing age, other ailments like endometriosis and uterine cysts can also contribute to reduced fertility.

Medicines: Medicines that contain steroids affect the pituitary gland which secretes essential hormones for proper functioning of the menstrual cycle. This creates an imbalance of hormones, which can affect the regularity of the menstrual cycle and ovulation. Medicines that elevate levels of prolactin hormone (this hormone is used to produce breast milk and reduce ovulation) in the body also reduce fertility.

Contraceptives: Oral contraceptives or birth control pills stop the ovulation process to prevent pregnancy. It might take some time for the menstrual cycle to come back to normal, after stopping the intake of the pill. If the menstrual cycle is not normal even after 6 months after discontinuation of the pill, it’s better to consult a physician.

Medical conditions: Diabetes, Thyroid abnormalities, skin ulcers and arthritis are known to reduce fertility.

Body Weight: Increase in body weight by 10 – 15% can increase estrogen levels, which cause abnormal hormone levels, that can adversely affect the normal ovulation cycle. Body weight below normal levels by 10 – 15% can reduce the estrogen levels which also causes hormonal imbalance and therefore, affect ovulation which is controlled by estrogen and progesterone levels.

Diet: Adequate nutrients are required for all body functions to work properly, including the reproductive system. A diet consisting of right balance of carbohydrates, proteins, minerals and vitamins etc required by the body ensures good health of all body functions.

Vigorous Exercise: Exercise routine that demands lot of physical effort and force can affect the menstrual cycle. Women who perform vigorous exercise daily and more regularly have been noticing irregular and fewer periods. Therefore it is recommended for women to do exercises that do not put excess stress on the body.

Other Factors: Stress, exposure to high amounts of chemicals, pollutants and harmful radiation, frequent air travel, irregular sleep-patterns and bio rhythm.

The inability to conceive after 12 months of unprotected intercourse is known as infertility. In such a condition, both partners should visit a physician for an infertility evaluation. Some lifestyle habits or medical conditions are responsible for reducing the fertility in both males and females. Most of these conditions are preventable or can be cured if appropriate medical advice and treatment is undertaken.

Infertility is known to be a stressful situation for both the partners. The evaluation and treatment for infertility can also be a difficult experience emotionally, and requires patience and understanding between partners and support from family. Today’s medical technology is well advanced and there are much less painful and effective cures for infertility.

Consult a well known, well reputed and a friendly doctor who has professional and well qualified staff. You can ask the OB/GYN physician you are already visiting or ask friends and family. Make a list of the best specialists and arrange meetings. Try to take opinions from several specialists before going for the tests or surgery. Different doctors may have different ways of solving a problem and you may get a good advice and safest procedure to cure infertility. Make sure you have all relevant medical records ready, arranged and safely kept.

Infertility Tests for Women (What a physician would do – The following are the common tests performed to check reasons for infertility in women and only the appropriate tests will be performed out of the following):

• Infection in vagina or cervix.
• Blood Tests (Hormone Levels, HIV, STDs, Germen Measles, Immunity Related Tests)
• Pelvic Ultrasound
• The doctor may ask you to perform some tests to be performed at home (BBT Test, Ovulation tests using commercial ovulation predictor, for specified number of months). Ovulation Tracker
• Endometrial biopsy (Performed few days before beginning of menstrual period)
• HSG Procedure (Performed few days after completion of menstrual period) is performed to check for any obtrusive growth(s) in fallopian tubes or uterus.
• Hysteroscopy
• Laproscopy

Infertility Tests for Men (What a physician would do – The following are the common tests performed to check reasons for infertility in men and only the appropriate tests will be performed out of the following):

• Blood Tests to check hormone levels and infections.
• Semen Tests (large number of WBC(white blood cells) indicate infection)
• Urine Tests (To check presence of WBC and sperms. High amount of sperms indicate retrograde ejaculation.)
• Analysis of Semen (To check sperm count, sperm quality and movement)

In case you are not sure about your fertile health, a preconception visit to the doctor can also help in providing information about yours and your partner’s reproductive and general health for planning a healthier pregnancy.

A healthy start to a pregnancy is important for a healthy pregnancy – for which right nutrition is extremely important. Near the time you try to conceive, pack your food with nutrients your baby needs during the early development stages. Here are some foods which you must have during this time:

• Asparagus – A folate packed food. Also contains Vitamin A and C, iron and potassium.

• Lentils – Seeds of health – They are packed with folate, Vitamin B6, zinc, iron and magnesium.

• Broccoli is rich in iron content, Vitamins A, C and Calcium.

• Papaya – Rich in folate, Vitamins A, C and dietary fiber. Also improves cardiovascular health.

• Spinach – High in iron content, protein, Vitamin A, Vitamin K, folate, vitamin C and antioxidants. Steam cooked spinach retains most nutrients.

• Soybeans – Rich source of protein, folate and B vitamins, iron and potassium. Soak them in water overnight, in the morning discard the water and boil the beans in water until soft. Make a salad of these beans by adding tomatoes, cucumber, lettuce leaves, bell pepper, small pieces of cottage cheese or tofu and a dash of lemon. Season with herbs of your choice. This will provide you all the essential nutrients found in soybeans.

• Cucumber – take it along with iron rich foods. It is a good source of vitamin C, iron and potassium and will help absorb iron from food. It is great in salads and sandwiches. Tastes great with a dash of lemon juice.

• Salmon Fish – rich in omega 3 essential oils, Vitamin D, Vitamin A, Iodine, selenium, phosphorus, potassium, iron and calcium.

• Eggs – Rich in Vitamin A, vitamin D, riboflavin, iron and calcium. Weight watchers can increase amount of egg whites (proteins and Vitamin B₂) and reduce egg yolks (which contain iron, vitamin A and B vitamins). Only consume completely cooked eggs.

• Dried fruits and nuts – rich in vitamins, minerals and essential oils.

• Pomegranates, blueberries and apples – rich in antioxidants, vitamins and minerals.

• Oranges and Orange juice – packed with Vitamin C which helps absorb more iron form food, also contains folate (essential for early development phase of your baby).

• Carrots – source of Vitamin A and beta carotene.