ZITA WEST’S GUIDE
TO GETTING
PREGNANT
Zita West

dedication

I would like to dedicate this book to my mother for her help, guidance and support over the years in all I have achieved.

contents

Cover

Title Page

Dedication

Introduction

The way I work

Part 1: The Basics

Understanding Female Fertility

Understanding Male Fertility

Conception

Part 2: Preparing Your Body for Pregnancy

The Right Nutrition

Lifestyle Factors

Thoughts and Emotions

Traditional Chinese Medicine

Part 3: Fertility Problems And Solutions

Fertility Work-up

Miscarriage

Assisted Conception

Pregnancy

Useful Contacts

Index

Acknowledgments

Praise

Copyright

About the Publisher

introduction
Information Overload!

Having a child is the most creative thing you can imagine but, for so many, the balance between what we are told to do as responsible parents and what we need to do to maintain an effective and enjoyable life in work and leisure seems to have gone. There are self-help books, theories, courses, experts, gurus galore, all with something to say, demanding attention. The driving aim of my work is to help couples to make sense of the maze – to gain a better understanding of where they are and how to move forward, practically – and it gives me the greatest pleasure.

Let’s be realistic about modern life: Lots of men and women work long, stressful hours, particularly at the time of life when they are thinking of having children. They are bombarded with stimulation, information, expectations: it all leads to overload. So many couples have lost focus, running down many routes: Trying to conceive, undertaking all sorts of treatments, but often not looking at their everyday environment and things that they can do for themselves. Let’s keep it simple.

The focus of many clinics and books like this is often wholly on the woman and her situation. But, as I’ll point out, problems conceiving can equally be with the male partner. So in this book you will find me frequently talking about the health of both partners in a couple, and there is a lot of information about male fertility.

If you are going to take control of your own fertility, you need to understand it properly. This book offers you practical knowledge and information about how your fertility works, how to monitor it and how to help improve it. Many of my clients are extremely intelligent, high-achieving, successful people, but they are ignorant of the biological basics. It’s something they are often acutely embarrassed about, but it’s not entirely surprising – it’s easy to get lost in all the medical jargon. However, hidden in that jargon is important information. Don’t be tempted to just give up on it and flee to complementary treatments as an escape. The medicine we’ve got used to in Western countries is highly technical, and has perhaps become impersonal in its approach, but it can be used to extremely good effect. Good complementary approaches, particularly those that deal with the whole person – body, mind and spirit – can be very valuable, too, but it is important to choose the right ones, the right practitioners and, crucially, to combine them with a proper medical approach.

This book brings both approaches together, getting the best from each. It reflects the special aspect of the work I do every day in my own clinic – a truly integrated use of Western and complementary practice. Western medicine is evidence based and founded on proven measurable results. As far as possible, the treatments I advocate are equally evidence based, even in the area of complementary care.

More than that, I am interested in why couples want to have children; what else in their lives is making that possible or difficult; why perhaps they haven’t thought about it before.

It is a fact that women are leaving it later to have children. There are many reasons for this trend, but there is no getting away from the fact that the chances of conception diminish with age. Being realistic, I firmly believe that women in their thirties should be fast tracked for investigation. They do not have indefinite time left to keep trying, and there may be fertility problems to be addressed.

Perhaps one of the reasons couples delay pregnancy is an increasing need and expectancy for perfection. They think, ‘We’ll just wait until next year for a better income/home/lifestyle’ and so on. But of course the perfect moment never comes, even though there’s an industry of self-help programmes guiding you towards that perfect balance. And then, as with ‘perfect’ diets, when you stray from the path there’s often guilt and remorse to cope with and you have to start all over again. This book is not about being perfect, but about being practical.

the way I work

Planning to get pregnant often follows other life plans – getting a longed-for job, finding a life partner, buying a first home – then comes having a baby. For some there comes a period in their lives where all the pieces of the jigsaw are in place, and the timing is right for having a baby. For others, there is an emphasis on getting everything ‘just perfect’ before ever considering having a baby.

Working with couples who are trying for a baby is multifaceted. Couples trying for a baby have many issues that are unique to them. I try and work with a couple to see their individual and unique whole picture.

Having said this, I believe there is no point in our lives when the timing is just right, and I wish I could encourage more couples not to set themselves unrealistic goals. Now I am a mother with a teenage daughter, it’s only natural that I want her to get a good university degree, find a rewarding job and a steady relationship. I was 27 when I found myself pregnant with her, and was devastated at first. I did six pregnancy tests to check, because I had not ‘planned’ on having children until my thirties. Although I had been married for a while, my husband and I had no money and were working abroad, and I thought the timing was terrible. Now, I wouldn’t have done it any other way!

Having been doing this work for the last 15 years, I found in the first few years that it was very much the woman in a partnership who would come along for the initial consultation; I would never see the partner. Nowadays I am delighted to say that I see couples together all the time – which is only as it should be, as the problem, statistically, usually has to do with women 50 per cent of the time and with men the other 50 per cent of the time.

The majority of couples don’t have a problem conceiving, but if you have bought this book, maybe getting pregnant isn’t happening for you as quickly as you would like and you are looking for some information and answers. No matter what route you take, I believe that you can take control of your own fertility – not hand it over to a doctor or fertility clinic. This is how I work with the women and men who come to see me. I don’t give them a pre-set, ‘one size fits all’ formula. Each couple is unique, and while their emotional and physical well-being is my main concern, I don’t tell them what to do. Together we work out what will work best for them. It is my hope that this book will help you do the same. I am really delighted that more and more clinics are starting to take on my work, particularly as of course not everyone can come to our clinic. My aim in this book is to help you to plan the best course of action for you, and to indicate the kind of treatments you should try to find in your own locality.

Keeping It Simple

Day after day I sit with couples who have experienced difficulties at every stage of the fertility process, from the pre-conceptual check-up to those who have battled with miscarriage or assisted conception. Each of these couples has the same goal: they want to have a baby. Some are more desperate than others, and with desperation comes a kind of vulnerability. Many couples are running down endless routes, trying every available therapy without any real focus.

Many come to me just as they are about to embark on their goal. They are still optimistic – and usually with good reason – and want reassurance about their approach to conception and what steps to take in adjusting their lifestyle, diet or activities. They prove how starting off on the right foot can make all the difference; I have seen the results, and have a clinic full of photos of smiling mothers and babies to prove it.

Others who come to see me have already pursued all sorts of ways to get pregnant, and know they are having problems. Sometimes just the process of being listened to and being asked the appropriate questions elicits that nugget of information that may be key to the outcome (which is why the questionnaire I use is so detailed).

For example, I see many, many couples who are just not having sex often enough. It’s as simple as that, but just saying ‘have more sex’ wouldn’t be helpful. Helping a couple take a really good look at their lifestyle can be a real turning-point in their whole approach to having a baby, demonstrating the need for a radical change in their priorities and for unqualified commitment. The baby is not just another ‘must do’ item to fit into their life-plan.

There are so many myths around nutrition, intimacy and sex (see Male and Female Fertility chapters). Many GPs and clinics don’t ask enough about couples’ sex lives; the usual question is ‘Are you having regular sex?’ But what is regular sex? Once every Sunday morning may be regular sex to you, but it doesn’t help if you are ovulating on a Wednesday. Also, couples who are on different schedules, do shift work, travel a lot-these are all huge factors when you are trying to conceive. There can also be psychosexual problems, and naturally many couples are embarrassed to discuss such matters, particularly if their GP or clinician is not asking the right questions, of if he is not making them feel comfortable or even worthy of his complete attention.

It Takes Two

Basic knowledge about anatomy and physiology is one area that inevitably needs to be explored. Not the nuts and bolts of what goes where, but the details of a woman’s fertility cycle, and what the implications are for ovulation and possible conception. This is why fertility awareness is so integral to the way I work. Spending a king’s ransom on ovulation-predictor tests won’t help if you think your cycle is 28 days when what is normal for you is a 35-day cycle. Many women have been on the Pill for a long time and have no idea what their normal cycle is; nevertheless they often feel embarrassed by discussions around basic biology, as they feel they ought to know all about it.

In my experience of looking after couples who are trying to get pregnant, I am convinced that the neglect of the man’s role in conception has also confounded many of their attempts to have a baby. The man is very often badly neglected when it comes to assessing a couple’s fertility. A quick, cursory look at the quality and quantity of his sperm is about all that’s done in most fertility clinics, with all the emphasis focused – often wrongly – on the woman. There may also be a notion that the whole of a man’s ego and masculinity is bound up in his sperm, making any possible criticism – or even discussion – of his effectiveness in this area an attack on his masculinity. Neglecting a man’s role in the scheme of things is not helpful. The way I work places as much importance on the man’s role in conception as the woman’s, which is why the questionnaire I supply for men is just as detailed as the one for women.

A Holistic Approach

Many couples find my approach to be very different from a consultation with their GP or a fertility clinic. The physical checks they give to patients’ reproductive organs, systems and processes are, of course, invaluable, but there is often more to it than this. I take a holistic approach, taking into account the social, emotional and lifestyle context of the couple as well as the pure mechanics of reproduction. The pre-consultation questionnaire provides me with an invaluable tool for assessing this wide range of issues, and also helps many couples to think about their lifestyle and their true aspirations.

Prior to the first consultation, couples who come to my clinic are given a detailed questionnaire, one for women and one for men. This covers:

• the main reason they are seeking a consultation

• fertility history

• contraceptive history

• sexual history

• sexual issues

• general medical history

• family history

• diet and exercise diary

• blood sugar profile

• digestion and elimination profile

• immune profile

• pollution profile

• vitamin and mineral status

• food allergy profile

• details about other hormonal-related conditions that may exist

These questionnaires are long and detailed, to provide, in conjunction with consultation, a full profile on which decisions about the way a couple can choose to proceed can be based.

The questionnaire helps pinpoint areas that may be affecting fertility: factors to do with nutrition and exercise are often highlighted. These may be associated with emotional or lifestyle issues. In this way I try to help couples focus on their situation, so that together we can work out a plan of action. After the initial assessment, we consider what tests, treatments or therapies might be necessary along with the steps a couple need to take for themselves to make conception more possible.

For example, a couple may use cocaine at weekends to relax and chill out. That is their choice, and it is essential that they do relax, but the effects are very serious and if they want to conceive a baby they must stop. I try and keep things very simple, with explanations – as you will see in this book – about why change may be necessary. In this way I encourage couples to take responsibility for their own fertility.

It’s self-evident that, if you want to improve your likelihood of achieving a successful pregnancy, you have to be willing to make changes. There is often an instinctive reaction against change, but, in truth, the necessary changes are likely to be in areas of your life that you recognize are causing you stress and difficulty. Getting things into perspective for pregnancy is likely to result in a much more balanced, well-managed and satisfactory lifestyle all round – but you need support, advice and encouragement to make this happen.

I see many couples who have already taken steps for themselves along these lines, but this often takes the form of a random blitz of nutritional supplements, complementary therapies, weight-loss regimes, high-protein diets, etc. undertaken without any real knowledge of how these measures will affect their ability to get pregnant. Inevitably, some of these efforts can be unhelpful or even counter-productive.

This problem is not helped by the fragmented nature of available advice. Medical specialists, including obstetricians and gynaecologists, may be engrossed in the mechanics of conception but have little awareness of the patient’s emotional or personal situation. Complementary practitioners may have a more holistic view, but are unlikely to be fertility specialists with the appropriate technical knowledge. And nothing in the plethora of highly focused and specialist diets on the shelves of your local bookshop is likely to have been devised with the vital nutritional needs and sensitivities of pregnancy in mind.

Crucial Questions

One way I help couples to understand the need for taking a close look at their lives and finding a way to make the changes necessary to achieve more balance is by asking them to sit down and write out how much time they spend on each area of their lives. You might find this helpful, too, and may want to take a moment to do this for yourself.

In my first session with each couple I always ask a crucial question: How far are you prepared to go to have a baby? Couples just starting out do not realize how important this question is. When you first start trying, you’re probably only looking ahead six months or so, and are still very optimistic. The hard thing is that as time goes on there are many things you may have to negotiate: IVF, egg donation, adoption, for example. Where you are on the road now, and the effort you’ve already spent getting here, will make a difference to the outcome and how far you are prepared to go. Just as you have to be prepared to make changes at the outset, you must also be ready to alter your course as you proceed, as there will be obstacles to encounter and overcome with every success and failure.

This initial, important question makes couples think realistically, often for the first time, about what the quest for a baby might really mean. Sometimes there is a difference of opinion, which can come as a surprise – and is important to discuss. Without agreement on how far a couple want to go to achieve a pregnancy, issues arising from any difference of opinion between partners can lead to tension later on.

There is also a need for flexibility. Minds can be changed, and having opened up the area for discussion it’s important for couples to continue to be able to do so.

For those who have reason to suspect they have a problem, there is often little idea of the maze into which the first step to their doctor can take them. Often, in particular if the woman is over 35 and a couple has been trying for a year, there is a tendency to fast-track them into assisted conception – without properly assessing the fertility of either partner.

There is so much that needs to be looked at before assisted conception is even considered, and unless there is significant reason to know that natural conception will be unlikely, this needs to be done before catapulting a couple into assisted conception. And again, so often too much focus is put on the woman, when the man very often has the problem. I have seen many valuable months of fertility lost in this way. That said, a lot of couples I see do need assisted conception, but they also need holistic care and support to help ensure that they are physically and emotionally prepared for the process.

Your individual needs

At the end of the first consultation, I draw up a relevant action plan for a couple. Depending on what the consultation has highlighted, this can vary – but it is always specific to the couple. It may include referral for further tests from a gynaecologist and a specialist in male fertility. It is entirely up to a couple how they wish to proceed, but the majority can see that taking a holistic approach is beneficial. Sometimes the action plan is very specific – for example if there is a need to boost the body in preparation for IVF – and sometimes it’s more general, where there is a need for fertility awareness and lifestyle changes to improve the chance of conceiving.

I can’t stress strongly enough that every couple is a unique combination of needs – both physical and emotional. The way I work is to address that individuality. That said, experience has shown me that when couples have the benefit of a holistic approach – which may encompass medical treatment, nutritional supplementation, relaxation and distressing techniques, detoxifying, acupuncture and massage – the personal outcome for the couple is always positive.

Today’s Choices

The difficult choices couples are faced with today are new ones. Years ago, you either had a baby or you didn’t. Now the length of time you try can go on almost indefinitely – you start off trying naturally, then perhaps try IVF or egg donation or surrogacy.

Very often I see couples trying for years when certain problems, procedures or decisions could have been reached or ironed out earlier. All this has to be done in the context of a good understanding of a couple’s fertility, shared between them and their clinic. It really is a team effort, and one in which the couple are equal partners with the rest of the team.

First Impressions

The process of diagnosis starts the moment a couple walk through my door. I can tell a great deal from the way people walk, their handshake, their posture while seated. For instance, I can tell immediately if a man is inclined to think it is not ‘his problem’: If he walks in with his head down and arms folded, and avoids eye contact.

As a qualified and practising Five Element Acupuncturist, I use my classical Five Element training to begin assessing each person’s constitutional type (see page 223). I look at a person’s colouring – not just eye and hair colour, but the texture and hue of his or her skin tone – and I start to build up a picture of an individual’s emotional and physical strengths and weaknesses, and in which organs any weakness may be lying. I look at what the general emotion is – worry, anger, grief, fear. Sometimes it’s very positive and joyful. I need to understand each person’s individual circumstances, and how they are affecting him or her – individually and as part of a couple. I also look for the dynamic between the couple, how vital their relationship is, how close they are, and how they communicate – verbally and non-verbally.

Obviously I take into account that this is an incredibly personal and intimate experience they are sharing with me, which can make many people feel vulnerable. Often they can react defensively, sometimes aggressively, to mask their anxiety. Couples often want me to provide answers, when what I do – and what I hope this book will do for you – is help them find the answers in themselves. Only a full understanding of what you are facing will make it possible for you to make choices, effect any necessary changes and feel positively involved with the process.

I believe that a positive attitude affects the mind and body hugely. The couples I see fall into many categories: those who are starting to try, couples just about to embark on IVF, couples who have had multiple failures, women who have miscarried, couples considering moving on to egg donation, sperm donation, surrogacy or adoption. Help is available to you at every stage of this journey.

If You Are Just Starting Out

Couples in this place tend to be at the end of their twenties or in their early thirties. In many cases the woman has come off the Pill and has no idea what her normal fertility cycle is. It is worth saying here that I don’t hold with the belief that a woman shouldn’t try to conceive when she first comes off the Pill. The research shows that a woman actually has much more chance of conceiving when she first comes off the Pill. Very often, however, women rely on ovulation kits since they don’t yet know how to work out their most fertile time. Ovulation kits are fine, but need to be used in conjunction with a knowledge of your cycle. A good biology lesson, as given in Part 1 of this book, removes the element of panic and can put you on the right track. Very often all you need is a fertility awareness session to get you to understand your individual cycle.

At our clinic we also make an assessment of how long a couple have been trying based on age and how often they are having sex, and also give them guidelines for further medical tests they may need alongside the treatments we suggest. At this stage, as far as we know there is no reason why the couple should not get pregnant. Detailed questions can help to pinpoint any lifestyle or nutritional changes that need to be made to enhance fertility, as well as integrating other therapies that might be helpful such as nutrition, acupuncture or hypnotherapy. It might be advantageous to lose some weight, to get your cycle regular using acupuncture, or to assess any emotional issues. Often these quite simple measures make all the difference, and I have seen case after case of straightforward conception in couples who have been trying for some years, and failing, just because of some basic misconceptions that can be readily corrected.

Men are just as important, even in these apparently straightforward cases. If a couple have visited their GP, the man has often had a semen analysis, but seldom understands the implications of the results – not least if they are apparently ‘normal’. Not only that, but often semen analyses are done, not in a laboratory, but in a fertility unit and just given a quick check. This is not adequate. A semen analysis should be done under laboratory conditions, assessed by experts and subject to a full analysis, which may include DNA fragmentation (see page 287) and prostatic massage (see page 277) as part of a full sexual health screen. Often a sub-clinical infection with no discernible symptoms is detected that requires antibiotic treatment. Only when there has been an adequate analysis, with the proper explanations, is the man likely to take the steps necessary to improve his sperm quality.

Individual fertility cycles

So many couples just don’t have sex often enough to get pregnant! However, I don’t advocate sex just for the sake of getting pregnant; it should be part of every couple’s normal, loving relationship, a way of sharing intimacy and having fun together. That way, sex doesn’t become an issue or a chore – where the man thinks the woman is only interested in sex as a means to an end, and not as an expression of her feelings for him. Women, in turn, can become fixated on their fertile time, and only want sex at this time. Prior to this, a couple’s rate of sex may have dropped to once week, or a couple of times a month, which may suit them fine – but it’s probably not happening enough for a pregnancy to result!

Sex can steadily become mechanical for so many couples; it is so hard for it not to. Many men suffer from ‘performance anxiety’ around sex if it seems that their partners are only interested in having sex around the time of ovulation. This puts a huge pressure on them. I have heard stories of women emailing their husbands at work, driving to their offices and demanding sex, which inevitably ends in a row and no sex.

If you have been trying for a while, a few basic questions:

• Are you sure you have been having sex at the right time and often enough?

• Are you only interested in sex at the right time of the month and not at any other time?

• Are you still making an effort with your relationship?

Plan ahead; make some of the changes specified in this book before moving on.

If a couple can keep their lines of sexual communication open, and enjoy this aspect of their relationship for its own sake, and not just as a means to pregnancy, then the process will be less stressful all round.

Contrary to popular belief, having sex often does NOT weaken sperm. Research has shown that the more a couple have sex, the more fertility is improved. Here are the figures for women aged 20–30:

A plan of action

I like couples to leave my clinic with a sense that they have a plan of action, specific to them, and to feel optimistic about it. Together we formulate a four- to six-month action plan, so there is room for a relaxed approach, with the view that the action plan will be reviewed after that. This serves two purposes: it provides both a positive structure and a timescale that takes the pressure off in the short term. This allows a couple to relax, knowing that they have positive steps to take with the opportunity for reviewing the situation in six months’ time.

I find that with people in this situation, because the couple have every reason to believe they can get pregnant, they usually do!

If You Have Been Trying for a While

If I could say to couples who have been trying for some time that, by such and such a date, they would be pregnant – they would skip out of my office in delight. But unfortunately there just are no guarantees, and the apparently ‘unexplained’ causes of infertility are of course the hardest to accept. I often hear women say how difficult they find it when all around them their friends are getting pregnant and having babies. They describe the news of a friend’s pregnancy with phrases like ‘a knife going through my heart’ and find it really difficult to express pleasure or smile at other women’s good fortune. Social gatherings become a nightmare, with others asking tactless questions such as, ‘When are you starting a family, then?’ Nor is it helpful to hear advice such as ‘Just relax’ or ‘Let nature take its course.’

Comments like this may be well meaning, but can result in anger, envy and jealousy, which can in turn lead to feelings of self-hatred. And the stress of it all can lead to quite severe anxiety and depression. Men can be equally affected by these feelings. It’s hard on both partners, but women in particular can become obsessed with their monthly cycle, focusing every aspect of their lives on getting pregnant.

Telling a woman not to get obsessive isn’t helpful. What is helpful is providing a structure for dealing with the reasons behind the obsession, and finding tactics for managing the feelings of frustration, anxiety and sadness that arise.

If couples have been trying for anything from six to 18 months, a lot of emotional and relationship factors start to come into play. For some couples, they find that this shared aim brings them closer together, but often couples can start to feel demoralized and pretty hopeless.

The knock-on effect of this can be detrimental to a couple’s sex life. Sex is no longer about intimacy, it has become associated with ‘getting pregnant’. Yet, when asked, it can still turn out that the couple are not having sex anything near as often enough to get pregnant. Sex becomes mechanical, with all activity focused on when a woman thinks she’s ovulating, so her partner becomes fed up, or afraid that he might not be up to the job when necessary.

This can be further aggravated if a problem has been identified in the man. Coming to see a fertility specialist may be the first time this is openly discussed, and for some men a poor sperm test result makes them feel like a complete failure. The great thing is that there is so much that a man can do to improve the quality and quantity of his sperm production. I would also like to reassure you that, even with a less-than-optimum sperm result, if everything else is going well, conception is still possible. This is important because some couples give up trying at this stage, assuming there is no point. I always encourage couples to keep trying. Many couples go on to conceive, even with a poor sperm result. Nevertheless I do understand that in cases like this it’s very hard to be positive.

Sometimes couples become so involved in each other’s biological details that all the mystique goes out of the relationship. I saw one couple where the man had taken to examining the cervical secretions in his wife’s pants! Another knew every detail of his partner’s periods, right down to the consistency of the flow and the amount of blood clots. No wonder some couples’ sex lives take a turn for the worse!

A couple’s sex life is very important, whatever the circumstances. It is one of the best forms of physical and sensual communication, and can be enormously restorative to a relationship under strain. For those women obsessing about ovulation and insisting on sex there and then, I tell them to stop, throw away the ovulation kits and temperature charts, take a break and put some energy into the relationship, for its own sake. Get romantic, be seductive and take time out together for a walk, a nice meal, a massage, anything shared that can lead to sex within the context of a loving relationship – the same relationship into which you want to bring a baby. The two are not separate, and are paramount to keeping a sense of balance – which is what pregnancy is all about. Creating a family takes energy, a sense of humour, time and love. The other thing about having a good, regular sex life is that it creates a natural high, releasing mood-enhancing endorphins and the bonding hormone oxytocin. I encourage couples to use aromatherapy oils, for massage or in candles – essential oils such as jasmine and ylang ylang stimulate the secretion of endorphins. We all need a little help when times are stressful, so utilize what’s available to set the scene and enhance the mood.

The options available

Ultimately you can’t control your fertility or when you will get pregnant. But I tell couples that they can control the options available to them, and the path they take to get there. It takes a degree of patience to seek out opinions you trust, rather than flit from one fertility plan to another. You need to do the research and then take a step back. Learning to keep a perspective on the situation takes practice – though, naturally enough, many couples find this almost impossible. I find that there is sometimes a tendency for partners to blame one another – even if this is unspoken. This is sometimes not even apparent to the partners themselves, but if I am aware of it I can help diffuse any tension by explaining things and providing a structure for the steps that can be taken.

Another problem can arise when the woman starts to feel she is the one making all the effort. I often find that women drive everything when it comes to trying for a baby: they buy the books, the vitamins, etc., and expect their partner to follow suit. She may try forcing every available vitamin or dietary supplement down her partner’s throat, plus enforcing changes in diet and lifestyle, etc. Her partner, meanwhile, may have come to his own conclusions, and very often will only make changes if he has been convinced there is really a problem. Some women make their partners give up absolutely everything, and get fixated about helping their partners make healthy sperm within a precise, limited timeframe. Then if the man lapses, say has a few drinks, the woman gets angry and feels they have to start all over again.

So, for you women: Don’t nag. Put time and effort into your relationship and accept that men see it from a different perspective. Be kind to one another. Women can feel extremely angry if they have given up alcohol, or smoking, and their partner hasn’t or won’t. It feels very unfair, and as if they are making all the sacrifices. Men, for their part, can start to feel very guilty. Obviously, none of this is conducive to success!

For women, with the highs and lows of anticipation during the month, and disappointment if a period arrives, it can be all too easy to get into the blame cycle while forgetting that their partner, too, may be living in dread of a period arriving. Some men start to dread going home, and to feel hopeless about what they can do. Blame can arise from the feeling that ‘If only I had done this or hadn’t done that’ or ‘If only he had drunk less or not been on that business trip when I was ovulating …’ The permutations are endless.

I know it can be hard, but please try not to start the blame game. Instead, it’s important to be kind to each other and remember to share those things that brought you together in the first place.

Keep communicating

It is essential to keep talking. Often things come up in the safety of the consulting room that have been bothering one or other partner. As I’ve said earlier, trying to get pregnant – especially if it’s not happening as expected – is inevitably emotional, and ignoring this can create problems. So I look for opportunities to encourage couples to share their feelings, ideas, and even their resentments! It’s much better that these are aired, addressed and resolved than left to fester. I can provide the space for this.

I often recommend couples-counselling for those for whom the situation has become too difficult to deal with. It is far too easy to become estranged through the process of trying to get pregnant. In some cases, I have found that men seem to accept the situation more readily than women. The man may be more relaxed about getting on with life, while his partner may interpret this as a lack of commitment, especially if she is researching on the Internet, seeking out opinions and information, and wanting to focus on getting pregnant almost to the exclusion of everything else. Understandably, many men get fed up, and this can exacerbate the situation still further.

Very often, a few sessions of skilled couples-counselling is all that is needed to bridge the gap, allowing partners to express their feelings and their views, relieve tensions, reduce blame and establish a united platform from which to proceed.

Men need to express how they are feeling, and in the right setting it is amazing what comes out between a couple, especially when a man feels safe about being able to express what he is truly feeling about the situation.

Case History

Linda was 38 and had been trying to get pregnant for two years. She was tearful, angry and upset about her situation. She was on the Internet for up to four hours a day, plus all day at weekends. In the consultation with me, when I asked how it was affecting their relationship, her husband Paul said he had started to dread coming home – Linda would have inevitably found another treatment to pursue, another pill he was going to have to take. He felt completely unable to get through to her; any suggestion he made would get shot down. He felt that Linda was in a total spin; he felt depressed, isolated and fed up of constantly trying to please her. He felt inadequate, and that Linda resented this. His deep, deep concern, which he only felt able to voice in consultation, was that as much as he loved her, he felt that the drive to achieve a pregnancy was becoming destructive for the relationship. Paul had tried to understand Linda’s burning desire to have a baby, but he wanted their old life back together where when he came home they had a drink, a chat, a laugh, not him spending time on his own while she was on the Internet.

Linda was able to express that, on her part, she felt panicky that she was running out of time. She felt very stressed and was waking at 4 in the morning and grieving about the child she might never have.

The plan we came up with was to set an absolute limit on Linda’s Internet searches and work on getting her internal environment back into balance by doing some yoga and meditation. We did a detox with her to help her lose some weight and we changed the IVF clinic that she was currently attending. Linda got back in contact with me later, to say that our consultation had really been a turning-point. She had not really been aware of the impact her pursuit to have a baby was having on her relationship. Her interpretation of Paul’s behaviour was that he wasn’t interest ed in any suggestion she made about treatments, and she felt that he was blocking her at every point. After our consultation she felt she really understood where he was coming from and felt much calmer as a result.

Women in their late thirties/early forties

This age group accounts for a large percentage of the women I see. Often they are career women who have got used to high degrees of control over their environment, and are in uncharted territory when they can’t control their own fertility.

Although some come just for a pre-conception ‘check’, many have been trying for a while. Some have been down the IVF route unsuccessfully; often there is a history of ‘unexplained’ infertility or recurrent miscarriage, or some anxiety about their fertility cycle. Some couples are taking ovulation-stimulating drugs such as Clomid, or doing intrauterine insemination, and want to improve the chances of conception by supporting and preparing their bodies. Some have been recommended for egg donation without having had a full, clinical work-up or assessment. Very often they have been to only one clinic and were told they have had a poor response and no eggs. Going to another clinic might have meant a better result. In short, there are many factors to consider.

If you have been trying for a while:

• Have you had a diagnosis and have you both been tested?

• How is it affecting you emotionally?

• Are you nagging or resentful of each other?

• Is your relationship starting to suffer?

• Are you losing the balance in your life?

• Are you giving up everything?

• Has your sex life been affected?

• Are you ready to move on to assisted fertility?

The starting-place for these couples has to be an in-depth analysis and discussion with the couple about where they currently feel themselves to be, covering any anxieties or misunderstandings. Without this, there isn’t an adequate baseline from which to work. Some couples, especially those who have been round the infertility block a few times, feel that this is unnecessary, as they have already had many medical interviews and tests. In my experience, however, many clinics are not thorough enough when it comes to identifying what the problem might be. Often I find that couples have not even been asked how frequently they have sex! All the medical tests in the world will make no difference if a couple are having sex only twice a month. If the length of a woman’s cycle hasn’t been worked out properly, any chance of getting the timing of ovulation right is unlikely. As I mentioned earlier, a lot of couples get fast-tracked into assisted conception without a proper assessment. I am sure that this is key to the success we have in helping couples achieve happy, healthy pregnancies.

My Programme

The programme I have devised to help couples always works alongside Western medicine while incorporating complementary therapies and Traditional Chinese Medicine. Looking at the whole picture enables me to come up with an appropriate plan. The main message I try to get across is keep it simple. So many couples are running down too many routes with no focus. The initial consultation enables me to look at lifestyle factors and the range of treatments on offer – fertility awareness, nutrition, detox, acupuncture, hypnotherapy, abdominal massage, deep breathing, manual lymphatic drainage (MLD) and counselling. There’s more about all of these later in the book. Depending on what suits the couple, usually there are two or three treatments undertaken over a period of four to six weeks, with a review every three months.

The most important thing we offer is support and advice. I believe you can get through anything if you feel supported.

Right from the start, when I first see a couple I stress that they must be flexible in their thinking and not become obsessive. I advise against information overload: endlessly trawling the Internet investigating other people’s experiences or solutions may not be relevant, and can even be unhelpful. I recommend trying to keep things in perspective – although many couples feel they have had to give up a lot in order to achieve conception, there is still room to enjoy life as a couple. This should never be forgotten.

I also advise couples to keep in mind that their difficulties with conception, if they arise, are relatively temporary. Actually starting a family may seem like a long haul, but in the greater scheme of things this will represent only a short period in your relationship – it’s important to keep this in mind. Long after your fertility problems are resolved, your relationship will still be there – so it’s worth nurturing and making time for. A good relationship will also sustain you when things get difficult.

part one the basics

understanding female fertility

This may sound strange, but many women today have no idea what a normal menstrual cycle is – many of them have been on the Pill for 15 years or more, so this is hardly surprising. Women often feel embarrassed that they don’t know everything about their fertility, and this lack of basic knowledge isn’t helped by the numerous myths out there about what they should and should not be doing in order to conceive successfully!

I am very fortunate to work alongside Jane Knight, who has done so much to raise awareness for women in this area of fertility. I encourage all women to attend a fertility awareness session, because even if you understand the basics, your cycle is unique to you. At our clinic, the aim is to make it easy to understand when and how ovulation occurs, without getting obsessed about it – which months of ‘charting’ can do to you. As Jane says:

An understanding of fertility – fertility awareness – is an important life skill and is every woman’s right. My work involves providing fertility – awareness sessions for both men and women. During a consultation I explain how a woman can identify the fertile ‘window’ during her menstrual cycle. I also help men to understand their own reproductive potential. Couples who understand the key concepts of fertility are in a much better position to understand how fertility declines with age and how factors may damage, reduce, enhance or optimize fertility.

Female Reproductive Organs

The primary indicator of fertility for a woman is her cervical secretions – because this relates so closely to oestrogen levels and ovulation – so we encourage women to focus on this, alongside ovulation-predictor kits or temperature charting, because it is just as important as good nutrition, relaxation and you and your partner’s health in your efforts to conceive.

A Woman’s Fertility

At birth, every baby girl is born with a full complement of immature eggs in her ovaries – around 2 million, although only between 300–400 will mature during her lifetime – which sounds as if the whole process should be pretty straightforward. But it is the maturation, release (at ovulation), fertilization and implantation of one of these eggs that results in pregnancy. No new egg cells are produced after you are born, so it’s worth thinking about what those egg cells need in order to mature successfully and produce an egg capable of being fertilized. A woman’s eggs are her most precious reserve, and need looking after.

Up until puberty, the egg cells lie dormant in the ovaries, waiting for a shift in the hormonal patterns of a girl’s body to ‘switch on’ her fertility. At what age this starts is largely influenced by genetics – if your mother started her periods early, then it’s likely you will have done, too. Starting menstrual periods is the marker of the beginning of a woman’s fertility, and is known as menarche.

In Western countries, the average age of menarche is between 12 and 14, but can be as early as 10 and as late as 16. All are completely normal. Ovulation can occur before the first period, but a girl’s early menstrual cycles can be erratic, and often without ovulation. Over the next few months, or sometimes longer, the pattern of cycles settles down to what is normal for that girl, as regular ovulation establishes itself.

If you think back to GCSE biology, you will remember the term ‘secondary sex characteristics’, which are the outward, visible signs of puberty and the onset of a woman’s fertile life. In a woman, increasing levels of FSH (follicle – stimulating hormone) and LH (luteinizing hormone) and the beginnings of oestrogen and progesterone production lead to the development of breast tissue, pubic and underarm hair, and a different distribution of body fat, all of which are designed to create a body capable of nourishing a growing baby, both before and after birth. These changes begin before the first menstrual period occurs, and can happen slowly over a couple of years, or relatively quickly. Again, this depends in part on genetics, and a mother’s experience of puberty will give some insight into what her daughter might expect.

Remember how you were warned in your sex education classes at school that sex inevitably led to pregnancy? Remember, too, all the efforts you took in the past not to get pregnant, not to mention all those false alarms? So it may feel a bit of a mystery as to why getting pregnant is now so elusive. This chapter is designed to help you understand your own fertility cycle, and how to work with it to achieve pregnancy.

Understanding Your Own Fertility

With so much misinformation about how, where, why and when, it’s always best to start with the basics. Once you are informed and familiar with your own body’s fertility indicators, you will feel more confident about managing to get pregnant.

And there is a lot of confusion out there! According to research carried out by Unipath (who produce Persona – the personal hormone-monitoring system), while 92 per cent of women accurately described ovulation, a third of them thought it occurred during a period! Out of six European countries covered in the research, the UK women surveyed had the worst knowledge of when their fertile days were: 21 per cent thought they were fertile for more than 21 days a month. And while 72 per cent of women knew that the fertile time was mid – cycle, one – third thought it possible to get pregnant at any time during their cycle.

It is essential to remember that every woman is different. Although the basic principles remain the same, what is true of your friend is unlikely to be true of you – from your cycle length to how your body indicates its fertility, to how you react physically and emotionally. This is why it is so useful to understand your own fertility.

Most women seldom think about their fertility, or menstrual cycles, but most women – when they do stop and think about it – are aware of cyclical changes to their skin, appetite, mood – all of which are indicators of their individual cycle.

The Menstrual Cycle

Most of us have learned to live with certain symptoms in our cycle, but it’s also important to remember that our fertility cycle is controlled by the pituitary gland, located deep within the brain and influenced by all activity there. Hormones, which are chemical messengers, are primarily controlled by the brain’s activity – it’s like a constant conversation that occurs between the hormones of the brain and the ovaries, sending messages back and forth (see page 8).

The pituitary gland is often referred to as the ‘master gland’ of the body, because it secretes at least nine major hormones designed to stimulate the ovaries, adrenals and thyroid, amongst others (including the testes in men), which all have a role to play in fertility. When we are producing the right amount and blend of hormones, we feel fine. When there is an imbalance, these chemical messengers can make us feel pretty lousy. We talk about having ‘hormones from hell’ when we, as women, feel imbalanced at certain times of the month. PMS is a clear indicator that hormones are out of balance. The hormones are doing their job, and the body is reacting as it should, but because the balance is out, then the effects are negative.

Each of the fertility signals that you observe when you begin to chart your own fertility corresponds to a hormonal process and the presence of hormones in your bloodstream. The hormones oestrogen and progesterone are particularly important, and both affect the body in a number of ways that are easy to note.

The menstrual cycle is a constantly changing hormonal environment, but oestrogen influences the first part of the cycle – up to ovulation – and then progesterone exerts its influence. Some women would probably prefer not to be so influenced by the ups and downs that a cycle brings, but these changing hormonal events will help you to know when your chances of conceiving are best.

Few women have a 28-day cycle, but we can say that the average length is around 28 days. For some women their normal cycle can be short (around 25 days) or long (around 35 days). Provided there is a regular pattern, this is normal for you, and you can be relatively sure that ovulation is occurring. It is when cycle length fluctuates from 25 days one month to 30 another, or 42 another, that ovulation is likely to be haphazard, or even non – existent during some cycles.

The fertility, or menstrual, cycle starts on the first day of menstruation or a ‘period’. Sometimes on medical forms women are asked to give the date of their ‘last menstrual period’ or ‘LMP’ – this would be the date on which you started to bleed.

Oestrogens are the dominant hormones during the first part of the cycle – the time before ovulation, also known as the follicular phase (see page 8) – while progesterone takes over during what is known as the luteal phase (see page 31) and also during pregnancy, should conception occur. Your cervical secretions are linked to oestrogen secretion, and can give a good indication of the availability of oestrogen.

Menstruation, or a ‘period’, is the bleeding with which every woman is familiar. It heralds the end of one cycle and the beginning of another. The hormones responsible for the activity of ovulation and womb – preparation effectively ‘take a break’ at this stage, in order to activate the next cycle. Many women are quite susceptible to the effects of this hormonal switch.

Women often ask me what’s ‘normal’ for a period: how long it should last and how much blood should be lost. The average period lasts for between 3 and 5 days, and the total blood loss is between 30 and 80 ml (6 to 16 teaspoons). However, this is only the average; each woman’s experience of her period will be unique to her. Some women seem to have a lot of abdominal cramping (caused by contractions in the womb) when they have a period, or back pain, while others have none. For some, the bleeding happens in a flood at the beginning, while for others it’s a slow, continuous bleed.

Hormones and the Phases of Your Cycle

A question I get asked all the time is, ‘How do I know if my hormones are balanced?’ Hormone balance is such an important part of a woman’s fertility, and so easily influenced by poor diet, stress, lack of sleep and environmental factors, that assessing a woman’s hormone levels – and addressing any rebalancing that needs to be done to help her achieve optimum fertility – are important aspects of the work I do. And although there are sometimes quite clear indicators of hormone imbalance, often a bit of detective work is needed.

The one major thing that will help balance hormones is a well-balanced lifestyle – which seems to be increasingly difficult for many of us to achieve these days.

A well – balanced lifestyle is important for hormonal balance because all hormone activity is an interplay between different hormones, which are the body’s chemical messengers: for example, secretion of fertility hormones will be affected if the body is producing too many stress hormones. Understanding the inter – relationship between all the hormones in the body is the first step towards achieving a positive balance.

Like all hormones, oestrogen and progesterone operate as chemical messengers, in this case controlling the length of a cycle, and ovulation, while also having an impact on other body systems. When in perfect balance, their effects are hardly noticeable, but most women have a degree of hormonal imbalance within the normal range, which makes these hormonal fluctuations more noticeable. Although the effects can vary – not just between women but also from month to month in the same woman – knowing about them and recognizing your own emotional and physical response to them are helpful when you are trying to understand your own cycle.

The Follicular (pre – ovulation) Phase

On Day 1 of the cycle, which is the first day of a period, the brain releases GnRH (gonadotrophin – releasing hormone) from the hypothalamus, which in turn tells the pituitary gland to release FSH (follicle – stimulating hormone). The levels of FSH in the bloodstream build over the next couple of weeks, stimulating follicles in the ovaries to start growing.

The follicle grows and starts to secrete oestrogen from the granulosa cells. It is the rising level of oestrogen that inhibits the secretion of FSH, while also causing ovulation. At this point, LH (luteinizing hormone) is secreted.

This first part of the cycle, the follicular or pre – ovulation phase, can vary in length. This explains why some women have longer cycles than others, and also why their cycles can sometimes be irregular.

The interplay of hormones throughout a woman’s fertile life forms the basis of her cycle. Not only do these hormones have a crucial role to play in fertility, they also have other effects on the body, which can be extremely useful when trying to define and assess your own levels of fertility. For example, progesterone has an effect on body temperature (as it’s designed to keep a fertilized egg warm in the incubator of the womb), while oestrogen has an effect on cervical secretions, which are so essential to helping achieve pregnancy.

Looking at oestrogen and progesterone individually, and also at how the subtle interplay between them and other hormones affects fertility, is the first step to understanding what is necessary for a pregnancy to happen.

Oestrogen

During the first part of the menstrual cycle, when the levels of oestrogen are rising, endorphins are also released, which are your body’s natural painkillers and ‘feel – good’ hormones, elevating mood. Many women say they feel very energized and creative during this phase.

While oestrogen has an effect on the internal reproductive organs, making the womb receptive to a fertilized egg, bringing the top of the Fallopian tube closer to the ovary and increasing its contractions to help the egg move down towards the womb, it also has other effects.

There are highly specialized cells in the cervix, for example, which produce cervical secretions, and their increased activity is directly caused by increased oestrogen. (The importance of these secretions and their role in conception is crucial, and is explained in more detail on page 18.)

Oestrogen also has an effect on libido, your sex drive. As oestrogen levels rise, so does libido – nature’s way of ensuring that sexual intercourse is welcomed close to ovulation. And when an animal is in oestrus, i.e. fertile, we refer to them as being ‘on heat’. This recognition of a link between oestrogen and heat comes partly from the effect of oestrogen on the blood vessels, causing a degree of dilation and increasing the flow of blood and its heat.

A good blood supply helps the organs of the body function properly, as nutrients are brought to cells and waste products removed. The transportation of oxygen in the blood is also important to developing cells, not least the maturing egg in the ovary. This blood supply also keeps tissues plump and supple, whether in the vagina or the tissues of the face. It is this effect that is lost after the menopause, when the lack of oestrogen causes the thinning of the skin and other tissues.

A good blood flow is beneficial to other organs, too, including the brain. Some women’s experience of increased productivity and creativity around ovulation may be explained as their own particular response to oestrogen. On the other hand, for some women this same effect provokes feelings of irritation. It just depends on how your body reacts to and copes with this powerful hormone.

Oestrogen is also essential for maintaining strong bones, as it provides the chemical ‘bridge’ that allows calcium from the diet to be used by the bones, keeping them dense and reducing porosity.

Oestrogen and Signs of Fertility

The term ‘oestrogen’ actually refers to a group of hormones that stimulate growth and strengthen tissues. Oestrogen is needed to build up the lining of the uterus so that it can nourish and sustain the fertilized egg, ensuring implantation – a crucial part of conception. When we are talking about fertility, the kind of oestrogen we are referring to is called oestradiol. Oestrogen is produced by the developing ovarian follicles and later, in increasing amounts, by the dominant follicle before the egg is released at ovulation.

Oestrogen has many roles:

• It signals the release of LH (luteinizing hormone), needed to trigger ovulation.

• It is needed to build up the endometrium (lining of the womb) so that a fertilized egg can find nourishment and implant successfully.

• It stimulates the production of cervical secretions, which are essential for the sperm to travel through the cervix to the Fallopian tube where an egg may be fertilized.

• It causes the cervix to soften and open, making it easier for the sperm to enter the womb and reach the Fallopian tube for possible fertilization of an egg.

Some of the signs of increased oestrogen levels, such as the amount and quality of cervical secretions, and cervical position, can be easily noticed. These signs offer some of the best indicators of your fertility status. Observing and recording your cervical secretions are vital to assessing fertility, and the optimum time for intercourse, in order to conceive (see page 21).

Factors That Can Affect Oestrogen Production

I often get asked how you can tell if your body is producing enough oestrogen, and what might make you oestrogen – deficient:

• body weight 15–20 per cent below your optimum can cause menstruation to stop, and levels of oestrogen to drop

• an excess of fibre in the diet

• antibiotics – though occasional use is OK

• excessive exercise

• smoking.

Modern women aren’t actually making more oestrogen; it’s just that today’s diet and lifestyle encourage higher levels of the hormone in the body. This is in part due to environmental oestrogens, delaying childbirth and breastfeeding, and an over – refined diet. The methods used to clear ‘old’ oestrogens from the body involve optimum digestive and liver function, which are often compromised by a poor diet and stressful lifestyle. Changing to a low – fat and nutrient – rich diet with adequate (but not too much) fibre can significantly influence the balance of hormones and help to optimize the conditions for getting pregnant.

Equally, an excess of oestrogen can be counter – productive to conception. But take heart: there are ways round these issues – we’ll be taking a look at them in the Nutrition chapter.

The Ovulation Phase

The rising oestrogen level makes the hypothalamus reduce the secretion of GnRH and FSH. As the FSH decreases, oestrogen levels from the maturing follicle rise abruptly. Only then will the pituitary gland secrete LH (luteinizing hormone), which allows just one mature follicle to release an egg – ovulation.

The Magnificent Egg

The ovum, or egg, is the largest cell in the body – 550 times bigger than the sperm. As it matures within its fluid – filled follicle prior to ovulation, it needs a lot of energy, which is supplied by the granulosa cells (specialized cells in the ovary). These cells have two functions: to secrete oestrogen (to help the egg mature) and to nourish and feed the egg as it grows.

The maturing egg is now suspended in a fluid – filled cavity (sometimes referred to as the graafian follicle, after the scientist who first discovered it). This follicle measures about 18–23mm just prior to ovulation, and when ovulation – the release of the egg – occurs, the follicle bursts and the mature egg is released into the Fallopian tube.

There are an estimated 7 million granulosa cells packed around an egg, greatly increasing the availability of energy. When the egg is eventually released, it takes with it a mass of these cells, giving it a ‘sunburst’ appearance. These cells also serve to protect and nourish the egg on its journey, and will provide a barrier against all but the one sperm that will fertilize it.

The hormonal stimulus for ovulation is the rise of oestrogen, and the primary factor that determines when you will ovulate is the level of oestrogen getting to a certain threshold, which creates a surge in luteinizing hormone (LH), responsible for the rupture of the follicle and release of the egg. So anything that depletes oestrogen will keep it from reaching the necessary level, and ovulation will not take place.

Ovulation also won’t occur unless the optimum level of oestrogen is maintained for the correct length of time. The timing of ovulation is quite exact, occurring about 36 hours after the surge in LH. Only a mature egg, once fertilized, will result in conception. Immature eggs are unlikely to be capable of being fertilized, and even if they are they tend to produce an abnormal embryo that won’t implant or develop properly, resulting in an early miscarriage (before 12 weeks). So it’s very important that the level of oestrogen produced accurately reflects the egg’s maturity. It’s a delicate feedback process, and the timing is crucial. A mature egg is necessary for fertilization because only then will it have chromosomes at the right stage for further development, allowing one sperm in and blocking the rest, and ensuring that the egg and sperm fuse properly.

At the same time, just before ovulation the follicle generates a rapid rise in the hormone progesterone. The rise in progesterone also keeps the FSH secretion going just long enough to allow full maturation of the follicle. As the hypothalamus is shutting down on FSH secretion, it is releasing prostaglandins to the follicle just before it ruptures. It is thought that these prostaglandins may help to expel the egg by breaking down the follicle wall.

Once the egg is released, the resulting cavity and the remaining granulosa cells start to produce more progesterone. These cells also stain the ruptured follicle an orangey – yellow colour, giving rise to the name corpus luteum, from the Latin for ‘yellow body’.

The egg is at its most susceptible to nutrient deficiency during this phase of the menstrual cycle, leading up to ovulation where the egg is maturing, and during early embryonic life (the first 30 days after conception). Research shows that a 70 per cent increase in sensitivity to toxins, alcohol and smoke occurs between 11.30 a.m. and 7 p.m. on the day preceding ovulation. In the five days prior to ovulation a good diet and as few toxins as possible are particularly important for achieving pregnancy. Also, it is not wise to drink heavily during this phase of your cycle. If the diet is too low in proteins, for example, too few eggs may ripen, while a vitamin B1 deficiency can inhibit ovulation. Because it can be difficult to gauge exactly when ovulation occurs, however, it is always wise to maintain good nutrition throughout your cycle.

Lifespan of the Egg

Having managed to ovulate a mature, functioning egg and, with all other things working to advantage, the lifespan of the egg is only estimated to be around 8 to 12 hours. This is further complicated by the difficulty in knowing exactly when ovulation occurs. For example, if you ovulate at 3 a.m. but don’t have intercourse until the following evening, chances are that the egg is no longer capable of being fertilized. Now, I wouldn’t want any woman reading this to start lying awake at night worrying that she might be ovulating then and there – this won’t help you or your partner in the long run! – but this is why regular and frequent sex is an essential feature of successful conception. Keep in mind that sperm deposited in a woman’s vagina stay alive, on average, for between two and three days (and in some cases for up to a week), so if you are having sex every day or every couple of days around the most fertile time of your cycle, the chances of conception are increased dramatically. Research shows that most pregnancies occur within a ‘fertile window’ of six days before ovulation and one day after. If there are live, potent sperm in the Fallopian tubes when ovulation occurs, then conception is much more likely than if sex occurs sometime after ovulation.

Why Cycle Length Matters

The length of the menstrual cycle is measured from the first day of menstruation (first day of fresh bleeding) up to the day before the next period starts. The time you are fertile will vary according to the length of your cycle. The time from ovulation to the next period is likely to be constant – approximately 10 to 16 days – whereas the time before you ovulate can be more variable.

The fertile time in a woman’s cycle is identified by two different approaches:

1. by looking at the length of your cycle and making calculations based on observing your secretions (see page 22)

2. by a combination of recording your temperature and knowing the position of your cervix (see page 22) – though I don’t usually encourage women to use these measures, as trying to do so can be confusing and stressful.

Understanding that the post – ovulation phase remains constant at around 14 days, while the pre – ovulation phase is the one that’s variable, is essential because this will help you to work out, roughly, when you are ovulating. Once you have a rough idea of what’s normal for you, working out the other indicators of fertility becomes easier.

Only if a woman’s cycle is a regular 28 days does she ovulate mid – cycle, around day 14. If her regular cycle is 25 days, then ovulation occurs around day 11; a cycle of 35 days means ovulation around day 21; and for a very long cycle of 42 days, ovulation occurs around day 28.

Many women mistakenly believe that ovulation occurs ‘mid – cycle’, then wonder why they are getting their calculations wrong. Everywhere this myth continues to be perpetuated, and it can really hamper couples’ attempts to conceive. For example, if you thought the middle of your 35-day cycle was when you were ovulating, you’d think this was day 17 – when in fact, it’s day 21 – and would thereby make a crucial error when it came to timing sexual intercourse to coincide with your fertile time.

If you don’t have an understanding of this basic information about the two phases of the menstrual cycle, all the other indicators of fertility you are trying to evaluate just won’t ‘add up’.

Case History: Christine

Christine, who was 34, had had one child with IVF. Two further attempts at IVF had been unsuccessful. She came along to our clinic to see what she could do to improve her chances. Having looked through her questionnaire, apart from the fact that she was tired from coping with a toddler, and also a little bit underweight, there were no obvious lifestyle factors that might be affecting her chances. I went back to basics with her and asked about her cycles and sex, and suggested that, as she had irregular cycles, a session of fertility awareness would benefit her. I could tell she thought that this would be a total waste of time, as she’d been told that she wasn’t ovulating.

‘How do you know you don’t ovulate?’ I asked. She said that when she used the ovulation – predictor kits (see below), nothing happened. When I asked about her cervical secretions, she said she didn’t have any. Then I started to ask about her periods and how long her bleed lasted. Her bleed lasted 7 days, and on the 8th and 9th days there was what she thought was mucus but mixed with the blood; she also thought that this was part of her bleed. Her cycles were quite varied – between 28 and 38 days – so by her calculations if anything were going to happen it wouldn’t be on the 8th or 9th day of her period; it would be much later in the cycle. She was wrong about this.

She went on to conceive naturally a month later.

I could write about many more cases like this, of women who have had IVF when they have never even been offered the most basic kind of help with understanding their fertility.

Ovulation Predictor Kits

Luteinizing hormone can be measured by ovulation – predictor kits, which use chemicals to identify the presence of LH in your urine. LH is not released all at once, but rises and falls for 24 to 48 hours. The LH rise usually begins in the early morning while you are sleeping; it appears in your urine about 4 to 6 hours later. For this reason, first-morning urine may not give the best result. It is important to follow the instructions on the kit for optimum results.

If you are able to recognize the pattern of your cervical secretions, ovulation – predictor kits have little value except to reassure you. You may just want to use them to cross – check your other signs of impending ovulation. If you have irregular cycles or multiple patches of fertile cervical secretions before ovulation, however, ovulation kits can be helpful.

I think ovulation – predictor kits are fine – so long as they’re used in conjunction with examining your cervical secretions (see below). They can also encourage women to have sex only when the predictor kit indicates – therefore missing out on opportunities for sex during the preceding five days, which is essential to maximize the chances of conception.

There is absolutely no point rushing out and buying an ovulation-predictor kit if you don’t have at least a rough idea of your cycle. I see women who have got into a real muddle using them, and have often convinced themselves that they’re not ovulating because, without any idea of what their normal cycle is, they’ve used the kit at the wrong time.

Once you know your own, individual cycle, the kit can help confirm when ovulation is coming up – but by then you will be so confident of reading your own body’s fertility indicators that you won’t need it!

Cervical Secretions

Your secretions are your fertility. It is my hope that all women trying for a baby get to know and focus on this. If you take only one thing from this chapter, take this: recognizing the range of and changes to your secretions is key to understanding your fertility, because they are so closely linked to oestrogen levels.

Cervical secretions are produced continuously by the glands lining the cervix, and provide a slightly acidic barrier during the infertile phase of your menstrual cycle, protecting against any bacteria or germs that can enter the body via the vagina.

These secretions are influenced by the changing hormones of your cycle, as we have seen, and provide the most useful indicator of hormonal activity. Highly fertile secretions, which tend to resemble raw egg white, are stimulated by peak oestrogen levels, and not only indicate that ovulation is imminent, but also provide channels for the sperm to swim along and an optimum environment for sperm. Influenced by oestrogen, the secretions at this time are also more alkaline, protecting the sperm from the normal acidity of the vagina.

For women who have spent a long time on the Pill, cervical secretions and the way they change during a cycle can be something of a mystery. Coming up to ovulation, cervical secretions become more obvious, but only by looking at and feeling them can a woman be really sure of what stage in her cycle she is at.

Oestrogen and cervical secretions

The easiest way to assess the presence and quantity of oestrogen in your bloodstream, and gain clues about your fertility status, is to check your cervical secretions throughout your cycle.

Increased production of oestrogen, as your body prepares for ovulation, stimulates the cells of the cervix to produce more secretions, which creates an increasingly wet and slippery feeling around the vagina as you approach ovulation. While your cervical secretion pattern may vary from cycle to cycle, a typical cervical secretion pattern over the course of a menstrual cycle will look like this:

• Day 1 of your cycle is marked by bleeding, which may continue for between 3 and 5 days, depending on what is normal for you.

• Immediately following the end of a period, cervical secretions aren’t produced in any noticeable quantities and the vagina can be described as quite dry.

• After a couple of days, you may notice a creamy – white secretion which has no odour and produces no discomfort. It may leave a bit of a mark on undergarments.

• This creamy – white secretion then becomes a little thinner and whiter, and increases a little in quantity. Some women have described this as being similar in colour and consistency to moisturizing lotion.

• Over the next couple of days these secretions change quite dramatically, becoming increasingly more clear and ‘elastic’.

• Just prior to ovulation, cervical secretions become completely clear, exceedingly ‘stretchy’ and can be described as resembling raw egg white. This is the peak time for cervical – secretion production, and with good reason: for sperm to reach an egg they need to be able to swim upwards, and through a lubricated channel that allows this. In addition, when looked at under a microscope, these cervical secretions appear to have channels within them, assisting the sperm even further. Not all women notice the elasticity or stretchiness of these highly fertile secretions, but they may simply be aware of an increased wetness. Some women even describe this as feeling as if they have wet themselves. This may be because this type of secretion is produced in small ‘pulses’ from the top of the cervix.

• Almost immediately following ovulation, the cervical secretions stop being clear and stretchy, and revert back to a thicker creamy secretion, which can become quite ‘blobby’ over the next few days. This is the progesterone effect. It creates a bit of a seal to the cervix (neck of the womb), designed to prevent any foreign bodies – from sperm to bacteria – ascending the womb. It also makes the vagina more acidic and hostile to sperm.

• Over the next couple of weeks, leading up to the next period, cervical secretions become minimal again, producing just enough to keep the vaginal canal moist and protected.

When you first attempt to identify and interpret your own cervical secretion changes, it’s worth being aware of the factors that can make this difficult. Wash as normal, using soap and water and rinsing well, but avoid the use of vaginal deodorants, talcum powder or lubricating jellies. Wear all – cotton underwear, and avoid absorbent pads, thongs, G – strings or nylon tights – stockings are better!

Television adverts for panty – liners have broached the subject of cervical secretions, although not overtly, preferring to refer to those ‘in-between days’ when you need some protection. Certainly, for some women, the secretion of cervical mucus can be copious and very watery at times. However, I don’t recommend the use of panty liners, as they can be very drying and too absorbent, so many women miss their fertile secretions. Better to bring a spare pair of pants to change into during the day if necessary.

In summary, the general pattern is for cervical secretions to change throughout the menstrual cycle, increasing in quantity and becoming more clear (transparent) and stretchy as you get closer to ovulation. Noticing and recording these changes for a few months will help you recognize your individual fertility pattern. In the most common pattern, as mentioned, cervical secretions start out dry (just after your period) and then get sticky, then creamy, then wet and watery, becoming most like raw egg white as you get closer to ovulation. You may, though, get different types of cervical secretions on the same day. Always record your most fertile cervical secretions to make sure that you do not miss a potentially fertile day.

How to check for cervical secretions

Avoid checking your cervical secretions just before or after intercourse, as arousal and seminal fluids will skew your observations. The best way to check your cervical secretions is to make observations whenever you go to the bathroom. After you wipe, note what, if anything, you find on the bathroom tissue. This will soon become second nature and you will find yourself noticing your cervical secretions every time you use the toilet. You can also use clean fingers to check for cervical secretions, and you may also notice some in your underwear.

What to Look For

• Does your vagina feel wet or dry?

• Are there any secretions on the bathroom tissue?

• How do they look?

• What colour are they?

• What consistency are they?

• How much is there?

• How do they feel when you touch them?

• Can you stretch them between your thumb and index finger?

Exercise, and having a bowel movement, will push cervical secretions to the vaginal opening, making observation easier. You may even find that the best time to check is after a bowel movement.

Position of the Cervix

Just a quick word about this: Women are stressed enough trying to conceive without trying to find out what position their cervix is in – and trying to check this might also interfere with or obscure any cervical secretions you have got! I don’t believe that the position of your cervix is a useful enough indicator for women trying to have a baby.

Keeping a record

Always record your most fertile type of cervical secretions, even if you notice more than one type on any given day or even if it is scant. This is so that you won’t miss a potentially fertile day and so that you have a consistent record of your cervical secretions from cycle to cycle.

Immediately after a period you may notice one or more dry days – when no secretions can be seen or felt (these days are not likely to be fertile). As soon as the secretions start, this means that the cervix is preparing to accept sperm and you are into the start of your fertile time. At first the secretions will feel slightly sticky and be white or creamy in colour, then they’ll gradually change to become cloudy and wetter, then more transparent and sometimes quite slippery and stretchy – the highly fertile sperm – friendly secretions. After ovulation the secretions change back to being thicker, more sticky and white again, then back to dry again in the run – up to your next period. As a quick ‘rule of thumb’, if you feel wet – have lots of sex!

Factors that can influence your pattern of secretions

Some factors that can influence the quality and quantity of cervical secretions that you produce may be a result of hormonal factors, while others may be related to lifestyle or medications you are taking. If any of these applies to your case, make a note. If you are using a fertility-awareness chart there is usually a special section where you can do this. This way you can see at a glance if there were any special circumstances that may have had a bearing on your cervical secretions.

Factors that can have an impact on cervical secretion patterns include:

• medications such as antihistamines and diuretics

• fertility medication such as Clomid (ask your doctor)

• tranquillizers

• antibiotics

• expectorants – as found in cough medicines

• herbs (ask your doctor before taking herbs while trying to conceive)

• vitamins such as vitamin C (over 1,000mg a day), as this may have an anti – histamine effect, reducing cervical secretions and making them more acidic

• vaginal or sexually – transmitted infection (ask your doctor if you think this is a possibility)

• delayed ovulation (can cause an interrupted pattern of secretions)

• vaginal douching (not recommended)

• being overweight

• arousal fluid (can be mistaken for raw egg white cervical secretions)

• semen residue (can be mistaken for raw egg white cervical secretions)

• lubricants (not recommended when trying to conceive, as they can be hostile to sperm)

• breastfeeding – high levels of prolactin suppress oestrogen secretion

• decreased ovarian function – for example in the years approaching the menopause

• after you’ve stopped taking the Pill – a normal cycle may not have had a chance to re – establish itself. (Remember, though, that it’s still a good idea to have regular sex even if you’ve just come off the Pill!)

If you notice anything that concerns you about your cervical secretions, for example if they are smelly or causing you discomfort or itchiness, or if you are bleeding or spotting, see your doctor. Any infection must be treated (for more about routine tests for infections, see the Fertility Work – up chapter).

If you have questions about how to observe and interpret your cervical secretions, or if you have specific concerns about your own experience, then it’s well worth finding a fertility awareness teacher (see Useful Contacts, page 358).

No Raw Egg White Secretions

If you do not see any cervical secretions that resemble raw egg white, the first thing to do is to check out how you are observing this, especially if you are new to it (see page 21). If you are sure you are checking properly, but your cycles are irregular, you may not be ovulating every time. If your cycles are regular, then your secretions may have been affected by one of the factors outlined above. As long as you are having sex every other day or so, then the absence of an obvious indication of imminent ovulation is not something you should worry about too much.

Fertile Cervical Secretions after Ovulation

Some women notice what seems like highly fertile cervical secretions (wetter, transparent and stretchy) around the time they are expecting their period. This is because towards the end of the cycle there are some hormonal fluctuations between oestrogen and progesterone. As the progesterone level falls (due to the degeneration of the corpus luteum), the secretions appear more oestrogen – dominant. These secretions, however, should not be interpreted as a sign of fertility.

Predicting Ovulation

Predicting ovulation is not a precise science, but familiarity with your cervical secretions makes it a whole lot easier. The general advice is always to have lots of sex, rather than limiting it to a specific time – but when the pressure is on to conceive, sex can lose some of its spontaneity, which makes knowing the most fertile time of your cycle useful.

Try and keep some perspective about this, and don’t restrict sex to an exercise in conception – try and make sure you and your partner enjoy it for its own sake, too, and as a way to express your loving feelings for each other.

Cervical Secretions and Semen

If you find that you have more watery or raw egg white days than you would expect and that these often follow days or nights when you’ve had intercourse, then you may be mistaking seminal fluid for cervical secretions. They are quite similar, but remember that fertile cervical secretions are clear, stretchy and shiny. They can stretch a couple of inches without breaking. Semen may be more whitish and will break when pulled. Generally if you have had sex the night before, by lunchtime the following day there should be no trace of semen and you should be able to concentrate on your secretions.

Many women continue to experience a degree of cervical secretion after ovulation (necessary to keep the vagina moist and healthy) because the corpus luteum produces small amounts of oestrogen along with larger amounts of progesterone. However, this is no indicator of fertility: once ovulation has occurred for a cycle, it won’t occur again until the next one.

When you first start to take note of your secretions, they may be erratic and won’t follow the usual pattern of dry, sticky and white→clear and wet→sticky, white and dry again. Stick with it; it may take a while to work out.

Increasing cervical secretions

Evening Primrose oil (EPO) can play a role in the production of quality cervical secretions. EPO is an essential fatty acid (EFA) that contains gamma – linolenic acid (GLA), which is converted to a hormone – like substance called prostaglandin E1. EPO helps the body to produce raw egg white cervical secretions.

The recommendation is to take a supplement of EPO only during the first, pre – ovulatory time of the cycle, from menstruation to ovulation. This is because of the slight risk that EPO can cause uterine contractions, which you would want to avoid after ovulation. The recommended dose for the time between your period and ovulation should be 1,500 to 3,000mg per day (see Nutrition chapter for more details).

It may take a month or two to build up and produce the results you are looking for. If you are keeping a record of your fertility signs over the months, this will help you identify the first part of your cycle, prior to ovulation, when taking this supplement is advised. You will also know when you have ovulated, so you’ll know when to stop taking the EPO.

However, if you have had a diagnosis of high oestrogen levels, you will not know when you have ovulated and taking EPO will not be advised because of its oestrogenic properties. Far better, in this case, to visit a nutritionist and get an individually – tailored programme.

Other Ways to Increase Secretions

• Drinking plenty of water will increase your internal fluid balance and make any bodily secretion more fluid.

• Avoiding antihistamines, which reduce mucus secretions.

• Avoid high doses of vitamin C (more than 1,000mg per day).

Does Robitussin Really Work?

In chat rooms across the Internet, hundreds of women swear by taking 2 tablespoons of cough medicine that contains guaifenesin as the only active ingredient before ovulation. (Guaifenesin works as an expectorant to increase the liquidity of mucus production in the lungs, and elsewhere, to make coughing up phlegm easier.) It is believed that this makes cervical mucus more liquid and hospitable to sperm. While this may work in principle – and anecdotal evidence is eagerly repeated – there is little scientific evidence to back it up, although one 20-year-old study does indicate that it can be helpful in thinning out cervical mucus.

If you are going to take it, you would want to do so about five days before and including the day of ovulation. However, when you are trying to conceive it’s worth thinking about the effects of any medication that you take, even those bought over the counter. There are some women who have allergic reactions to guaifenesin, although it is generally considered safe. Make sure there are no other ingredients in the cough mixture that could be harmful – check with your pharmacist.

Progesterone and Your Cycle

While oestrogen dominates the first phase of your cycle, progesterone dominates your second, post – ovulatory or luteal phase of your cycle. Before ovulation, progesterone is present only in small amounts. After ovulation, progesterone, produced by the corpus luteum, is present in higher amounts.

Progesterone has many roles:

• It makes the lining of your uterus soft and spongy, with increased blood flow, so that a fertilized egg can latch on to it and implant.

• It is needed to support and continue a pregnancy by ensuring that the lining of the womb remains intact and a woman doesn’t have a period.

• It also causes your Basal Body Temperature (BBT) to rise after ovulation so that it is measurable with a BBT thermometer.

Although some women choose to record their waking temperature, many of the women I see get so stressed out by this method that I do not normally recommend it. Nor is this method recommended by new NHS guidelines – for three reasons:

1. Progesterone causes a rise in BBT (that is, waking temperature – your temperature after you have been resting for at least three hours and before you get out of bed).

2. Your temperature does not rise until AFTER ovulation – by which time it is too late to try to conceive.

3. It can be very stressful having a daily reminder when you first wake up that you are not pregnant yet.

As I said earlier, generally I would not advise women to record their temperature. There may be an appropriate role for taking your temperature if you have been advised by a trained fertility awareness practitioner that this would be beneficial – for example to provide a more objective marker and to determine the length of the luteal phase of your cycle. Otherwise – don’t worry about it.

Having said this, taking their temperature does give some women reassurance that they are ovulating. Trying this for a month when you are first trying to conceive will do no harm, but not month in, month out – it causes too much stress. Many factors affect your temperature – a low – grade fever, alcohol, fewer than three hours’ sleep, air travel and electric blankets – so it’s really not the best indicator.

Because progesterone is the hormone designed to prepare the body for pregnancy, birth and breastfeeding, its effects are linked to these processes. Breasts tend to swell a little under its influence, and can become tender for many women during the second phase of their cycle (and during early pregnancy, if it occurs).

Progesterone also has an effect on muscles in the body, for example in the gut, making digestion less efficient. This can make some women more prone to constipation (another common problem for many women during pregnancy).

In addition, the progesterone effect on smooth muscle affects the ligaments, which soften. This is in preparation for labour, when the ligaments of the pelvis have to soften for the bones to ‘give’ a little during birth. Although this is not so extreme as during pregnancy, some women find they are more susceptible to minor injuries after ovulation, when progesterone levels are raised.

Some women whose blood pressure is naturally low may find these combined effects of progesterone can cause them to feel a bit faint, or more tired, in the run-up to their period. Ensuring an adequate intake of fluids, while avoiding those with diuretic effects like colas, coffee and large quantities of tea, can help with this.

Luteal or Post – ovulatory Phase

Progesterone is the hormone that keeps the endometrium, or lining of the womb, in place. It keeps it thick and ensures a continuing blood supply – just in case a fertilized egg needs to implant. If implantation does occur, the production of progesterone from the ovary continues until around 12 weeks, when the placenta is sufficiently developed to take over production for the rest of the pregnancy. If there is no implantation, the body responds by reducing its levels of progesterone, and a period occurs – when the thick, blood-rich lining of the womb is discarded.

Progesterone Deficiency

Progesterone deficiency is the most common hormonal deficiency in women of all ages. Many women are already familiar with the symptoms of a degree of progesterone deficiency, which may or may not affect their fertility. These symptoms include painful or lumpy breasts, cyclical headaches, anxiety and irritability, insomnia and sleep problems, unexplained weight gain, recognizable PMS, dysfunctional patterns of bleeding during a cycle, and finally, impaired fertility.

The causes of progesterone deficiency are often linked to imbalances of other hormones, and the effect of these. For example, if ovulation fails, no progesterone is produced in the luteal phase. There may also be defects during the luteal phase – either the corpus luteum fails to produce enough progesterone, doesn’t produce it for long enough, or the luteal phase is too short (fewer than 10 days). In addition, in some cases the follicle develops but doesn’t rupture and expel the egg, so too little progesterone is produced. Finally, the messages from the hypothalamus and pituitary gland may be faulty – there is faulty FSH secretion, inappropriate surges of LH or excessive prolactin.

Having identified a progesterone deficiency, there are a number of solutions:

• natural progesterone (should only be used under proper medical supervision)

• vitamin and mineral deficiencies can be remedied (supplements for low progesterone include vitamin B6, vitamin E, evening primrose oil and magnesium)

• herbs such as Vitex Agnus Castus, prescribed by a medical herbalist, can help regulate ovulation

• causes of stress can be identified and removed

• excessive exercise can be reduced

• low body weight can be increased.

A Time to Reflect

I encourage women to see their period as a time of contemplation and renewal, and to see the process of bleeding as cleansing. Our modern lifestyles encourage women to disregard how they feel during their period, advocating the use of tampons and treating this phase of the cycle just the same as any other. I encourage women to use this time to reflect and to recharge their emotional and physical batteries. It is perfectly natural that very often women find themselves not wanting to socialize during this time, preferring to be quiet and reflective.

What is useful for me when I am working with a woman is to know what a ‘normal’ period is for her, so I can see how this relates to the rest of her cycle.

In Traditional Chinese Medicine (TCM), much more attention is paid to a woman’s period than in Western medicine. The length of a period and the colour, amount and quality of the blood flow are all considered, alongside other information and observations (see page 217). In my work I use the principles of Five Element Acupuncture, a feature of TCM that I find very useful in assessing each woman and her individual concerns or problems.

Period pains, if severe, can be indicative of the sort of hormonal upsets that suggest problems in the menstrual cycle. In TCM it isn’t considered normal to have painful periods; this is seen as an indication that some sort of hormonal rebalancing is needed. In the West, many women accept that their periods are painful, and take large quantities of painkillers in order to function, without realizing that these drugs can be detrimental to their fertility (see page 172). TCM, and acupuncture in particular, along with abdominal massage (see page 229) can all help in alleviating not just the pain but also the cause of it. This is a much better alternative to swallowing lots of painkillers, some of which are quite strong and anti-spasmodic, which can in turn interfere with the menstrual cycle. I also believe that it’s far better for women to use nutritional means to deal with painful periods. Taking an EFA (essential fatty acid) supplement, and one that contains evening primrose oil (GLA) can help normalize the hormones called prostaglandins. Period pains can be an indicator that prostaglandins are being over – produced, which can, in turn, have an impact on your overall hormonal cycle and may affect your fertility.

Women with severe period cramps often show a depletion in the mineral magnesium, for example, and taking a supplement of this – which helps with muscular tension – can help to alleviate the pain.

For women trying to conceive, the arrival of their period can be a time of sadness as it means conception hasn’t been successful that month. There is no question that the emotional response to this can be quite profound, and it can also be exacerbated by hormonal changes. However, the menstrual period can also be seen as a sign for optimism, as it can be used for contemplation, renewal and preparation – physically and emotionally – for the next cycle and another opportunity – with increasing knowledge – for conception.

I think it’s better for women to use pads rather than tampons during their period, especially if they suffer from endometriosis. I realize that this isn’t always practical, especially if the bleeding is very heavy, but women should be aware that tampons can be very drying to the vagina, absorbing normal vaginal moisture. If you are going to use tampons, opt for those made with organic, non – bleached cotton, and use pads on lighter days. TCM also recommends keeping the abdominal area warm, either with direct heat (from a hot water bottle, for example) or through warming, nourishing foods – especially when there is discomfort during a period.

Keeping a Diary

First of all, without making a daily note of where you are in your cycle, it’s hard to gauge your individual pattern of fertility, either for yourself or for a health professional. Many of the women I see keep note of the length of their periods. Knowing roughly the length of your previous six cycles, the length of the shortest and of the longest can be a big help in identifying your fertile time: your shortest cycle minus 20 gives you your first fertile day, and your longest cycle minus 10 gives you your last fertile day.

Your diary should record the following:

• First day of your period (Day 1 of your cycle).

• Signs of cervical mucus (particularly noting the very fertile clear, wet, stretchy secretions).

• Lifestyle notes (evenings out, alcohol intake, stress at work, travel, holidays, etc.)

• Use of any medicines – such as painkillers for headaches, antihistamines, antibiotics, etc.

• Occasions of full sexual intercourse.

• Libido.

• Physical feelings – abdominal cramps, headache, energy levels, breast tenderness, etc.

• Emotions – moods, happiness, irritation, etc.

Most women need to observe their secretions for about three cycles before they feel confident about recognizing changes. Do bear in mind that keeping a diary is designed to provide you with an overview of your cycle, not a foolproof means to conception. It is all too easy to get obsessive about these things – try to keep a sense of perspective.

One of the reasons keeping a diary is so useful is that it is only possible to evaluate your cycle length retrospectively. It’s only after keeping a note of several cycles that any sort of recognizable pattern will begin to emerge. If you have been on the contraceptive pill, or have no idea of what your cycle length might actually be, then keeping a diary noting down this information before trying to get pregnant can be enormously helpful and quite revealing. It also provides you with an objective record of events, which can be equally helpful in identifying problems such as a fluctuating cycle length, inadequate frequency of sexual intercourse, use of medication, etc.

Even though fertility awareness seems to involve a lot of information, as you become more aware of what is happening during your cycle, it soon becomes second nature. What is important, however, is to remain aware without becoming obsessive. When all’s said and done, the single thing that is most likely to improve your chances of conception is having lots of sex, not just sex at specific times. If you can do this without focusing solely on procreation, but keeping the pleasure in mind, it can only be beneficial for both you and your partner.

Questions and Answers

What if I have a brown discharge for a few days before my period starts? Does this count as Day 1?

No, Day 1 is the first full flow of blood, the first day of red bleeding.

I have just come off the Pill and want to get my system cleaned up before starting to try for a baby.

Don’t, because research shows that you are more fertile in the first couple of months that you come off the Pill. Getting pregnant can become harder in following months.

Most women get pregnant very quickly after stopping the Pill – in fact, some fertility clinics put women on the Pill to get the ‘rebound’ fertility effect. With newer lower-dose pills, there is no reason to wait for the Pill hormones to get out of your body. There are no adverse effects shown if you get pregnant immediately after stopping the Pill (or other hormonal methods of contraception).

Will it take time to get pregnant following taking the Pill?

Some women get pregnant straight away, while for others it takes time to get their cycles back on a regular basis. It can be harder for some women to conceive after stopping the Pill – particularly if they are over 30 years old and have never had a child. So planning ahead is useful. You could also check your rubella status (by having a simple blood test) while still on the Pill, because if you need to have a vaccination it is essential that you are not pregnant.

One of the disadvantages of the very effective contraceptive Pill, on which many of us rely to control our fertility, is that it wipes out a woman’s individual menstrual cycle, which is of course its aim. The doses of hormones given to achieve this have to be large enough to over-ride a woman’s own hormones, and this tends to blanket any normal fluctuation and effects a woman might recognize.

Coming off the Pill to get pregnant means also getting back in touch with those signs and symptoms of fertility, some of which might not be welcome if the Pill was prescribed for menstrual cramps, acne, mid – cycle spots or other hormone-related aggravations. But it’s important to become familiar with your own cycle, if you don’t become pregnant straight away, and to see these hormonal fluctuations as positive signs of your fertility.

It used to be thought sensible for women coming off the Pill, or stopping any other form of hormonal contraception, to wait a few months for their cycle to regularize and also to allow time for these artificial hormones to be excreted from the body. However, it is now advised not to wait, especially as there is some evidence to show that coming off the Pill kick – starts a woman’s hormonal activity and may actually encourage conception.

The other advantage with being familiar with your own cycle, and what its ups and downs might be, as well as its regularity or otherwise, means that if there are problems with conception you have a baseline for considering what those problems might be.

For some women, once they know what to look for, their personal indicators of fertility are very clear – cut – it’s that, ‘Oh, yes…’ moment. Fertility UK statistics illustrate that over 60 per cent of couples who contact a fertility awareness practitioner via www.fertilityuk.org do so in order to increase their understanding of the menstrual cycle to help plan a pregnancy.

How long can I expect before my periods return following the Pill?

Delays are not uncommon, especially in women over 30. It really helps to understand your cycle. Initially you may experience some irregularities in your cycle, including cycles that are longer than 35 days. Also, you may not ovulate in all cycles. If you are doing a temperature chart you may not get a rise in temperature – this happens, on average, in 10 per cent of cycles. Some women will have no periods (amenorrhea) or a cycle lasting over 90 days.

Am I more likely to have Polycystic Ovary Syndrome (PCOS) after taking the Pill?

It seems that some women who do come off the Pill and then have irregular cycles are diagnosed with Polycystic Ovary Syndrome. The Pill prevents PCOS, as it prevents ovulation and reduces the hormonal activity that causes PCOS, but there is little evidence to suggest that you are more likely to get PCOS after stopping the Pill, if you have not had it before. However, existing PCOS symptoms may have been masked by the Pill – and so become apparent after stopping.

If I am trying to chart my fertility following the Pill, what can I expect?

The first thing to remember is that there are many different types of Pill – some are combined pills containing oestrogen and progestogen (synthetic progesterone), other hormonal preparations (including pills, patches, injections and contraceptive implants) contain progestogen only. The main effect of oestrogen in pill preparations is to prevent ovulation, while the main effect of progestogen is to cause a thick mucus plug at the cervix, stopping sperm from getting through.

After stopping the Pill (or other hormonal contraceptive products) there will be much variability in how long it takes for full ovulation to return and for cervical secretions to return to their most fertile characteristics. Normally these things happen very quickly after stopping contraceptive pills (or sometimes, of course, even if you miss out on taking your pill regularly!), but sometimes it takes several months to a year or more for the return of full fertility.

After stopping the Pill it is possible that you may immediately have regular cycles with clear – cut fertility signs, but many women experience irregular cycles – often longer cycles – and there may be disruptions to the normal pattern of secretions because the progestogen in your pill has kept your cervix tightly closed and plugged with a sticky white mucus to stop sperm from entering. It can take a while for the cervix to start producing the more sperm – friendly wetter, clearer secretions again in good quantities.

If you are recording your temperature, there may be some cycles with no temperature rise (possibly indicating the absence of ovulation), while other cycles may show a rise in temperature but it may occur fewer than 10 days before the next period starts (indicating a short luteal phase). If this is the case, your cycle would not be fertile as there would be insufficient time for implantation to succeed.

Many women report heavier and brighter red bleeding after stopping the Pill – this can be quite alarming. Hormone – withdrawal bleeding which you get during the pill – free interval is much lighter and pinker than the fresh red bleeding of a normal period. If you are concerned, do talk to your doctor.

How will I know if I am ovulating or not?

It is not possible to tell from cervical secretions, temperature or LH kits whether ovulation is happening or not. The build – up to the wetter, clearer secretions indicates that ovulation is approaching, LH kits generally show that ovulation is imminent, and the rise in temperature may be a sign that ovulation has occurred – however none of these signs is conclusive.

Aim to have as much sex as possible at any time you see any cervical secretions – this gives sperm the best possible chance to start their journey!

It will be hard at first to recognize your individual pattern. If you are concerned about a delay in conceiving, of course you should speak to your doctor in the first instance.

For many women there is a wealth of minor signs and symptoms that can help identify their fertile times. Let’s take a look at some of these.

Increased Libido

An increase in libido – of course this is also related to other emotional, social and physical factors, but for many women trying to get pregnant, increased sexual interest is an indicator of hormonal changes around the time of ovulation.

Mid – cycle Abdominal Pain

Because the ovarian follicle enlarges, prior to ovulation, by up to 23mm, and ruptures at ovulation, it’s not surprising that some women become aware of a sharp twinge or dull ache on either the right- or left-hand side of their lower abdomen, about halfway between the navel and hip bone and halfway between the navel and pubic bone. This can last for anything up to a couple of hours, and may be combined with a crampy feeling, not dissimilar to menstrual cramps, which may be because of the swollen ovary or the extending of the womb and Fallopian tubes, caused by the increase in oestrogen. The actual cause of the pain is still not known – the most likely culprit, as identified by research carried out in Germany, is related to a very slight bleed into the peritoneum as the follicle ruptures.

With other fertility awareness already in place, many women can easily identify this time of peak fertility, which can be an extremely useful indicator. Mid – cycle, or ovulation pain is also referred to as mittelschmertz – though it has to be mentioned that research has shown that of all the subjective indicators of fertility, this one is the most varied in relation to ovulation (when studied on ultrasound scans).

Breast Tenderness

This is also an indicator, often unwelcome for many women, that they are about to ovulate. Tenderness leading up to ovulation tends to be tingling in nature, because of the oestrogen effect. Tenderness that comes on towards the end of the cycle, influenced by the progesterone effect, is usually characterized by a heavy and full feeling, rather than tingling.

Spotting

In a very few women it is normal for them to experience a little mid-cycle spotting, or to have pink – coloured cervical mucus because of this spotting. For those women this is an indicator of peak fertility, but because it is so uncommon is not often listed as a fertility indicator. In addition, any mid – cycle spotting or bleeding must be reported to your doctor and checked out, as it can be an indicator of infection or disease. Make sure you are up to date on your smear tests.

What if my LH surge does not relate to my secretions?

An LH kit shows that ovulation is about to happen (within the next 24 hours). Cervical secretions give you about 5 days’ warning. To optimize your chances of pregnancy, have sex from the time your secretions start (this is the start of the fertile time). Normally the LH kit will become positive after you have had fertile secretions for a few days. Do not wait for a positive result from a urine sample – by the time you get this you are nearing the end of your fertile time. If you do have a positive LH test, continue to have regular sex for at least two days afterwards.

What if all of the LH tests are negative?

This can be very alarming for women, as you only get five test sticks, and if you have no idea about your fertility you won’t even be sure of when to start testing. If a woman has an irregular cycle, ovulation could vary anywhere between days 14 and 28, or even earlier or later than this, making it very hard to pinpoint exactly.

The LH sticks may not work for some women, for example some women over 40 may have higher LH readings. Similarly, some women with PCOS may have raised LH levels. If you use the sticks and find that you do not see any negative days – i.e. all your test results are positive – this may be a sign that you have an abnormally high LH level throughout your cycle. This should be checked by your doctor.

Ovulation does not occur in every cycle. It can be affected by factors such as age, the amount of time since you last gave birth, whether you are breastfeeding, how long it has been since you stopped taking the Pills, your body weight and stress levels. It is quite common not to ovulate in around 1 out of every 10 cycles. If you have two or more consecutive cycles where you do not think you have ovulated, see your doctor.

Why is my doctor going to check my progesterone levels?

Your doctor may do a progesterone test to check for ovulation. This is commonly called a Day 21 progesterone test. Doctors aim to test for the hormone progesterone about halfway through the second half (luteal) phase of your cycle – and for a woman with a cycle of 28 days, halfway between day 14 and 28 is Day 21. However, this only gives an accurate reading if your cycles are 28 days long. For shorter cycles the test may need to be done earlier, for longer ones, later. To time this test more accurately – and if you are aware of your fertile secretions – aim to get the test done about a week after your peak secretion day (i.e. one week after the secretions change back from being clear, wet and stretchy to being thick, white or dry again). If you are taking your temperature regularly, aim to have your progesterone test about six to seven days after your temperature rose to its higher level.

If you are told that a progesterone test shows you are not ovulating, this is not necessarily all doom and gloom. It simply means that you did not ovulate during that particular cycle. The test may need to be repeated to get an idea of whether this was an isolated incidence or a common occurrence for you.

What does it mean if my secretions do not get to the raw egg white stage?

Some women never notice egg – white type secretions yet conceive quite normally. It is the quality of the secretions high up in the cervix that count for the sperm. Avoid feeling inside your cervix to check for secretions, as this can be quite drying. As we get older the amount and quality of secretions reduces – so you may have noticed that these secretions were more abundant in your younger years. A reduction in secretions could be related purely to your observations – or may be related to slightly lower oestrogen levels. Many women never see the really stretchy type of secretion – but feel wetter only.

Can I use saliva, KY jelly or egg whites for lubrication during intercourse if I am dry?

No, unfortunately saliva has been found to be quite detrimental to sperm. In laboratory conditions, sperm cannot swim if they are in contact with saliva or any other lubricant – either water – or oil – based – all of these have some effect on sperm motility (movement). Although this has not been tested in women (and would be quite hard to study!), one has to assume that the effect would be the same in the body. Saliva of course contains an enzyme, ptyalin, which starts the digestive process – digesting carbohydrates – so this is not good news for the sugars contained in sperm or their swimming fluids!

Lubricating gels block the sperm. Egg whites are protein and can trigger an allergic reaction in some women.

I don’t seem to have many secretions, yet they seemed plentiful when I was younger. Is this common?

Yes, as we get older the quantity and quality of our cervical secretions are reduced. This is one of the reasons why fertility rates are lower in older women. The other factor is often that when young we are often unaware of the significance of these secretions and may even be quite alarmed by them. Sometimes women feel the secretions are a sign of infection – or that they may have damaged themselves somehow.

It is also common for women to report that as soon as they start to look out for the secretions, they no longer seem to see them. The amount of secretions will vary from woman to woman and sometimes from one cycle to the next in the same woman. If you are having sex around your fertile time (which is of course pretty vital) then often some of your natural secretions will get mixed in with the seminal fluid, which then comes away a few minutes after you have sex (even if you are lying flat) and can give you the impression that you’ve fewer secretions than you really have.

What if I spot between periods?

This depends on when the spotting is occurring. The first thing to remember is that ANY unusual bleeding or spotting must be checked out by your doctor. It is important to keep your cervical smears up to date, as these check not only for pre – cancerous changes but also for signs of infection.

If any spotting has been checked out medically and you are told that there is no concern medically, the following information may be helpful. Some women get spotting towards the end of a period – this may be quite normal as the period dries up. Some women have spotting leading into a period. This should be recorded at the end of the cycle – with the new cycle (Day 1) starting on the first day that you notice fresh red bleeding. If you consistently get some spotting for a day or so before your red bleed starts (pre – menstrual spotting), this may be an indication that your progesterone level is falling and may require medical help.

Very occasionally women who are observing cervical secretions report slight spotting tingeing the wet stretchy secretions – this is nothing to be concerned about (provided you are having regular smear tests) and may simply be due to the fact that you are more aware of your secretions than ever before!

Some women notice a tiny spot or so of blood (or even more) around the time implantation is occurring – so this could be a very positive sign.

I seem to have a long cycle and have secretions nearly all of my cycle.

Although most women report that they are dry immediately after a period and when approaching the next period, some will observe secretions for most, if not all, of the cycle. Again, if you suspect any infection, get this checked by your doctor.

Quite a common reason for secretions throughout the cycle is a cervical eversion (where the inner lip of the cervix protrudes onto the outside of the cervix, causing an increase in the wetter type of secretions). This is more common after you have been on the Pill, or after pregnancy or miscarriage, and may go away of its own accord. See your doctor or practice nurse, who will be able to see if there are any signs of an eversion. It is not necessary to treat this, unless the secretions are causing trouble with increased wetness. Your doctor will be able to advise you.

Women can learn to distinguish cervical secretions more easily if they get expert help from a health professional trained in fertility awareness methods – such help can be found at www.fertilityuk.org.

When I take my temperature it seems to be very low, and never gets above 35.5°C. Is this a problem?

If your temperature does not seem to fit on the scale of the usual fertility chart, the most likely reason is either a faulty thermometer or inexperience in taking your temperature. It may be worth consulting a trained fertility practitioner. If you have a very low waking temperature – and you are sure you are taking it correctly – then do check this with your doctor. If you also have other symptoms such as tiredness, or are feeling the cold, then there may be a thyroid problem. Your doctor will be able to check your thyroid function as part of other hormone testing.

I suffer from PCOS and have very irregular cycles. How can I know when I should have sex?

This is difficult. Many women with PCOS have erratic ovulation and confusing fertility symptoms, and can have patchy secretions throughout the month due to erratic hormone levels. Ovulation kits will be of no value if your level of LH is raised or high, as it sometimes is when you have this condition.

Plan to have frequent, regular sex throughout the month. I have seen many women conceive with PCOS; the good news is 70 per cent conceive naturally and 20 per cent conceive with the help of appropriate medication.

If you are older, have been diagnosed with PCOS and have made all the necessary lifestyle changes, don’t leave it too long before you consult with your doctor about problems getting pregnant – it’s possible you may not be ovulating.

understanding male fertility

Male Reproductive Organs

A man’s general health is just as important to conception as a woman’s, although this often gets overlooked by fertility experts, who tend to be gynaecologists and obstetricians – specialists in female, not male, reproductive health. And your health is never more important than when you and your partner are trying to conceive. Very often, problems in conception are thought to be wholly the woman’s, but this is not the case. When a couple have a problem with conception, the problem is only with the woman in around 35 to 40 per cent of cases and with the man between 30 and 35 per cent of the time. Problems that arise from combined difficulties in both partners account for the other 25 to 35 per cent of cases.

I do think that, slowly, the message is getting through: The health of the sperm is just as important as a woman’s gynaecological health when it comes to conception. At our clinic we will offer a semen analysis straight away; if you focus all clinical attention on the woman, valuable fertility time may be wasted.

Unlike women, men do not have cycles which could alert them to the fact that there may be problems – so very often it can come as a real shock when the results of a semen analysis are poor. And semen analysis is only part of the story: the sperm may look fantastic but there may be infections or DNA fragmentation, which will not show up on semen analysis. Specimens sent to standard general microbiology or pathology labs may not receive immediate attention, and morphology assessment in particular (see page 286) may be inadequate, giving false or misleading results. We have seen this happen so many times.

Twenty-five per cent of male infertility remains unexplained. Sperm counts have been steadily declining over the last 50 years. Scientific evidence clearly points towards our constant exposure to toxins in our everyday modern lives, contributing to our reproductive downfall. These factors are known to affect male reproductive function seriously, and may well contribute to this high number of unexplained cases.

Insufficient emphasis is put on the contribution of lifestyle factors to sperm quality and male infertility. Infertility is multi – factorial and, in many cases, the severity of male infertility is exacerbated by lifestyle factors, which can and should be addressed to optimize whatever fertility potential there is. Even if the semen analysis is good, good sperm genetic health and metabolic fitness can always be improved by cutting down on the lifestyle factors that are known to harm the sperm, and eating a good healthy diet to reduce oxidative damage to the sperm.

Sperm Production

Sperm are produced in the seminiferous tubules of each testis. The two testes are contained in the scrotal sac, next to the penis. Unlike women, who are born with around 2 million immature eggs in their ovaries, although they don’t begin to mature and ovulation doesn’t occur until after puberty, a man doesn’t produce sperm at all until puberty, when his reproductive hormones become active.

Hormones are sometimes called the ‘chemical messengers’ of the body. Secreted by a gland in one part of the body, hormones are transported via the bloodstream to another area of the body, where they have an effect. At puberty, for both men and women, an area of the brain called the hypothalamus starts secreting gonadotrophin – releasing hormones, which cause the pituitary gland to produce two other hormones: follicle – stimulating hormone (FSH) and luteinizing hormone (LH). When these two hormones are produced, the gonads – testes in men, ovaries in women – are stimulated, to produce sperm in the man and to stimulate ovulation in a woman. The average age for male puberty is between 12 and 14, although this can vary quite widely and is influenced to some degree by genetic make – up, race and diet. Hormonal stimulation of the testes leads to the production of sperm and, as long as the necessary hormones are available and at the correct levels, and there is no disease or illness affecting production, this is a continuous process from puberty onwards.

The other effect of FSH and LH on the testes is to stimulate the production of testosterone, within the testes, responsible for the development of male characteristics like facial, armpit and pubic hair, and body hair in general. The voice also deepens as the testosterone makes the Adam’s apple at the front of the neck enlarge. Muscle tissue is increased and strengthened, and mood is also influenced – not least in promoting sexual interest. Some men seem to produce more testosterone than others, but this doesn’t mean they are more fertile than other men. Testosterone is responsible for the secondary sex characteristics described above, and isn’t particularly an indicator of the quality of sperm or a man’s fertility.

The process by which sperm are formed in the testes takes around 100 days – 74 for the sperm to develop, and then another 20–30 days to reach maturity, which is what you have to allow before you can expect to see any improvement in sperm quality or quantity. But as sperm production is happening continuously, a man is continuously fertile, unlike a woman who is only fully fertile for about eight hours during each one of her fertility cycles!

Within the testes, the sperm start their journey through the thousands of tiny, coiled seminiferous tubules. Sperm start as spermatocytes, primary cells that divide and develop into spermatids, which are immature, tail – less sperm. During their journey along the seminiferous tubules, where they are nourished by the sertoli cells that line the tubules, each spermatid grows a head that contains all the chromosomal material. Chromosomes carry all of a man’s genetic material ready to pass on to a child, including the chromosome (usually referred to as the sex chromosome) that decides whether a baby will be a boy or a girl. Whereas every one of a woman’s eggs contains the genetic material for a girl (the X chromosome), a man’s sperm will contain either an X chromosome or a Y chromosome (for a boy).

As well as growing a head during their 74-day development, the sperm form a middle piece that contains the energy source, and a tail. It is the mid – piece of the sperm, with its energy source, which is responsible for the tail’s ability to move and transport the sperm independently. Without a properly functioning tail, sperm may swim around in circles rather than forward in a straight line, or may not swim at all.

From the seminiferous tubules, the maturing sperm move into the epididymis, which is a long tube, around 18 feet in length but only a three – hundredth of an inch in diameter, which is coiled and situated at the back of the testicle.

Once produced, sperm then move up into the vas deferens, the tubes that eventually feed into the urethra and on through the penis, via the ejaculatory duct. Here, the sperm mix with secretions from the seminal vesicles and the prostate gland to form the seminal fluid. Once combined, the sperm and seminal fluid are referred to as semen. The secretions of the prostate gland are alkaline, which helps to neutralize the acidity of the woman’s vagina, and protect the sperm. The vas deferens travel from the testes out of the scrotum and through the lower abdomen via the groin, then around to a point underneath the bladder where they join the urethra. They hold an astonishing amount of sperm: it would take around 30 ejaculations to empty the vas deferens of their full load!

Only around 20 per cent of semen is sperm. The seminal fluid that combines with sperm to form semen is composed of more than 22 different chemicals, including sugar, vitamins C, E and B₁₂, prostaglandins (which help stimulate muscle contractions and the dilatation of blood vessels), the minerals zinc, potassium and sulphur, and essential fatty acids (namely DHA). Altogether, ejaculate consists of around 2 to 4 ml of semen, which is quite viscous at first but then liquefies after about 10 minutes. Sperm need to be nourished by this liquid on their journey, and protected from the acidic environment of the woman’s vagina, before any of them can reach an egg. Around 250 million sperm are ejaculated each time, but it takes only one to fertilize an egg.

Why this enormous quantity of sperm? Only a certain proportion – and this varies from man to man – will be normal, active enough and capable of fertilizing an egg in the first place. Then, because the woman’s vagina is acidic, and hostile to sperm, treating it as it would any other ‘foreign body’ and attempting to get rid of it, as it would an infection, this also reduces the available sperm. From here, only around a million sperm will actually get as far as the woman’s cervix, and only around 200 of these, at most, will reach the woman’s Fallopian tube, to fertilize an egg.

If you then consider how many of the remaining sperm are actually of a good enough quality to fertilize an egg – and in sperm analysis only a maximum of 20 per cent pass this test – it’s no wonder that fertilization can be a tricky business. And even if fertilization does occur, if the sperm responsible is faulty in some way then development of the fertilized egg can’t continue, and miscarriage may be the outcome.

A Good Diet

When you consider what sperm need to develop, and the journey they have to undertake in order to stand a chance of fertilizing an egg, it’s easier to understand why good health in a man is just as important as in a woman when it comes to making babies.

The good news is that, because of the continuous 100-day cycle of sperm production, it is possible to improve sperm’s quality relatively easily, by making the necessary health and lifestyle changes.

While the Nutrition chapter (see page 89) offers general guidelines, it is worth mentioning here, too, that when it comes to the sort of adequate nutrition that makes a difference, there is no point grabbing a general multi – vitamin, or an expensive supplement, unless you know what you’re getting and what you need. Before that, it’s worth looking at your general diet and how to improve it.

Generally speaking, the fresher and less processed the food you eat, the better. Many people advocate organic foods, and there is a good argument for this. In one Danish study, an unexpectedly high sperm count was found among organic farmers. Their sperm count was twice as high as that of a control group of blue – collar workers. But it’s tricky, because if it’s a choice between organic beans flown in from Kenya that have taken five days to get to your supermarket shelf and have then sat in your fridge for two days, and some locally – produced beans that are not organic but were picked yesterday, you might want to choose the latter, as the vitamin and mineral content of the fresher food will be higher, and washing it carefully will help remove chemical and pesticide residues.

Now is not the time to go on some extreme weight – loss diet, either. Some men opt for high – protein diets to lose weight, but we have noticed anecdotally that men following this type of diet have poor sperm. There’s evidence to show that extreme diets, like the low – carb ones in such favour these days, increase the body’s acidity if not actually leaving you malnourished, which won’t be good for sperm production. Better to adjust the balance of what you eat, increase your exercise a little, and reduce your weight that way.

Ideally, you should follow the guidelines set out in the Nutrition and Lifestyle chapters.

Try also to eat a proportion of your foods, especially fresh fruit and vegetables, raw. And when you do cook, try steaming and grilling rather than boiling or frying, which will preserve more of your food’s nutritional value.

It is probably a good idea to cut out all highly processed foods, if you can, as they are alarmingly high in hidden fats, sugars and chemical preservatives. In addition, the nutritional content of food is greatly reduced during processing. Opt for whole foods where you can.

If this feels rather overwhelming, start gradually, introducing a different change into your diet week by week as you adjust.

Water

When it comes to what you drink (and alcohol is covered separately: see page 62), make sure you are not over – doing your caffeine intake. Caffeine is mildly addictive, so if you are used to drinking a lot it may take a while to kick the habit. There is also some evidence to show that if a man has a high caffeine intake before conception, the risk of premature birth is increased. Tea contains tannin, which is less of a stimulant than caffeine, but excess quantities will deplete you of iron.

Most men do not drink enough water. Sperm need to swim!

Start changing your drinking habits first of all by increasing your water intake – most of us drink too little, generally, to be adequately hydrated.

What Do Sperm Need?

There is a lot of research available now about free radical damage to sperm, but thankfully there’s a lot you can do to improve this. To produce sperm your body needs a good intake of certain nutrients, which may need supplementing if they are not readily available from your diet. Research has shown that certain vitamins and minerals improve overall sperm counts – I’ve seen it many times. It is important, however, to remember not to exceed the recommended daily allowance (RDA) of any one item, even if you have heard that it might be beneficial, unless under supervision from a health professional. An excess of one item can deplete others, so a balance is needed.

Also see the Nutrition chapter for more advice on how to improve your diet to increase the chances of conception.

Vitamin C

A well – known antioxidant, under normal conditions vitamin C protects sperm from oxidative damage, and certainly improves sperm quality in men who smoke. However, some men have a condition of their sperm called ‘agglutination’ where sperm clump together and fertility is reduced. In these cases, vitamin C supplementation of up to 1 gram a day helps reduce agglutination – and was shown to increase fertility in one group of men in a controlled study.

Zinc

Semen is rich in zinc, and men lose a certain amount of this mineral per ejaculate. Zinc is often referred to as the ‘fertility mineral’ and its presence in foods like oysters, which are said to have aphrodisiac properties, may reinforce this idea! Certainly an insufficiency of zinc can lead to both reduced numbers of sperm and impotence in some men. It has also been found that the levels of zinc in the semen of infertile men are of a lower level than in fertile men. Numerous studies have been done, and some of the results seem to conflict, but overall there is enough evidence to suggest that for men with poor sperm quality, sperm count and sperm motility, a supplement of zinc can help.

In areas of the country where the copper content of water is naturally high there may be a general zinc deficiency, as these two minerals have to be in balance: an excess of copper can reduce zinc. Conversely, where long – term zinc supplementation is recommended, then supplementation with copper is needed.

Vitamin B12

Necessary to maintain fertility, there are studies that have shown an improvement in sperm motility where oral vitamin B₁₂ was given. In the latter case, around 60 per cent of those men who received an oral supplement of vitamin B₁₂ (1,500 mcg per day of methylcobalamin) had improved sperm counts.

Vitamin E

Certainly a deficiency in vitamin E, in animals, leads to infertility. In one human trial, the giving of 100–200 iu of vitamin E daily to both partners led to a significant increase in fertility. Vitamin E seems to reduce the amount of free – radical damage done to cells. Supplementing reduces the amount of oxidative stress on sperm cells, although it should be said that the research is at a preliminary stage and needs further work before a definite case for sperm improvement can be made.

Co-enzyme Q10

This is a nutrient used by the body’s cells in the production of energy. Its exact role in the production of sperm isn’t known, but there is evidence to show that as little as 10mg a day over a two – week period will improve both sperm count and motility. In one study, where men with low sperm counts were given 60mg a day over a three – month period, although no significant change was observed in most measures of sperm quality and quantity, in – vitro fertilization rates improved significantly.

Selenium

This is an essential trace mineral that acts with the antioxidant vitamins A, C and E, and is found in large quantities in Brazil nuts. In one double – blind study of infertile men, supplementation of 100 mcg per day of selenium for three months significantly increased sperm motility, but not sperm count.

Calcium

The motility of sperm is partly determined by the concentration of calcium in semen, and this mineral is also a key regulator of human sperm function. However, although we know it is important there has been no evidence to confirm that a calcium deficiency causes male infertility. Neither is there any evidence to show that calcium supplementation improves male infertility.

Pycnogenol

Pycnogenol (French maritime pine bark extract) is a natural antioxidant that has been found useful in maintaining the health of blood vessel walls and circulation. It works, at least in part, by subduing free radicals. A preliminary study recently presented at the 54th Annual Meeting of the American Society for Reproductive Medicine/16th World Congress on Fertility and Sterility in San Francisco reported the findings of Dr Scott J. Roseff and his colleagues at the West Essex Center for Advanced Reproductive Endocrinology in West Orange, New Jersey. In the study, four ‘subfertile’ male patients took daily supplements of Pycnogenol® for three months. These men had had relatively high numbers of deformed sperm, as well as low sperm counts and activity. After 90 days, the percentage of structurally normal sperm – that is, non – deformed sperm – increased by an average of 99 per cent. ‘The number of deformed sperm went down and the number of normal sperm went up,’ Dr Roseff said. ‘The increase in morphologically (structurally) normal sperm is significant, although this is just a preliminary study. Pycnogenol could enable some couples to forego expensive in – vitro fertilization in favour of simpler and less expensive intrauterine insemination.’

SAMe (S-adenosyl-L-methionine)

SAMe is manufactured in the body from the amino acid methionine, with the aid of the co – factors vitamin B₁₂ and folic acid, and is essential in the production of the nucleic acids DNA and RNA and other proteins. Although its use as a supplement has been mainly for those suffering depression, migraines, osteoarthritis and liver disease, some preliminary research has shown that SAMe may also increase sperm activity in infertile men, although it’s too early for this to be conclusive. Also, as this amount is over the RDA, please consult a qualified nutritionist before you take it.

Arginine

Another amino acid, arginine is found in many foods needed to enhance sperm production. Research, of which most is still in its preliminary stages, has shown that supplementation with L – arginine over several months increased sperm count, quality and fertility. As a supplement it is also an immune – system enhancer and powerful growth – hormone stimulant, while also playing a role in circulation and sexual function. In some susceptible individuals it can also reactivate a latent herpes infection, and shouldn’t be used by people with diabetes.

L-carnitine

Another amino acid – like substance, made by the body and also found in meat, L – carnitine is responsible for utilizing fat in the energy centres of the body’s cells, and is essential for the formation of lean muscle in the body. It also appears to be necessary for the normal functioning of sperm cells. In preliminary studies, giving an L – carnitine supplement for four months helped to normalize sperm motility in men with poor sperm quality. In another trial, acetylcarnitine was used, and a supplement of 4 grams a day proved useful for male infertility caused by immobile sperm. However, again, this amount is well over the RDA, and should not be taken without supervision.

DHA

So important for sperm. The semen contains high levels of DHA. Animals fed a diet lacking in DHA showed decreased levels in their sperm.

For more about eating well to increase fertility, see the Nutrition chapter.

Other Important Nutrients

These include folic acid – a nutrient just as important for men as it is for women – saw palmetto and NAC. As always, please do consult a qualified nutritionist for more information about dosages and how all these nutrients can assist fertility.

Environment and Lifestyle Factors Affecting Sperm Production

I think the way we live and our environment have definitely had an effect on the decline of sperm. Laptop computers, solvents, chemicals – such as those you may use for a hobby or as part of your work – ‘gender-bending’ environmental oestrogens, paints, pesticides, plastics, aluminium – all of these affect fertility. So, too, can natural substances such as genistein, a compound found in soya products and pulses, and various contaminants in drinking water. In addition, there are factors brought about by the trend towards increasingly sedentary occupations and lack of physical activity, which increase scrotal temperature and affect sperm production, count and motility. All in all, the risks are far greater than they were even 20 years ago.

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