Zita West’s Guide to Getting Pregnant

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).