Zita West’s Guide to Getting Pregnant

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?