Calendar Method Vs. OPK? It's All In The Timing...

Question:

So my husband and I are trying for our first child. We've trying for about 3 months with no luck yet. i was thinking of trying the ovulation test but i'm not sure if its worth it. I've read online that they can help but i figure it would never hurt to ask. Do you know much about them and if there worth the money or should i just track my temp every morning.Thanks for the help! S. from Canada

Answer:

Hello S. from Canada,

An ovulation predictor kit (OPK) does not help any more than timing it well. I don't recommend it to my patients. Instead, I recommend the calendar timing method. It goes like this:

CD#1 The day your period starts. Mark you calendar then count each day. For instance the next day is cycle day #2, then cycle day #3 etc.

CD#10 Stop having intercourse. You can have regular intercourse until that day but you have to stop on that day.

CD#13-17 Assuming you have normal regular cycles, this is your fertile period. You should have intercourse each day, only once per day and only one ejaculation per episode. After cycle day #17 you can resume your normal frequency.

Keep in mind that 85% of women under the age of 30 take 8-12 months to achieve pregnancy so you have not yet been trying long enough. Hopefully this method will help.

Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

Comment: Ok thank you so much for the advice! I'm going to try the calendar method.

Canadian TTC Wants To Know When Is The Best Time To Use A Pregnancy Test Kit

Question:

My husband and I are trying to get pregnant with our second baby, I got pregnant very easily with my now three year old son. As of right now I am 8 days post ovulation. I have been using 10 miu pregnancy tests which have all come up negative the last three days.

I have two questions I hope that is okay. My first one is what is the average day for a positive pregnancy test using 10 miu tests? My second question is if I am experiencing ALL of my usual pms symptoms does that mean I am likely not pregnant? Thanks so much! L. from Canada

Answer:

Hello L. from Canada,

You'll have to wait at least 10-14 days to check a home urine pregnancy test. At 8 days post-ovulation (assuming that is when it occurred because there is no way to know for sure), entrance into the uterus is just occurring for the embryo and implantation has not yet occurred. Keep in mind that an ovulation predictor kit does NOT tell you when ovulation occurs but the range of when it will occur. There is no way to know when it occurs exactly.

PMS symptoms are usually due to the increased progesterone levels in the luteal phase and not an indicator of a lack of a pregnancy. You'll just have to wait and see.

Also keep in mind that despite the fact that you got pregnant easily the first time, it takes the average woman 8 months to get pregnant and 85% will achieve pregnancy by one year of trying. So, in fact, you have not tried for a long enough period of time to worry. :)

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thanks you so much! I feel much better that you have answered my questions, and I now know I do not need to worry.

Woman Underwent Medical Miscarriage 8 Months Ago & Had Continuous Spotting, No BFP Yet: Should She Be Concerned?

Question:

Hello, I am a 29 year old female from Pennsylvania. My husband (also 29) and I started trying to conceive last year. We got pregnant on our 2nd month trying, and were very excited. At my first ultrasound, there was only a yolk & gestational sack, which showed growth only until 5w5d. I should have been much further along. I opted for medical management, offered by my doctor, to force the miscarriage. I took a mix of Mifepristone & Misoprostol - 4 pills were inserted vaginally, 24 hours after I'd taken the first pill orally.

The miscarriage began right away, and took days to complete. After 7 days, I went to my doctor for a checkup where she deemed the miscarriage complete with no side effects. I had spotting for months, which my doctor said was normal, and my period resumed in 4 weeks. Since then, we have tried for 8 months to get pregnant, with no luck. We track my cycles through BBT & OPK's, and it ranges now. I used to be regular, now I ovulate anywhere from day 11 to day 18. But I do ovulate every month. My period ranges from day 24 to day 29, depending on when I ovulated. My luteal phase went from 14 days pre-miscarriage to about 11-12 days post miscarriage. Are these cycle changes potentially a bad sign, or can they be normal?

My doctor does not seem concerned at all. She's run blood work, and done an internal ultrasound (last month) and said everything looks fine. She said that a medical miscarriage cannot cause scar tissue or block tubes. Is this true? I find it hard to believe because it was so painful w/so much bleeding. So my major concern is that my miscarriage caused me to become infertile. Is this something you have heard of? Is there a chance of scar tissue if I never had surgery, had no infections, and have never had an infection or any problems before my miscarriage? My husband has had all the male tests run as well, and they have said his tests are perfect.

My doctor will not put me on a fertility drug or run an HSG, as she said it is simply stress causing me to not get pregnant again. Is there anything you think I am misinformed about, or anything you recommend I do different? I am concerned that I took a really scary medication that did damage to me. Thank you so much for your help! J. from Pennsylvania

Answer:

Hello J. from the U.S.,

In general, a medical induction of miscarriage should not lead to scar tissue formation within the uterine cavity (known as Asherman's syndrome). This syndrome is usually a result of over-scraping of the uterus at the time of a D&C. However, if not all the products from the pregnancy were discharged, as can happen from time to time, then the resultant inflammation caused from the retained tissue can prevent pregnancy. It would be the same mechanism as an IUD. By checking you, I presume that your doc did an ultrasound and the cavity looked completely empty. To be absolutely sure, a hysterosonogram or hysteroscopy can be done. If the cavity is normal, then your current fertility issue is not due to the miscarriage.

The fact that you got pregnant easily before shows that your body does have the ability to get pregnant. We don't consider a woman to have an infertility problem until she has been trying for at least one year without success. At that point, an infertility evaluation should be done. I never never tell my patients that they are not getting pregnant because of "stress." Sure stress can impact the chances of pregnancy, but it is not significant enough to be a birth control device, so not good enough to be the cause of pregnancy failure or infertility. It is a patronizing remark. More than likely, you just haven't been as lucky this go around as you were the first time. Because you got pregnant so easily, you are assuming that you will again. But in fact, the average woman under the age of 30 will take 8-12 months to get pregnant naturally. So you still have to give yourself a chance.

The BBT's and ovulation predictor kits is ONLY to help you predict when ovulation is about to occur. They DO NOT say when ovulation has occurred. There is no way to know that. They also cannot be used to diagnose a short luteal phase, known as luteal phase defect. This has to be done by endometrial biopsy dating. The fact that there is a little variation in your cycles does not indicate irregularity. Cycles can vary +/- 7 days normally.

I understand and sympathize with your concern, but also advise you to keep it in perspective. Give yourself a chance for your body to do what it needs to do without undue pressure on yourself or your husband. Then if it does not happen in a few months (which would make it over a year of trying for you both), then insist on an infertility evaluation. At this point, evaluation and/or treatment might be premature.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Do Not Measure BBT For Ovulation When You Are Sick

QUESTION:

Hi, I came down with a mild case of shingles (no pain, just itching) last week. I have had a high BBT (I am tracking my BBT for ovulation and luteal phase) for the past 13 days now (my BBT went up a couple days before I developed a rash). Can having even a mild case effect my BBT? I have been checking my temp through out the day too and it doesn't look like I have a fever. Just trying to make sure my high BBT is actually from ovulating. How long can a luteal phase last? Thanks.

ANSWER:

Hello Cathy from the U.S.,

Any inflammation or disease can cause a reaction in your body and elevate your temperature. A BBT would not be valid during that period.

As I have said in a previous posting, I would not analyze the temperature chart so closely anyways. It is not that accurate. Many factors, such as your shingles, can influence the temperature. It is only useful to see if there is a rise in the mid-cycle, which is an indirect measurement of the LH surge, indicating ovulation is going to occur. If you are going to continue using the chart, use it only for that indication i.e. timing of intercourse, and nothing else.

Another option, which I think is more accurate but more expensive is the ovulation predictor kit or OPK. However, with this kit you also cannot evaluate the luteal phase. The only way to evaluate the luteal phase is to do an endometrial biopsy. You will need to begin infertility testing for that.

To answer your last question: The luteal phase is usually 14 days.

Sorry about your shingles, I have had it and it is not a pleasant condition at all!!!

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Using BBT chart and Ovulation Predictor Kit while on Clomid

Question:

First, thank you for your time. It is awesome that you would offer your advice on line.

I am on Clomid 150mg. I show on my BBT chart that I ovulated on cd 17. My temps stayed above the coverline till 7 DPO and again today on 8 DPO it is still low. All of the research I find says that implantation dip is only a single day, but that my temp should drop of between 10-16 days to start menstruation.

Here is the link to the website where I get my BBT chart. http://www.fertilityfriend.com

Thank you for your time.

Answer:

Thank you for your question, I try to give as good advice that I can considering the limiting factors, which of course include not being able to talk to you at length and in person.

I would not analyze the temperature chart so closely. It is not that accurate. Many factors can influence the temperature. It is only useful to see if there is a rise in the mid-cycle, which is an indirect measurement of the LH surge, indicating ovulation is going to occur. If you are going to continue using the chart, use it only for that indication i.e. timing of intercourse, and nothing else.

Another option, which I think is more accurate but more expensive is the ovulation predictor kit or OPK. However, with this kit you also cannot evaluate the luteal phase. The only way to evaluate the luteal phase is to do an endometrial biopsy. You will need to begin infertility testing for that.

Follow-Up Question:

One more question. My cycles are very irregular I take progestrone to start before the clomid. When do you recommend taking the home pregnancy test?

Thank you for your time.

Follow-Up Answer:

You are going through a lot of effort that is not very efficient.

The way that I do Clomid cycles is I follow my patients using the Ultrasound starting from day # 10 of the Clomid cycle. This allows me to see if the patient is responding to the dose that I prescribed, count how many potential ovulatory follicles there are so that there are not too many, and to time when intercourse should occur. I also use HCG to trigger the ovulation. With this method, the cycle is done more efficiently. I then do a pregnancy test two weeks later. It is programmed. There is no guessing. If your doctor is not doing it this way, then you are probably not seeing the right person or specialist. This is the correct way.

If you don't have a choice, then you have to go by the calendar method which is based on your period. Cycle day # 1 is the day your period starts. Begin intercourse on cycle day # 13-17, once per day, only one ejaculation per day. Do a pregnancy test on cycle day # 28 and repeat on cycle day # 30. If it is positive, then have a blood pregnancy test done on those days.

I hope this helps. Good Luck!

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Tips On How To Boost Your Fertility & National Infertility Awareness Month

The month of October is National Infertility Awareness Month. Understandably, we appreciate the opportunity to educate the public regarding issues and current advances in this field. The American Society for Reproductive Medicine's annual meeting will be held in Atlanta October 18 - 21st. You can follow along on Twitter to see some of the issues that will be discussed by entering #ASRM09 on those days!

I would like to share some tips on how to improve your fertility. This issue affects some 7.3 million women and men in the United States, representing 15% of couples in their prime reproductive years.

AGE
I want to start with age, because it is one of the biggies. Women are born with 1-2 million eggs and by the age of 37 they have 25,000 left. How well you reproduce depends on an number of factors but one of the most important is the age factor. The quality of those eggs begins to deteriorate after 30, and more significantly after 35, due to poor egg quality. There is no way to change egg quality. Consider trying to start your family earlier rather than later. If that is not possible, staying on birth control pills might extend the viability of the eggs in a woman's ovaries by putting the ovaries at rest. Seek out help for infertility issues early instead of putting it off. If you are over 35 years old, make a well defined, aggressive treatment plan with a set time-line. Don't let your doctor reassure you that "everything is just fine and you just need to wait for it to happen." Basically I counsel my patients over 35, if no pregnancy after 6 months, see a fertility specialist for a complete and thorough evaluation (which should only take 1-2 months to complete), create a treatment plan in a set amount of time and move through that plan sequentially. For example, if you start with ovulation induction and intercourse, use that for 4-6 months, then move to IUI for 4 attempts only, then move to IVF. As time passes, your chances are only getting less, even with IVF.

HEALTH
The key ingredient here is good health and exercise in the years before trying to conceive. Exercising for at least 5 hours each week is recommended. Good habits start early, but it's never too late to start! Weight can also affect your ability to get pregnant, in some cases, and being too much above or below your ideal BMI (body mass index) can be detrimental. See the National Institute of Health's website to calculate your BMI: www.nhlbisupport.com/bmi/. Aim to be at an ideal BMI, however, don't postpone pregnancy for weight reduction if you are over 35.

DIET
A good diet prior to beginning your efforts to conceive is important as well. It makes sense to eat plenty of fruits and vegetables, but did you know that it's been found that milk products and yogurt are equally important? A Harvard Medical School study suggests that whole milk products, not skim, are responsible for protecting against ovulatory infertility. Another interesting finding has been that folic acid improves ovulation in women, and in men, sperm quality! It can be taken as a multi-vitamin and found in foods such as oranges. Eliminating trans fats in women who have diabetes seems to help as well. Moderate caffeine and alchohol intake is important as well. Again, ideal weight is beneficial. No matter what anyone says, there are no diets or foods that "enhance" fertility, but a healthy diet can help overall.

TIMED SEXUAL ACTIVITY
Many couples trying to conceive use over the counter ovulation kits. There are some things to keep in mind though. Most women ovulate 14 days before their next period. For example: If your cycles are 25 days, then you are most likely ovulating around cycle day #11. Your fertile period would then be CD# 9-13. Those are the days I would recommend intercourse. You should stop intercourse on CD#7 and wait until CD#9 to start. Have intercourse once per day on those five days, only one ejaculation per day. Start using your ovulation kit on CD #9 (counting back 16 days from the end of your average cycle). Remember, once the egg is released from the ovary, it’s only receptive to sperm and able to be fertilized for about 12 hours. If you have irregular cycles you may have another problem and you need to see a specialist to determine what is going on. But the absolute bottom line with timing is this, make it fun NOT scientific!! You husband will become a reluctant participant if it is forced. Don't tell him, "honey its my fertile time again we have to have sex", rather, he shouldn't even know. You should just set the stage to get him interested, excited and "horny." That way, you'll both enjoy the experience, and trying won't be a chore.

KICK THE SMOKING HABIT
Virtually all studies show that smoking impairs fertility. In women, 10 or more cigarettes a day reduces egg quality. Post-conception smoking has been linked to miscarriages and ectopic pregnancies. In men who smoke there is a problem of lower sperm counts and lower sperm motility as well, which means, lower sperm functionality. Even worst is smoking marijuana. Any chemical that goes into your body, goes into your blood stream, into your cells and into your sperm and/or eggs. This is an absolute no no! Same with other forms of recreational drugs including large amounts of alchohol. My rule of thumb is, if it affects your brain cells, then it affects your reproductive cells as well.

RELAX
Couples who are trying to conceive can become stressed, especially if they have been trying for more than a few years. Yoga, acupuncture, massage and meditation tapes expressly made for infertility patients all help. My patients are encouraged to use relaxation techniques. It helps them through the emotional ups and downs of the IVF process. The patients approach the procedure day in a much calmer, relaxed manner and it may make a difference in how well the retrieval and transfer goes. Going to see a therapist for massage therapy or meditation therapy may also be covered by insurance, if it can be shown that there is an anxiety disorder. As mentioned above, make it fun and enjoyable, not homework.

SCRUTINIZE YOUR DOCTOR

You want a doctor that knows fertility through and through. Most of these types of doctors will be able to offer ALL levels of infertility treatment. Just as you don't want a doctor that only does Clomid, your don't want a doctor that only does IVF. You'll be thrust into the only thing they can do for you, Clomid or IVF. It is easy to screen for this. . . just ask, "what levels and types of treatment can you perform for me?" Most importantly, infertility needs to be diagnosed and treated by a Physician specialist, not general practitioners, nurses, PA's or medical assistants.

IF ALL ELSE FAILS...
If your fertility journey is meeting too many roadblocks, then you may need to explore other options. Keep in mind, that if you fail to achieve pregnancy naturally, that is NOT the end of the road. I counsel my patients, "Nowadays, we can get almost anyone pregnant, it just depends on what I need to do to achieve the pregnancy". There are many reasons why a woman or man may be infertile and a visit to a good fertility specialist will certainly narrow down or actually pinpoint where the problem lies. Treatment often varies from person to person so don't expect to find the answer on a forum or in a chat room! Blocked fallopian tubes, high FSH levels, abnormal sperm count or low motility, all these and more account for infertility problems in many couples.

A diagnosis by a physician is necessary in order to effectively identify the best course of action for the couple trying to conceive. But, don't let your doctor just put you on Clomid without a good reason. Clomid is NOT a miracle drug. It has a specific purpose, which is to induce ovulation in women that don't ovulate. If you have regular cycles, that is a sign that you are ovulating. That means that the problem is something else and Clomid won't change that. Make sure that the treatment you are receiving is treating a specific problem. Ask you doctor to explain his/her strategy, why they are using the treatment they recommend and what they are treating. Treatment without a specific reason is a waste of time and money, as is treatment without the completion of a complete infertility evaluation. I can't tell you how many patients I have seen who have been on multiple cycles of Clomid or IUI's only to find out that her tubes are blocked!

Above all, stay positive, we are here to help!

Edward Ramirez, MD, FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF

Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf

TTC And Using Ovulation Kit

Here is a fairly common question that I get on the All Experts site having to do with ovulation kits...

Hi Doc,

I have a 25 day cycle and my period usually lasts 3 to 4 days. When do you think I would ovulate? When should I start testing with the ovulation kit?

Thanks in advance.

Hello,

Thank you for your question. Generally the second half of the cycle is the most constant. It is 14 days from the onset of menses. So, if your cycles are 25 days, then you are most likely ovulating around cycle day #11. Your fertile period would then be CD# 9-13. Those are the days I would recommend intercourse. You should stop intercourse on CD#7 and wait until CD#9 to start. Have intercourse once per day on those days, only one ejaculation per day. Start using your ovulation kit on CD #9 (counting back 16 days from the end of your average cycle).

Hope this helps and good luck!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center Monterey Bay IVF Program
Monterey, California, U.S.A.　

Check me out on Facebook http://www.facebook.com/home.php#/ejramirez1?ref=profile and Twitter with me at @montereybayivf.