Answers from our Experts

Folic Acid is a B vitamin that is used to generate new cells in the body. Research has shown that it helps to prevent fetal neural tube defects, such as spina bifida, when taken prior to, and during, pregnancy. The recommendation by the Center for Disease Control (the CDC) is to start taking 400 μg of folic acid at least 1 month prior to conception and continue it during the pregnancy. If a woman has had a child affected by a neural tube defect in the past, she should speak with her doctor about increasing the preconception dose.

Some foods are not recommended when attempting pregnancy because they can contain Listeria, a bacteria that can cause an infection that can be harmful to the baby. Any cheese product containing unpasteurized milk (such as brie or feta cheese) can be a vehicle for listeria, as can prepared salads that you might find in a supermarket. Also, raw foods (such as sushi, raw oysters or clams) can contain bacteria or parasites that are also harmful and should not be ingested. Women should also avoid fish that are high in mercury, like tuna and swordfish. Any raw fruits and vegetables should be thoroughly washed as well, and women should also wash hands frequently.

For early, uncomplicated pregnancy loss, some women were advised to wait 3 months. But, according to a growing body of evidence, there is no reason to delay attempting pregnancy again after having a loss. In fact, some studies have shown that the uterus might be more receptive to a pregnancy following an early loss. If the loss was due to an ectopic or molar pregnancy, or accompanied by other complications (like infection), then that might require longer follow-up prior to attempting to conceive again. Of note, though, ovulation can take days or weeks to resume after an early pregnancy loss.

Women with polycystic ovarian syndrome(PCOS) often do not ovulate regularly, and ovulation is necessary in order for fertilization and conception to occur. Fortunately, there are many medications that can induce ovulation, although a women's OB/GYN might refer her to a specialist to manage this.

Most clinicians advise that men with normal sperm count should increase the frequency of intercourse around the woman's fertile window (just prior to and at the time of ovulation) to increase the chance that fertilization takes place. Although an increase in intercourse can decrease the volume and total number of sperm, the level seems to remain high enough to fertilize the egg and the quality of the sperm might even be improved as opposed to longer intervals between sperm production.

The decision re: when to try for a subsequent pregnancy is a personal one based on the couple's age and desired family size. Medically the recommendation, according to the American College of Obstetricians and Gynecologists (ACOG) the optimal time between delivery and the next pregnancy is 18 months to 5 years. The greatest risk (for the subsequent pregnancy) occurs when this interval is < 6 months.

Routinely, early on during a menstrual cycle, a ‘wave’ of follicles starts to grow. One of them establishes itself as dominant and continues to grow, while the others get reabsorbed by the body. It is possible to ovulate twice per menstrual cycle, but this is usually the result of two eggs ovulating around the same time and, should both of them be fertilized, can be the reason for non-identical twinning. Ovulating during two phases of the menstrual cycle, though, is extremely rare

There is no optimal sexual position in terms of increasing chance of conception. The sexual position used should be one that provides the greatest comfort and enjoyment for both partners.

Women with mild endometriosis may conceive easily, although there is some data that their chances of conceiving without help might be slightly lower than women without endometriosis who are a similar age. Those with moderate or extensive endometriosis, which can affect much of the female reproductive tract, should be proactive in speaking with their doctor as soon as they know they desire to conceive.

Eating a balanced diet and maintaining a healthy weight are incredibly important prior to conception. Any additional nutritional needs can be met by taking a daily prenatal vitamin that contains the necessary vitamins and minerals. In addition, it's important to make sure that the prenatal vitamin contains DHA, which is an essential fatty acid that is critical for brain and neurological development. Babies depend on a maternal supply of DHA (since we do not produce it, and must get it from our foods or supplements). If the prenatal vitamin doesn't contain DHA, this should be added as a separate supplement to assure proper neurological health for the baby. Megavitamins, non-essential dietary supplements and herbal products should be discontinued prior to conception as their effects on the fetus have not been well studied.

We always recommend that our patients obtain their nutrients from food, whenever possible, instead of relying on supplements. Although some studies have shown that men's sperm parameters might be improved by supplementing with a combination of certain minerals and anti-oxidants, whether or not this improvement translates into increased pregnancy rates (which is the ultimate goal) is unclear in the literature at this point. What is known, though, is that lifestyle changes, such as maintaining a healthy weight, stopping smoking or any recreational drugs, and minimizing alcohol intake can improve the quality of sperm.

It is normal for cycle length to vary slightly as the amount of time it takes for a follicle (egg) to grow and mature can differ for women from cycle to cycle. If trying to conceive, though, it might be helpful to use a urinary ovulation predictor kit to help identify your fertile window.

When is Ovulation?

Conventionally, women were told that they ovulate on day 14 of a 28 day cycle. The challenge, though, is that cycle lengths vary and we don’t know the length of the current cycle for sure until the first day of the next cycle. Therefore, understanding when you ovulate can be complex and confusing. As a result, we recommend urinary ovulation tests to predict fertile windows as opposed to depending on cycle day alone.

Most women’s cycles are not “average”

The time that it takes for a follicle (fluid-filled cyst which holds an egg) to mature and ovulate can differ among women and even within the same woman. In an infertility setting, we would have to look by ultrasound over a number of days to predict ovulation, which can be time- consuming and expensive. The easiest, and most proactive, way for women to detect their own, individual fertile window is to use a urinary ovulation kit.

Get pregnant faster: use an ovulation test

It might seem fun, at first, being told to have intercourse for a number of days every month. But, over time, this can be a source of anxiety for a couple as one partner might not be available on a certain day or the couple starts to perceive sex as a chore as opposed to an enjoyable activity. Being able to narrow the window of fertile days, and reduce the number of days per month that a couple needs to have sex, in my experience, has helped reduce the level of stress that a couple might experience when attempts to conceive don’t occur right away.

How long does it take?

Female fertility varies among women and is impacted by age. The chance of pregnancy per month for a woman in her 30’s is about 20%. This number decreases with age to about 5% per month once she reaches her 40’s.
We know that age is not kind to ovaries regardless of how healthfully a woman eats or how often she exercises. Certainly, some lifestyle choices can hasten ovarian aging, like smoking, but often the quality of a women’s ovarian output (follicles/eggs) is not indicative of her general health. I discuss this paradox often with my patients who are perplexed when they are over 35, but trim and healthy, but are still experiencing the decline in conceiving each month inherent in that age group.
As discussed, the chance of conceiving per month gets lower as women age and declines rapidly after age 35. As a result, we advise women over 35 (who ovulate regularly) to try to conceive for only 6 months (as opposed to 1 year in women under 35) before seeking help from a Reproductive Endocrinologist (RE) specialist, (woman who don't ovulate regularly should not wait before seeing an specialist). Each month, then, is important so we often suggest that women be more pragmatic about their approach, focusing on timing intercourse the few days prior to ovulation, best predicted by urinary ovulation kits as the day of ovulation can fluctuate. We recommend the Clearblue Advanced Fertility Monitor to our patients as it is accurate and reliable and takes the guesswork out of when to try.

Stress and stressful situations may have a temporary effect on reproductive hormones, resulting in a lack of ovulation. This can be seen most commonly in acutely stressful situations, elite female athletes, women with severely low weight, and eating disorders. The alterations in ovulation can inhibit predictable attempts at pregnancy. However, as these stressors resolve, ovulation should return and fertility is no longer impacted.

The normal menstrual cycle range is usually from 21 - 35 days. Cycles shorter or longer than that can be associated with fertility
issues due to delayed or lack of ovulation, especially if the periods are not predictable. Over the course of a woman's reproductive life span, her typical cycle lengths should fall within this range. If your cycles are usually less than 21 days or longer than 35 days, you should see your physician for further evaluation.

The inability to get pregnant after a successful birth is called secondary infertility.  A number of acquired factors can impede your ability to get pregnant. The most common causes are a women's increasing age and changes in sperm production. If you had a child in the past and you are now over the age of 35 years, your ability to get pregnant may have decreased. This could be due to changes in ovulation, changes in the uterine or fallopian tube structures, and the genetic quality of the eggs being released. Also, as your male partner ages or acquires new medical diagnoses, he may have a sperm abnormality that has caused a decrease in his sperm count, motility or shape. If you are experiencing secondary infertility, you should speak with your healthcare provider to initiate a fertility evaluation.

Typically, a pregnancy termination will not affect your ability to get pregnant in the future. On rare occasions, you may develop adhesions or scar tissue in the uterus that can cause issues with future fertility. If you are having normal monthly cycles, the chances of these adhesions affecting your fertility are low. Seeing your fertility specialist or gynaecologist will be helpful in making sure your uterus has not been affected, especially in the setting of infertility for greater than 6 months (if > 35 years old) or 1 year (if < 35 years old). If your menstrual flow has lighten significantly after a surgical procedure of the uterus, seeking help from your health care provider is recommended

Women are born with all the oocytes (eggs) that they will have for their lifetime – this is your “ovarian reserve.” As women age, this ovarian reserve slowly decreases as oocytes are recruited and used during the menstrual cycle.

Once the ovarian reserve has been depleted, menopause will occur. There are two common ways of measuring the ovarian reserve: first with an ultrasound and second with blood testing, measuring you Anti-Mullerian Hormone (AMH) and/or your Follicle Stimulating Hormone (FSH).

The ultrasound should be performed between cycle day 2-5 and will count the number of resting follicles (cysts containing oocytes) within the ovary.

The Anti-Mullerian hormone (AMH) is a hormone created by the resting oocytes within the ovary. AMH levels can be drawn at any time during a menstrual cycle. The levels can be affected by current or recent long term birth control use. Fertility specialists use the AMH by comparing it to known “average levels” based on a woman’s age. The higher the AMH, the greater the number of oocytes present. The AMH level is helpful when determining medication doses during fertility treatments but is NOT correlated with a person’s ability to become pregnant.

Finally, FSH can be drawn in conjunction with Estradiol on cycle day 2-4 to measure ovarian reserve. Elevations in FSH when the ovary is at rest (low Estradiol levels) indicate that the brain is working harder than normal to force the ovary to start producing an egg.

Together, these two tests can be used to determine waning ovarian function, indirectly indicating a lower ovarian reserve.

More detailed information on ovarian reserve testing can be found at www.reproductivefacts.org

In 2012, the American Society for Reproductive Medicine stated that egg (oocyte) freezing is no longer considered experimental. Because of this, fertility centres can now freeze eggs for women who may want to use them in the future. Patients who are considering this option can either freeze eggs alone or freeze a combination of eggs and embryos (fertilized eggs) using donor sperm. As of now, the thawing of eggs and subsequent fertilization varies between fertility centres. However, newer data has shown that this can be a great alternative for women wanting to preserve their fertility for the future. The ideal age has not been established, however, freezing eggs between 30-35 years old provide the best chances of future success.

Women sometimes don't ovulate every month for a number of reasons. If you have menstrual cycles that occur predictably every 21 to 35 days and you have symptoms of breast tenderness, bloating, pelvic or uterine cramping, or mood changes prior to your menstrual cycle, you probably are ovulating. However, if your cycles are usually over 35 days or unpredictable, you may not be ovulating consistently or not at all. The most common reason for women not ovulating (outside of pregnancy) is Polycystic Ovary Syndrome (PCOS). PCOS is a condition that you are born with that causes hormone imbalances that prevent ovulation on a regular and consistent basis. Other conditions causing a lack of ovulation include low thyroid function (hypothyroidism), high prolactin production
(hyperprolactinemia), and perimenopause. If you feel that you are not ovulating consistently, you should see your health care provider.