“Despite of following my ovulation calendar I am not pregnant. Why?”

Give it a year

You may benefit from visiting your local Ob/Gyn for through history and examination.

Stay safe,

Dr. Chaudhury

Check other factors like male factor and tubal patency

For each month, fertility rates are about 18%. So there is an 18% chance of getting pregnant each month. On average, it takes 6-8 months to conceive.
Don't lose faith! I would recommend seeing a physician after 6-8 months for follow-up if pregnancy doesn't ensue

There are several possible answers including: are you ovulating? Having periods does not always equal ovulation. 2. Are your tubes obstructed secondary to a STI, such as chlamydia? 3. Does your partner have adequate sperm?

Chances of pregnancy range from ten to fifteen per cycles of unprotected sex. Try a few more months and if still not pregnant, see your doctor for further evaluation.

Many patients will be instructed to follow a basal body temperature chart but may not be told how to interpret the graph. Make certain that you mark day 1 as the first day of your cycle, mark each and every day’s temperature, taking at the same time of day each day, including weekends. The most important thing to know is that if you have an ovulatory cycle, you will have approx. 0.8 degree Fahrenheit increase in temp approx. d14 or halfway through the graph or menstrual cycle and keeping that higher average temperature until your next period at approx. d28. This biphasic temperature graph indicates ovulation; less than 0.8 degree increase from d14-28 of cycle may not actually be enough of a temp increase and may actually indicate low Progesterone. A graph that shows no real increase in temp indicates no ovulation is occurring or no Progesterone production; this needs to be investigated by your doctor. I always recommend patients have their day 3 Estradiol level drawn; if <150 on blood test, then you are not making enough Estradiol to support a healthy lining or healthy stimulation of an ovarian follicle and you will likely not ovulate so it won’t be useful to even try to conceive that cycle. I also then recommend patients have d21 Estradiol + Progesterone drawn. If Progesterone (P4) is less than 20, then supplemental P4 is recommended in your next cycle, taking every night from d15-28 of your cycle (or your period) as you may actually be unable to maintain a pregnancy if the P4 is too low. This situation is called a ‘chemical pregnancy’ as you never really know that you conceived because the lining in the uterus is not strong enough to hold a healthy pregnancy; only a blood quantitative HCG or blood pregnancy test would be able to answer this question.

If you are not showing an 0.8 degree increase in your temp or if your temperature never rises at all, then you are not ovulating; this can occur for up to 3 to 6months coming off of birth control pills and can occur for up to 12months coming off of the Depo Provera shot.

Approx 10-15% of patients may actually make a higher Testosterone amount than they should (average is a Free Testosterone value of >15th% of the female range). If you make higher Free Testosterone than 10-15%, you may actually not ovulate due to a condition called Polycystic Ovarian Syndrome or PCO disease. The PCO syndrome can have associated symptoms like facial acne, abnormal weight gain, male pattern hair loss to upper forehead or even top of crown of head and/or excess hair to upper lip/sideburns chin; some patients will even be shaving this excess hair. However, you may have PCO disease vs syndrome and may have elevated Free Testosterone levels but not enough to have the other symptoms mentioned above so you go undiagnosed by your doctor. Medicine will not diagnose a patient with infertility until you have tried for 12months and are still not pregnant. However, more and more patients are waiting longer to start their family and do not have the luxury of waiting an entire year to then find out there is a medical issue that needs to be addressed. In addition, once you are labeled with ‘infertility’, you may not have certain tests covered by your insurance because you may require a prior authorization; this means that your insurance company is already thinking you may cost them a lot of money for a work-up and they want to keep tabs on all aspects of the medical work-up and they may approve some testing but not other testing, making those unapproved tests an out of pocket cost to you. I always recommend knowing as much about your cycles and your hormone levels before you even think about trying, you are then being proactive and can work with more simple bio-identical hormone replacement if your levels return low or imbalanced before you feel rushed for time or face testing that you may suddenly have to pay for and may not have budgeted for.

Once you have appropriate hormone levels and whether or not you need additional Progesterone or not, you may still require fertility medication to help you ovulate; this medication is called Clomid and can usually be prescribed at low to medium dose by your GYN but must be carefully followed to be certain that you do not have ovarian hyperstimulation. Hyperstimulation may cause more than one follicle to ovulate; if 2 ovulate, you may experience twins, or if 3 ovulate, you may experience triplets; this sounds exciting but places you in a high risk pregnancy situation which a high risk of premature labor or even hypertension or toxemia with pregnancy which can put both you and your babies at risk and almost always results in early hospitalization with time off work and additional costs that again you may not have budgeted for. Clomid should always be under the supervision of an experienced GYN as a very small percentage of patients may even have abdominal ascities or extra abdominal fluid that can cause respiratory and GI issues. As well, Clomid may not be enough to stimulate ovulation; these patients then may require more intensive infertility work-up or in-vitro fertilization which is rarely covered by insurance and entails surgery to harvest eggs and surgery to put sperm and eggs or fertilized embryos into your uterus. Lastly, your male partner may also need a semen analysis to make certain he is ‘shooting good swimmers’ as he may have a low sperm count or a high percentage of abnormal looking sperm; this also needs further medical evaluation or work-up with a Urologist.

There are other reasons why you may not be getting pregnant:

1. Your partner’s sperm count may be low.
2. Your tubes may be blocked.
3. There may be other hormonal issues causing a lack of pregnancy.

I suggest you consult with your gynecologist as to the next step in your process.

Sincerely,

Andy Toledo, MD

Dear Asker,

How long is your cycle and which days in your cycle did you have sex? Also, has your partner had a sperm lab test? If so, what was the result?

Dr. Wing

Hello,

This is a great question. I manage a lot of couples that are trying to conceive and often the best thing is to be patient. We do not consider a couple infertile unless they have been attempting conception for 12 (yes, twelve) consecutive months. Using an ovulation calendar is a great idea, there are even multiple phone apps to help. The most important thing to know is what each day number means:

Day One: the day you start your menses, whether you menstruate for 3 day or 5 or 8, it does not matter. The first day is marked as Day 1 on your calendar. Most women will ovulate 14 days later. This makes day 14 very important as well. I counsel couples that some women may ovulate a bit sooner or a bit later than day 14 and I recommend unprotected intercourse on days 14, 16 and 18. Sperm is viable for 72 hours, so this gives you a total of 7 days in which viable sperm can reach the egg.

There are also ovulation kits available at any pharmacy which measure the LH (leutinizing hormone) in your blood and help predict when you are ovulating. If after 12 consecutive months, you are not pregnant, please consider discussing with your physician. Good luck and make sure you have already started a prenatal vitamin.

Sincerely,

Richard T. Burke, MD

Has your partner ever fathered a child? Are you checking for ovulation with a urine predictor kit? The apps on the phone do not always work. An app on a phone could not detect if you are ovulating or not. Get an ovulation predictor kit and start checking daily with the urine test starting with day 10 of your cycle (Day 1 is the first day of your period). Maximize intercourse when you get a positive. See a provider if you are not pregnant within 6 months to 1 year.

You may just need more time. If a year has passed and you still have not conceived, you should have a preliminary fertility evaluation. If there are other factors such as irregular cycles, or age over 35, prolonged infertility, history of tubal surgery, or male factor issues, then an earlier evaluation is advisable. Ovulation kits can be helpful for timing intercourse. Avoid using regular lubricants because some are toxic to sperm.

That is a question that can have many answers. Your gynecologist can discuss them with you and may refer you to a reproductive endocrinologist (a gynecologist specializing in infertility). Some possibilities include endometriosis, pelvic infections, blocked fallopian tubes, the male factors low sperm count, low motility and a varicocoel. The most important factor is stress, so patience with the process is important. 80% of women will conceive within 1 year assuming they have intercourse 2-3 times per week. Having sex more than that usually results in depletion of the males sperm count and can actually prolong the process. If you have none of the female issues and have discussed it with your GYN, then relax and enjoy the process. If you have any of those issues then He/She can begin to address them.