Yep. I've jumped on the bandwagon and am shamelessly using a right-royal-knicker-fuss to teach a good fertility lesson. Kate Middleton, along with millions of you, clearly likes to rule out the possibility of a VPL by wearing the skimpiest of - I hesitate to even call them knickers -underwear. Which is all well and good, but ...you knew there was a but coming (no pun intended). Women are often really surprised when I tell them that thongs are not really the best for their fertility. As well as making it harder for you to get rid of urinary and vaginal infections, they can transmit bugs and bacteria from your backside to your nethers which can disrupt the delicate balance in the vaginal area and have a detrimental effect on your cervical fluid. Which as we know is essential for conception. Here's a good Huffington post article about it. So what I tell my clients is go for granny knickers or no knickers! And Kate should get her Bridget Jones's out if she wants a spare after her heir.
I spent last Saturday at the second annual Scottish Information Day organised by the Infertility Network - it was a great opportunity for couples dealing with fertility problems to come to one venue and meet lots of people who may be able to help, to hear about treatment advances and how other patients who have trodden the path before them have coped.
In the morning a fertility consultant and IVF expert gave a run-down of what couples could expect from their first appointment at a fertility clinic - the various investigations on offer and how their treatment might progress from there. So far so good. Towards the end of his presentation he put up a slide about what people could do to help themselves, which was, after all, why they were here. (In Scotland we're still catching up with London in terms of 'coming out' as far as infertility is concerned and this was by no means The Fertility Show - thank goodness, some might say!) Anyway his slide said: stop smoking, cut back on alcohol, get your BMI into a healthy range. But it said nothing about food and nutrition and the final bullet point was "no need to take vitamins or supplements", with the consultant dismissing the notion, saying "there's no evidence that they will help you" and then swiftly moving on.
In the afternoon, however, Dr Marilyn Glenville, a famous and very well respected nutritionist who has years of experience dealing with infertility, stood up and gave a convincing and comprehensive talk about the importance of nutrition, pointing out where she thought supplementation was warranted and presenting a plethora of research evidence. So why the mismatch? The case for Vitamin D supplementation alone can hardly be disputed and I heard Prof Iwan Lewis-Jones stand up at The Fertility Show at least three years ago and say that the first thing he does with a man who has poor sperm parameters is put him on Vitamin C & E supplements. Because there is good evidence that they help! Indeed there was also an excellent presentation on Saturday from Prof Sheena Lewis about her research on DNA fragmentation in sperm - she concluded by saying she is trying to get government funding to pay for research into the food / vitamins / antioxidants link. Because that's the next obvious step.
So, of course I couldn't keep quiet and stuck my hand up at the question panel at the end to ask what on earth patients are supposed to think? Their doctor tells them one thing and we tell them another - time and again couples from all over the UK tell me that when they asked the consultant what they could do to help improve things they are told "nothing". In answering me, Glenville pointed to the fact that whilst there is plenty of research evidence, (e.g. the 2013 Cochrane review on anti-oxidants and male subfertility) not much of it is of the gold standard randomised controlled trial variety. And why not? Because Big Pharma pays for a lot of that research and food and vitamins cannot be patented.
Unfortunately the doctor who had given the morning presentation had had to leave before the final question panel. Another IVF doctor present, Dr Marco Gaudoin, said that doctors are taught, based on Hippocrates' teachings, "first do no harm" - he went on to say that a lack of evidence is not the same as a lack of benefit, just a lack of evidence for that benefit so far. So he tells his patients to go ahead if they feel it will help.
But, Doctors, why not go a step further? You need to keep up with some of this basic 'boring' stuff as well as the sexy IVF stuff. It wouldn't do any of you any harm to read Glenville's book, Getting Pregnant Faster - you'll have it done and dusted in a weekend I promise. And if a patient asks you what can they do to help themselves, instead of saying "nothing", why not say "well, the gold standard research isn't there yet but some studies have shown x, y or z and you could read more about it if you're interested". Or, and here's a radical thought, "I don't know - some researchers think this and some researchers think that". And remember, that as well as saying "first ,do no harm", Hippocrates also said "let food be thy medicine".
I'd love to ban the term chemical pregnancy. So many women misunderstand what it means and if I had £1 for every time someone's asked me to explain it I'd be very well off.
A chemical pregnancy is a proper conception and a proper pregnancy - just one that sadly ends in a very early miscarriage. It's not a false pregnancy or a false positive on a pregnancy test. And contrary to what you will read on some websites it doesn't mean that implantation did not take place. Implantation did take place because it is only after implantation that the pregnancy hormone HCG starts to be produced. It's a term that's there to distinguish between a pregnancy that has only been confirmed with a pregnancy test and one where a gestational sac or heartbeat has been seen on a scan - then doctors use the term clinical pregnancy.
Many women have asked me whether they were actually pregnant after being given the diagnosis "chemical pregnancy" and others only mention it as an afterthought when giving their history in appointments. There are important differences between a couple who have never conceived and one who have had several chemical pregnancies and we will plan their care in different ways so it's important to know.
Women tell me that they are often made to feel by medical and nursing staff that these very early losses are trivial mishaps and lesser somehow than miscarriages that happen at a later stage. There's a distinct whiff of impatience, even from staff in early pregnancy units - "well, a quarter of pregnancies will end this way so you just need to pull yourself together and get on with it" or "if you hadn't tested for pregnancy so early you'd probably never have known". We are where we are with super-sensitive pregnancy tests - we can't wind the clock back and get rid of them despite the fact that they may be responsible for making us consume more NHS resources or "upsetting ourselves" with knowledge we wouldn't have had 20 years ago.
And the thing is, for the woman who has only been trying to get pregnant for a few months a chemical pregnancy is bad enough. But for someone who has been trying to get pregnant for two years, who has seen the unwelcome streak of red, with her stomach swooping with crushing disappointment month after month after month, or who has been through the battlefied of infertility investigations and IVF treatment, then a chemical pregnancy is utterly devastating.
The Mumsnet campaign for better miscarriage care highlights the profound upset caused by "the 'official' language of miscarriage, which failed to distinguish between a miscarriage and a termination, or to acknowledge the loss of a baby with whom they already felt a profound emotional connection. Some felt that they were grieving for a whole set of hopes and plans for the future, but that the emotional impact of miscarriage was pushed to one side."
Maybe it's time to call time on 'chemical pregnancies' and refer only to early miscarriages instead.
Every week I meet new patients in my clinic who are trying to conceive and run through a detailed assessment with them. And every week I am surprised by the number of women who don't know of the risks of ibuprofen (and other non-steroidal anti inflammatory drugs or NSAIDS) while trying to conceive and during pregnancy.
The vast majority of them have not been asked whether they are taking these drugs and have not been told either by their GP or by staff in fertility clinics that they should not be using them for backache, headaches, menstrual cramps or indeed any aches and pains.
I have noticed when talking to people about painkillers how ibuprofen seems to be by far the most popular choice - probably this is down to packaging, advertising and marketing, with the leading brand, Nurofen, having a far sexier image than boring old paracetamol. There are exceptions but usually people say they just reach for whatever's in the cupboard rather than maintaining that ibuprofen actually works better.
The studies on NSAIDs and infertility suggest that they may impair ovulation (by leading to greater incidence of luteinizing unruptured follicle syndrome - where the egg is not successfully released from the follicle) and interfere with the implantation process. In addition, other studies suggest that their use in early pregnancy leads to double the risk of miscarriage. As far as infertility goes the majority of studies do relate to women who have been using NSAIDS long term (sometimes for conditions like rheumatoid arthritis) but even so it would seem wise to avoid them. This is all the more important since you can find stories all over the internet about women who have successfully become pregnant after starting to take aspirin - if you've been trying for a while it's easy to think that anything's worth a shot and anyway what harm is a little aspirin going to do? Aspirin or other blood thinning drugs can be very helpful for some women who have been diagnosed with blood clotting issues and are usually used in conjunction with steroids, however, this should only be done after the appropriate blood tests and under the supervision of a consultant.
Couples could be forgiven for not knowing which way to turn when it comes to the debate around the controversial new field of reproductive immunology - in other words can you be 'allergic' to pregnancy as it were, causing your body to reject an embryo? On the one hand a range of new tests and treatments are offered by elite fertility clinics with seemingly high success rates and on the other experts such as Prof Robert Winston and Prof Lesley Regan are sceptical to say the least, saying that the treatments are based on poor science.
It's important to remember that scientific progress is often a bumpy road and change can be glacial. Profs Barry Marshall & Robin Warren discovered the link between stomach ulcers and a specific bacteria in the late 1980's but were shouted down by scientist colleagues around the world who clung to the long held view that ulcers were caused by stress - it took ten years for their discovery to begin to change the way ulcers were treated and another ten years before Marshall was awarded the Nobel Prize for Medicine.
Dr David Servan-Schreiber, writer of the amazing book Anti-Cancer, makes points that are just as relevant in the ever changing field of fertility. He says that physicians are constantly looking for scientific advances, they go to conferences, read journals and meet drug company representatives to find out the latest new advances that are on the market. "They feel they are aware of everything going on in their field and generally they are. But in medical culture, changes in recommendations given to patients are allowable in one case and one case alone: when there has been a series of 'double blind' studies demonstrating the effectiveness of a treatment in humans. This is called, legitimately, 'evidence based medicine'." However, he goes on to point out that experts often don't agree amongst themselves, especially during the research phase in a particular area. In addition he says that one of a physician's "greatest worries is not to give false hopes. We have all learned that nothing is more painful for a patient than the feeling of having been betrayed by ill-considered promises." Because of all these legitimate concerns, he says, "my colleagues are sometimes tempted to refuse out of hand all approaches outside the confines of existing conventional practices."
When I first went to The Fertility Show in London five years ago, women who raised their hands to ask whether natural killer cells could be playing a part in their infertility were swiftly dismissed by the expert speakers and advised not to spend too much time looking up outlandish theories on the internet. Two years later and the immunology proponents were sharing a platform with the naysayers and speaking to packed out seminars. At the Natural Fertility Centre, we are open to the idea that immunology may play a part, and patients of ours have been successful after consulting doctors like Dr Mohamed Taranissi and Dr Amin Gorgy in London. We also have a great deal of respect for Jill Blakeway who runs the very successful Yin Ova Centre in New York - Blakeway says she has "been in practice for many years. Long enough to notice trends, and one of the things that I have noticed is a rise in autoimmune problems (allergies, lupus, Crohn’s disease, rheumatoid arthritis, chronic fatigue and some kinds of thyroid disorders). What concerns me about this rise in immune system dysfunction is the effect it has on fertility. Endometriosis, recurrent miscarriage and failed IVF are common problems for women who have autoimmune issues and in our book Making Babies: A Proven 3-Month Program for Maximum Fertility Dr. David and I talked about how we thought immunity issues were the third most commonly overlooked cause of infertility, after endometriosis and infections..."
"... Chinese medicine, when applied correctly can be very helpful in treating a misbehaving immune system... You may think that the best way to handle an immune issue is to boost the immune system. That’s what a practitioner would do if you caught colds all the time or had some other sign of immune deficiency. But simply making the immune system stronger when it’s already hyperactive, is a mistake. What we really aim to do is to bring your immune system back into balance, not turbocharge it. This is a job for an experienced herbalist, who has the skills to adapt a herbal formula as your internal landscape shifts. "
The HFEA has put together a helpful page about Reproductive Immunology. I would endorse their suggested list of questions to discuss with your doctor before embarking on a course of immunology treatment:
- Why do you think I need this treatment - can you explain what you think is happening in my body?
- What data or evidence do you have to prove that this treatment will improve my chance of having a baby?
- What will the treatment involve for me?
- How much difference do you think having this treatment will make for me?
- What are the side effects and risks of the treatment?
- How much will the tests and treatment cost me?
In the Edinburgh support group I run on behalf of Infertility Network UK, sooner or later we end up talking about how friends and family handle the whole infertility conversation. It's a very tricky thing to get right. Some people are quietly hoping you will ask about the progress of their latest IVF cycle because it's the elephant in the room and others just want to get on with it in peace without having to handle other people's reactions and emotions. One woman I was talking to recently had found out at the age of 29 that she had already had the menopause - no eggs left, none - and after she broke the news, clearly devastated, to her parents, they didn't mention it once again in the next 6 months! It sounds like an extreme example but that sort of thing is not uncommon.
The marvellous Brene Brown talks about empathy in this great little video and the nub of it is when she says, "one of the things we do sometimes in the face of difficult conversations is we try to make things better ... and the truth is rarely can a response make something better":
On the whole I'd say that most will appreciate it if you can properly empathise. It's a bit like the first conversation you have when you see a friend who's been recently bereaved - you know that nothing you say can alleviate her loss but you acknowledge her pain. Jessica Hepburn puts it very well in her new book The Pursuit of Motherhood:
In The Pursuit of Motherhood, Jessica Hepburn has written a really important book about infertility and modern fertility treatment in the UK. It's her compelling story of the heartache of being unable to get pregnant with the devastating 'non-diagnosis' of unexplained infertility and what it's like to undergo multiple rounds of IVF. Not for the fainthearted, it's brutally honest at times and the effects on her physical and mental health, her relationship and her bank balance are all laid bare. Having said all that it's an amazingly easy book to read which is testament to how well it's written - it's a real page turner and I found myself staying awake till the wee small hours to finish it in just over 24 hours. It will be fascinating for anyone who has struggled with infertility themselves and indeed should be compulsory reading for all fertility clinicians. I thoroughly recommend it.
The snail trail, fanny snot, the slippery wipe - call it what you like, if you're finding it trickier than you hoped to get pregnant, getting to grips (literally) with your cervical fluid is going to be really important. Toni Weschler, writer of Taking Charge of Your Fertility and the ultimate fertility awareness guru, tells a funny story in her book about being invited onto an American radio show to discuss her work. When the producer heard she wanted to talk about 'cervical mucus' he turned up his nose - she had to change her phraeseology to 'cervical fluid' before she passed the yuck test and was allowed on! I've lost count of the number of women in my clinic who turn and apologise to their man when we start to discuss their menstrual cycles in detail, "Sorry darling, this is all a bit too much gruesome detail, isn't it?" One woman even asked her husband to leave the room !
So yes, it's a bit yucky. But come on girls, if you can deal with your own snot and your periods, and you're planning to deal with all manner of messiness a baby can produce, there's really no need to be squeamish about cervical fluid. And knowing what's what in that department can be the difference between getting pregnant and not.
Fertile cervical fluid gets produced by cells near your cervix in response to hormonal changes shortly before ovulation. Its job is to help keep sperm alive and to help to transport it safely to the egg. Sperm is quite delicate and would be dead within a very short space of time if there wasn't fertile cervical fluid to keep it going. The idea is that you have plenty of sex when you are producing fertile cervical fluid (an article on timing sex to follow soon) - the sperm can then make it into your fallopian tubes and hang out there, bathed in the juicy cervical fluid, so that they are ready and waiting to fertilise the egg when it pops into the tube.
The type of cervical discharge you produce changes throughout your cycle. There is no better description of what to look out for than in Weschler's book and I do one to one sessions at The Natural Fertility Centre or via Skype if you want to be taught individually. It's not complicated and is very important for pinpointing your most fertile days in each cycle without the need for peeing on expensive ovulation predictor kit sticks and works even if your cycle is irregular. The most fertile cervical fluid is the stuff that looks like raw egg white, sometimes clear, sometimes a bit more streaky - (there are some amazing photos at www.beautifulcervix.com - see in particular Day 19 as this woman has a longer than usual cycle). The key characteristic of fertile cervical fluid (or egg white cervical mucus, often abbreviated to EWCM) is it's stretch. It will stretch for several cms between finger and thumb without snapping. When you see that it's time to get busy.
Hopefully you will notice several days of EWCM in each cycle but sometimes it's in short supply and as we get into our late thirties and early forties the quantity can certainly decline. When that happens paying close attention to what little you have will be key and a top tip is to look out for it especially when you have just opened your bowels. The 'bearing down' action during a poo helps to push EWCM out and sometimes women are surprised when I explain to them that it's EWCM and not something that's appeared from their bottom!
If you do find that you are not producing much EWCM there's a load of anecodotal evidence out there about things that can help. The #1 most important thing is to make sure you're getting enough fluids (and no, Diet Coke doesn't count.) EWCM is 98% water and if you're dehydrated that won't help. Other than that women who have consulted me have tried green tea, unsweetened grapefruit juice and guafenesin (the active ingredient in some chesty cough syrups) with some success and in the clinic we also find that acupuncture and Chinese herbs seem to help. You can also try some of the fertility friendly lubricants such as Pre-Seed and Zestica but if you have no EWCM at all it can be tricky to know when to use them - give me a call and I'll help!
Couples often ask me how often they should have sex and whether they should abstain from sex before the fertile time of the month to save up his little swimmers - no! When I was doing my fertility training I was told a story with great imagery that neatly illustrates why storing up sperm is a bad idea and I now tell it to all my clients.
Imagine a London underground train racing along the Picadilly Line in rush-hour. Imagine that all the passengers are sperm and that ejaculation is represented by the train stopping at a station and people getting off the train. If you don't ejaculate regularly you're not letting people off the train. But your testicles keep on manufacturing new sperm all the time. So it's like every time the train gets to a station no-one gets off ... but more passengers get on. And on to the next stop and the same thing happens again and the train gets more and more full and soon all the seats fill up. And it gets really hot and stuffy and before you know it there's standing room only and everyone's tired, feeling ill and jammed right up into the armpit of their neighbour. Next thing it gets so crowded people are puking and fainting and generally having hysterics and then people start to die! When the train gets to the end of the line certainly no-one is in a fit state to climb the stairs and get out through the ticket barriers and go home. It's exactly the same for your sperm - if you store it up, it's in no fit state to rush up the stairs at the end of the line and fertilise the egg! Men who haven't ejaculated in a while produce sperm that is generally of a lower quality. It's very common amongst couples who are trying to conceive to bonk like mad in the middle of the cycle and then collapse in a heap during the two week wait. Then her period comes and that's another week - if you're not careful 3 weeks have gone by before the next fertile phase comes around and if you haven't ejaculated in that space of time those swimmers are going to be good for nothing much.
So, let passengers off the train regularly, boys! It's a good idea to ejaculate (which doesn't necessarily mean having sex - just a thought...) at least every 3 days and according to leading UK andrologist, Dr Allan Pacey, more often that that is fine too. Don't listen when your partner tells you not to masturbate because she read something on the internet saying it's not good for getting pregnant - the reverse is true. For once a fertility top tip that isn't a chore.
I found myself well and truly irritated when I read this piece, Don't Believe Myths About Infertility, in The Irish Independent last week. In it a nameless journalist interviews Declan Keane, an embryologist who has recently opened up a new fertility clinic in Dublin. Splice together some of Keane's remarks with a quick rundown of the most common "myths" out there on the internet, which must have taken all of half an hour to "research", and hey presto you have a nice, bossy little piece on infertilty to jazz up a slow news day.
The fact is that there is evidence to show that tight underwear and lots of cycling can adversely affect sperm quality, there is evidence to show that caffeine can have an impact on the fertility of both men and women and I would suggest that if couples are not "having intercourse when ovulating" they're going to wait rather a long time to see those two little blue lines. Of course research studies can vary and sometimes be downright contradictory. If your semen analysis shows there's room for improvement it would be wise to avoid tight pants and cycling for two hours a day; if not you probably don't need to worry quite so much. The point is that trying to be too black and white about it does no good - things will vary from couple to couple. There is so much that we don't yet know about infertility - an honest "I don't know" and an explanation of all the possibilities still being researched would go a long way in the consulting room.
The article finishes up with:
Dr Keane added: "Dr Google and chat rooms are the main source of these myths and should be avoided. People these days are too quick to self-diagnose, which can prolong the process if they are not seeking the right advice."
The fact of the matter is, however much some doctors don't like it, that Dr Google is here to stay. Finding out more about their infertility online helps women to feel empowered and more in control of a situation in which they otherwise feel utterly helpless. Internet chat rooms where they can talk to other women in the same situation provide invaluable support when talking openly about infertility is still taboo for many people. More time to talk about their individual circumstances and have all their many questions answered in a warm and friendly way is what couples need, not lazily researched articles in the paper and patronising put-downs from doctors who wish it was still the 1950s.
Since 2006 I have helped hundreds of women get pregnant. This blog shares some of the knowledge I have gained about fertility and getting pregnant working in private practice at The Natural Fertility Centre in Edinburgh, UK