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Ask a doctor: why aren’t I pregnant yet?

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The exciting time has arrived – you’ve decided to have a baby!

You’ve thought about this for a long time, debated when to officially start “trying” and perhaps waited for a time when finances improved or you completed a certain course/job/commitment. Then finally all the planets align, you give yourselves the green light, a-a-a-a-a-a-a-a-and… nothing. Nada. Zip. No pretty little “+” on the pee-stick, no morning sickness or sore boobs – nothing!

Your period comes regularly each month in rude defiance of your reproductive intentions. Or perhaps you’ve gone off the pill and now have irregular periods, or none at all – what’s up with that? Well dear reader, let me help you work your way through this puzzle.

BEFORE YOU START

  • Are you in a same-sex relationship, or single? I suggest you seek the advice of a fertility specialist early to discuss your options for pregnancy; you will need a referral from your GP.
  • Do you need any immunisations? If you’re not immune to rubella (German Measles) or varicella (chicken pox) it is very important to have those vaccinations before you fall pregnant, and then avoid pregnancy for one month afterwards. Don’t assume that if you were vaccinated as a kid you must be immune – immunity wanes over time. Your GP can arrange some tests to determine whether vaccinations are needed, and perhaps other tests like infection or diabetes screening.
  • Does your health insurance cover pregnancy? Many private health policies have a 12-month wait period before covering your baby’s delivery.
  • Have you done your homework about what happens AFTER you get pregnant? Find out about the different options in Canberra for pregnancy (antenatal) care, what tests you’ll need during the pregnancy, and if you plan to use a private Obstetrician you may like to check them out in advance and see what your out-of-pocket costs will be.

WHAT SHOULD I BE DOING?

Firstly, let’s make sure you and your partner are well-informed and in tip-top condition to fall pregnant.

HAVE YOU SEEN YOUR GP FOR A HEALTH CHECK RECENTLY? 

Make sure you discuss things like diet & exercise, weight, alcohol and other drugs, medications, medical history and family history, particularly a history of any genetic disorder that may impact on your pregnancy or future-baby such as spina bifida, cystic fibrosis (CF) or thalassemia.

ARE YOU TAKING THE CORRECT SUPPLEMENTS?

For example, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommends taking folate for at least a month pre-pregnancy and during the first trimester to help prevent neural tube defects like spina bifida. For more information about what you should be taking check out their pre-pregnancy counselling guidelines.

ARE YOU ‘DOING’ IT RIGHT? 

The optimal timing of intercourse for conception is about every second day during the six days leading up to ovulation. Once you’ve ovulated you very quickly develop a thick dry cervical mucus that prevents any further sperm from passing through, so ideally they need to get in there ahead of time.

If you have a regular cycle you can check when you’re ovulating by subtracting 14 from your cycle length, ie. If you have a 28-day cycle you’re probably ovulating on day 14, but in a 31-day cycle, they are happening about day 17. If you don’t have a regular period it gets a bit trickier; you may like to try an app to help you work it out, or an ovulation test kit from the chemist, but if your period is very irregular or non-existent you should consult your GP.

HOW LONG SHOULD IT TAKE?

About 80% of “normal” fertile couples having regular intercourse will get pregnant within 12 months, but of course, this means that about 20% of normal couples will take longer. The pregnancy rate (fecundity) of a normal fertile couple is about 20-25% per month if they have sex regularly but certain factors will reduce this, eg. irregular periods, such as in PCOS (polycystic ovarian syndrome). Fecundity also declines as you get older and miscarriage rates rise, especially over 35.

WHEN SHOULD I START TO WORRY?

If you are under 35 and have no reason to suspect that you or your partner have any fertility issues then it is reasonable to try for about 12 months before seeking medical advice. See your GP fairly soon however if you suspect some potential barrier to fertility; some of these are listed in the next section.

Couples over 35 should consult a doctor after around six months of trying. Fertility declines more quickly from this age so it is more important to discover problems quickly. 

WHAT COULD BE WRONG?

To get pregnant you need to produce healthy eggs (ova) and be the recipient of some healthy sperm. Those sperm must enter the woman’s reproductive system and have an unhindered journey to meet up with the aforementioned healthy egg somewhere along the way. Against all odds one of the sperm must then gain access to the egg and cause faultless conception and cell division. Then the resulting embryo needs a good place to land and grow in the uterus without interruption by rogue immune cells, infection or defective DNA. It’s a miracle that anyone manages to get pregnant when you think about all the things that could go wrong!

In the female these things might include ovulation problems from conditions like PCOS, being underweight or over-exercising, ovarian cysts, or hormonal problems. Structural problems can occur such as blocked tubes (eg. from ectopic pregnancies, fibroids, polyps, endometriosis or STI’s), or congenital (birth) abnormalities of the uterus or other reproductive organs. Infertility might be due to a genetic problem like Turners syndrome or a condition causing recurrent early miscarriage. Endometriosis can be toxic to eggs and prevent their passage through the tubes. There are also a variety of immune and hormonal disorders, infections, drugs and medications that can impact on ovulation, conception and miscarriage.

Male infertility issues are often sperm-related: either low or no sperm production (eg. genetic factors like CF, or blockage or abnormality of the sperm pathway), or the production of abnormal sperm (eg. poor movement, or genetic flaws that prevent conception or cell division).

There may be testicular problems that impact on sperm production such as a history of trauma, infection (especially mumps), undescended testes or activities which routinely overheat the testes (like lots of lycra-clad bike riding!). Various lifestyle factors, drug and alcohol use, medications and health problems can also reduce fertility.

HOW CAN I CHECK WHETHER THERE IS SOMETHING WRONG?

  • Keep track of your cycle using apps or calendars, and observe mucus changes to judge when you’re ovulating or use ovulation test kits.
  • Talk to your GP and get advice about whether some preliminary investigations might be helpful. These should involve some timed blood tests at specific times in your cycle if possible.
  • It may be appropriate at some point to get a referral from your GP to see a fertility specialist for further tests and advice.

In Canberra, we are privileged with many excellent fertility specialists*. Mostly they work as independent specialists with their own protocols and fee structures and work cooperatively with one of the big fertility laboratories who can provide the scientific support needed.

If you are advised to undergo some form of Assisted Reproductive Treatment (ART) be mindful that they can be very expensive, and physically and emotionally arduous, so gather as much information as you can to help you prepare.

*The information provided in this link may be out of date or incomplete, and not all specialists working with each clinic are listed; you are advised to contact the fertility organisations listed for current information.

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