Our Infertility Struggle, So Far – part 1

This infertility update is going to be a little different. Right now, I’m not as emotional as I have been in the past, likely because I wasn’t expecting to get pregnant last cycle. This post series is designed to get everyone caught up on our infertility struggle. This will be a long, logistical post, with lots of links to previous blog posts and Instagram posts where you can find more details. I’ll be going over all the different infertility tests we’ve had, what we’ve found via testing, and what our plan is going forward.

This will be a three part update. The other two parts will go up over the next two weeks. This first part will focus on the background information necessary to understand the world of infertility. I cover the beginning of our story, as well as how a full menstrual cycle plays out, the steps necessary for conception, and what the main hormones are and how they fluctuate during your cycle. Part two can be found here, and explains our tests, procedures, and doctor changes.

Every person struggling with infertility has a different story. All I can speak to is my story, that I share with my husband, Dan. I am also not a doctor. I will tell you what supplements we are taking in part three, but I will not say doses. Do not use these posts as a guide for your situation, as I can guarantee that your doctor will have a totally different plan for you! Do not change anything in your medical routine without consulting your own doctor(s)! If you choose to ignore this disclaimer, I cannot be held liable for any harm you inflict upon yourself.

The Beginning

I think this all started in 2009, but I have no confirmation of that. In March 2009, a week after my 19th birthday, I collapsed in my dorm room because I had an ovarian cyst rupture – and internal bleeding is excruciating. I ended up in the ER, and they discovered another cyst still growing. By June, the other cyst had become massive and required surgical removal. I had two more cysts after that, but thankfully they resolved themselves with the right birth control pills.

Because of the cysts, I was on the birth control pill from March 2009 until June 2017, when we started trying to conceive. I never felt different on the pill, but I was thankful for some cycle regularity as I had never had that. The first period off the pill sucked – the pain was so bad that I was vomiting and dry heaving while stuck on the toilet screaming, crying, and shaking for two days. Thankfully, antispasmodic medicine from my gastroenterologist and Aleve (naproxen sodium) helped to alleviate the pain, and I was able to continue on with my life. My [old] gynecologist said I had an extreme reaction, but that it’s not unheard of when coming off the pill.

Side note: Due to my health conditions, I had been preparing my body and adjusting my medications for over a year before I came off the pill. I had multiple preconception consultations with maternal fetal medicine and my [old] OBGYN. If you’re chronically ill, and want to start a family, definitely start preparing yourself for “someday” way before you expect to need it. The preparation period was a nightmare as I adjusted multiple medications and treatments.

Dan and I didn’t try in June 2017, because we wanted to see how my body reacted to being off the pill. I’m glad we didn’t because I got so sick with that period. And, as you’ll see, it probably wouldn’t have worked anyway.

Even before coming off the pill, I started tracking my cycle using Clue. However, after using it for a little while, I was frustrated because it wasn’t designed for fertility purposes (it has some fertility features, but it’s primarily designed to track a normal cycle). I switched to using Ovia, a free tracking app specifically designed for women trying to conceive, the cycle that started on August 25, 2017. Since then, I’ve been happy with the information Ovia has provided me. I also started using cheap ovulation tests to try to figure out when I was ovulating. The cheap ones were confusing, however, so when I ran out I switched to using Clear Blue Digital Advanced. (My current fertility clinic wants me to switch to Clear Blue Digital, not “advanced,” once I’ve used up my current box of tests.)

This post is the first post about my infertility struggle. There is a section in the post where I talk about thinking I was pregnant and had a “chemical pregnancy.” However, after further thought, I’m not sure I have ever been pregnant. I think my body overreacted to the new hormones of ovulation, and that’s it. I suspected this a few months after that cycle, and I think that even more now that we know so much more about my body (part three of this series is where I will go into details of exactly what is going on with my body).

We had to take a break from trying February and March 2018 because I needed to have surgery on my arm. (You can read about the surgery in these three posts: preop, postop 1, postop 2.) The first cycle after my surgery, we did try but I decided not to do the ovulation tests, instead we used the “fertile window” that Ovia predicts based on your cycle length.

The cycle that started May 5, 2018 was the first cycle I got a positive ovulation test! Yes, that means I had not ovulated for eleven cycles. Well, I had not gotten any positive tests for eleven cycles, though the last three of those eleven I did not test. My [old] gynecologist thought it was impossible for me to not be ovulating since my cycles were still regular – I knew within two days when my period would start every month. I’m still not sure about that because I think my estrogen and progesterone were probably still fluctuating (which are the hormones responsible for triggering your period), but that I wasn’t producing LH (the hormone that makes your body release eggs – ovulate). My [old] OBGYN only ever ran a prolactin test on me, and never tested any other hormones.

Thankfully, my cycles since May 2018 have all had positive ovulation tests. I have read that sometimes bodies can take longer than expected to adjust to being off of the pill, so I may have been part of that group.

Summary of One Cycle

To understand infertility, you need to understand what a single menstrual cycle looks like. A single, normal menstrual cycle.

Labeled female reproductive system
(click to enlarge)

Cycle day one is the day you start the bright red bleeding of your period. There may be brown bleeding the day or two before, but those days are not technically part of your period. Brown bleeding is old blood working it’s way out. When you start bleeding bright red blood, that is when your period has officially started (it could be dark because it’s concentrated, but when it’s in the toilet or diluted somehow it will be bright red). The first day of your period is the first day of your menstrual cycle.

During your period, your uterus is shedding the lining that it built up during your previous cycle. Humans build up thick linings because the fertilized eggs like to burrow much farther into the lining compared to other mammals. Other mammals have significantly thinner linings, which is why you don’t see animals having a period. During our periods, our uterus contracts to push the unused (no baby) lining out so it can start over. Periods should be no longer than 10 days of bleeding, but average between 5 and 7. If you’re actively bleeding (not the barely there brown stuff) for more than 10 days, talk with your doctor and don’t let them blow you off. The contractions of the uterus can be painful, but should not interrupt your day. If they’re truly disruptive, like incapacitating or cause vomiting, you should speak with a doctor as that is also “not normal” and don’t let them dismiss your concerns. Several conditions can cause abnormally long and painful periods, and the sooner they’re addressed the better.

The part of your cycle between your period starting and ovulation is called the follicular phase. This is because, while your uterus is clearing out space to create a fresh lining, your ovaries are growing “follicles.” Follicles are the little sacks that hold your eggs. Multiple eggs on each ovary start to mature at once, and when one reaches a certain size it triggers the others to die so that it can focus its energy on maturing that single egg. (Rare exceptions happen, which is how you get fraternal twins.) When your body is ready to release the egg (when it’s mature) the follicle will rupture to help propel the egg towards the Fallopian tube. Some women can feel this and will get little stabbing sensations or cramping at the time of ovulation.

The ovary is not connected to the Fallopian tube. When the follicle ruptures, it ruptures with force to help propel the egg towards the opening in the Fallopian tube.

Speaking of ovulation, I should back up a bit and explain when these steps happen. The average length for a menstrual cycle is 28 days. That means there are 28 days between the day your period starts and the day before your next period starts. In an average length cycle, you should ovulate between cycle day 12 and 14. (Cycle days are often abbreviated CD# – such as CD12 – to make it easier to write.) Cycles can be anywhere between 21 days and 35 days, anything outside of that should be discussed with a doctor. My fertility clinic said that 28 to 30 days is an ideal length. This is because it takes at least 12 days for an egg to reach full maturation, and there should always be 14 days between ovulation and your period.

Once your body ovulates, you enter the phase called the luteal phase. Assuming you do not conceive this cycle, your egg will make its way from your Fallopian tube into the uterus. It will start to degrade as it makes the journey, and this will tell your body there is no baby to support this cycle, which will trigger your next cycle to start.

Conception Basics

For you to become pregnant, several steps must occur. First, you need to ovulate (your ovary needs to release an egg). Second, your Fallopian tube needs to grab that egg and send it towards your uterus; if it doesn’t then your egg will degrade in your abdominal cavity and the sperm has no chance to reach it. Third, sperm needs to reach your egg before it begins to degrade. Then, a single sperm needs to penetrate the egg. The sperm penetrating the egg should prevent others from penetrating. If multiple sperm penetrate, then it is non-viable and will not become a fetus. (There is a condition that can occur where the ovaries do not produce eggs with strong enough “shells,” which will allow more than one sperm to penetrate an egg every time. This condition is usually not discovered until a couple attempts in-vitro fertilization because scientists watch the fertilization process under a microscope.)

After the sperm penetrates the egg (fertilization), the fertilized egg will begin to rapidly divide. As it divides, it continues down into the uterus. When it reaches the uterus, it needs to burrow into the uterine lining. After it burrows into the uterine lining (implantation), it will produce human chorionic gonadotropin (hCG). The person with the uterus is now officially pregnant. The little bundle of cells needs to continue to rapidly and properly divide to become a fetus and create the placenta. The hCG also needs to reach high enough levels that your uterus knows not to shed the lining.

If all of those steps go correctly, the person with the uterus will be pregnant. (After this point, a lot of things can still go wrong. If anything goes wrong after this point it can lead to birth defects, miscarriage – 1 in 4 pregnancies ends in miscarriage – or even still birth. Pregnancy is a delicate condition.) If any single one of those steps does not happen, then the person with the uterus will not become pregnant and the cycle will start over.

If the fertilized egg burrows into the lining, but fails to properly grow or fails to produce enough hCG, then it is considered a “chemical pregnancy” and the period will start. Unfortunately, the term “chemical pregnancy” can feel very minimizing to the person experiencing it. If they got a positive test, calling it a “chemical pregnancy” can be cruel. It is an early miscarriage, and can carry the same emotional weight of any other miscarriage. The rate of early miscarriage / chemical pregnancy is thought to be extremely high, but it’s unknown since most people with a uterus don’t realize they’ve experienced one due to not taking a pregnancy test. (A chemical pregnancy can cause no delay in a period, or only delay it by a day or two.)

Hormones and Conception

Throughout the menstrual cycle, multiple hormones change throughout the body. Some of the key players that are mentioned over and over are estrogen (or oestrogen, which is an alternate spelling of the same word) and progesterone. Along with those, the menstrual cycle also depends on luteinizing hormone (LH) and follicle stimulating hormone (FSH). In the infertility world, there are a lot of other hormones that get tested as well, which I will talk more about in part two of this update.

Since the levels of these hormones vary greatly during a menstrual cycle, you cannot check them all at the same time. That means, to test your hormones and determine if they’re at the right levels, you require multiple blood tests throughout a cycle.

Chart from Clue.

As you start your cycle, your hormones are “baseline” (they’re all low). As your cycle progresses, your estrogen (often referred to as estradiol during testing) will start to increase. Your FSH will increase as well. Right before ovulation, your estrogen will spike and then it will start to decrease slightly as your body prepares for ovulation. At the time of ovulation, your LH and FSH will both spike. Within 24-48 hours of the LH “peak,” your ovary should release the egg. The peak for both LH and FSH is short, and they decrease back to “baseline” rapidly.

After ovulation, your progesterone starts to increase. Your estrogen will also start to increase slightly, but progesterone increases dramatically. If you conceive, your progesterone levels will continue to increase to help support the pregnancy before the hCG level is high enough to take over.

If you do not conceive, your hormones rapidly drop back to “baseline.” This drop is what triggers your period. When your hormone levels hit baseline, your body goes “oh okay, no baby then” and your uterus starts contracting to shed the lining.

The information in this section is from cumulative knowledge from years of research. However, to write this section I relied heavily on this chart from Clue (the tracking app).

If you’re unsure about steps to conceive or the menstrual cycle, please feel free to bookmark this post and use it as a reference. I’ve tried to make it as simple as possible – despite it being a complex process. You can find more in-depth information about the menstrual cycle and conception online. Medical websites and sexual health services are good resources.

Now that we’re all on the same page, I can go into more detail about my testing and other details in part two and three!

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