Fertility: A Spectrum

This topic has been on my mind and bugging me for quite some time, but it's kind of hard to put into words. I'm going to try anyway, because I have nothing else to talk about these days.

Fertility and infertility initially seemed like simple ideas to me: fertile meant able to get pregnant and infertile meant not able to get pregnant. In my head, this was just a yes/no, either/or kind of deal. But I've come to learn that it's really not like that at all. Fertility doesn't start and end with the flip of a switch. At first it seemed you're either on this side of the line or that side of the line. But the reality is that there is no line, not really. Doctors have created a definition of infertility that hinges on the inability to get pregnant after a year of unprotected sex. If you do get pregnant you're in the fertile camp, if not, you're infertile. But seriously, the definition is pretty obscure. If you're 35 or older the definition suddenly changes to only six months of unprotected sex. And what about if you get pregnant (again and again) but you miscarry within that year, what then? It's a mess I tell you.

Part of the reason this topic is on my mind is that I get asked about infertility A LOT. And not in a "Hey, how are things going with that infertility nonsense?" kind of way, but in a "Hey, so I've been trying for 4, 6, 8 months and I'm not pregnant. Do you think I'm infertile?" kind of way. Part of the reason I get these questions (I assume) is that I appear fairly knowledgeable about this junk... why thank you (takes gracious bow). I've spent more time researching this than I put towards my undergraduate degree, so I feel like I should be pretty darn knowledgeable at this point.

The other reason they ask is fear. My story is like a train wreck... everybody's interested. But also, to girls in their twenties (and most likely thirties), my story is terrifying. And I totally get that. I hate hearing obscure, rare, awful stories of someone's terrible disease or circumstance because I'm automatically terrified that it will happen to me. It doesn't matter that the chance of a stroke caused by child birth is exceptionally rare... I heard the story and now I'm terrified it will happen to me. Rare cancers that strike young, healthy people with no symptoms... just don't tell me about it. I totally understand that hearing or reading about a girl who can't get pregnant at 25 (26, 27, and now 28) is kind of shocking and terrifying at the same time. So now as friends start trying, when it doesn't work in three months, they immediately think of me and go "on no, not me too!"... no shame, I get it.

But here's the thing I'd really like to get across: Just because your best friend got pregnant the first month and you still aren't pregnant after four, does not, in any way, mean you are destined to be me. Your best friend and I, we are literally at different ends of the spectrum. I'm thinking this calls for a diagram.

The Fertile Spectrum: a chart showing time and/or resources required to conceive

As you can see, this is not to scale.... at all. There are wayyyyyy more people on the left side of this little chart than the right. But there were just too many fun stages to put on the right for them to all fit. So when I say that I, who sits somewhere between "IVF: your only hope" and "Not Gonna Happen" is at the other end of the spectrum from your best friend, I really mean it. The other thing to note is that I didn't mark the "INFERTILE" line in there with a big red line. That's because the diagnosis of infertile will hit for some at different points along the spectrum. But here's the biggest point I want to make: your friend and I, we're opposites, but the odds are you (my just thinking about, starting to, looking forward to trying friend) fall in the middle. Again, chart is not to scale, so not the middle, middle, but the "middle"... meaning shacking up one time may not do the trick, but you're also unlikely to require IVF, or any treatment really. The average 20 something has about a 20-25% chance of conceiving each month... that's the average. Remember what we learned about averages... there are people above and below that. You've got me, who's tanking the numbers and pulling the average way, way down. But you've also got Suzie Q who gets knocked up every. single. time... she's definitely got higher odds than 20%.

Here's another thing to note: remember that ol' saying, "it takes two to tango"? Well it's true. You can be uber fertile, but if your partner is completely sterile, it's not going to matter. In the same way, your partner can have super sperm, but if you don't ovulate, his swimmers are lost at sea. You with me? So if neither of you are Wonder Fertile Woman and Super Sperm Man, then you will most likely not get pregnant in the hot tub with your bathing suits on. I know, it's such a bummer. If you're both closer to average, you'll have to have intercourse in the fertile window... and it might take a few times. If however, he really is Super Sperm Man, then the fact that you're more average will still work out pretty okay. And if he's lacking the cape, but you're rocking some super woman thigh high boots, then things will most likely be okay for you both too, The problems start when one of you is down on the other end of the spectrum. Or, if both of you are what my doctors like to call "subfertile" then it may take you both a little longer.

I used to HATE that word... subfertile. Ughhhh. I wanted to punch them all in the face. But now, I kind of get it. It certainly doesn't apply to me, but it probably applies to a lot of people. There's a third "category" if you will... it's not either/or. It's not fertile/infertile. It's fertile, less fertile, less fertile still, even more less fertile, infertile, super infertile, and not gonna happen infertile. So the fact that you and your honey have done the deed five months in a row, and you've peed on more sticks than you can count, please don't lose it. I know that my story is scary as hell, but your situation and mine are (most likely) vastly different.

Lets's take a second and look at each partner here. I found this image the other day and I think it's kind of awesome. Take a look:

Average 20 something ovarian reserve:
Red dots are bad eggs and green dots are good eggs

Okay, so we all know that a woman ovulates one egg every month.... Imagine with me, that you closed your eyes and selected just one dot. Is it green or red? If it's green, then you ovulated a good quality egg meaning it's mature, it has all of the chromosomes needed, and it has a shape/size/surface sufficient for fertilization. Good for you, you have a fighting chance at pregnancy this month. If however, you landed on a red dot, things are not looking so hot. Something is less than stellar about that egg and you are unlikely to conceive this month, even if your partner has super swimmers. Here's the thing: everybody has good and bad eggs... everybody. The more eggs and specifically good eggs you have, the more fertile you are. Some women have very few eggs, some women have tons of eggs. Some women have a high proportion of good quality, others have a crummy proportion of good quality.

What about the dudes? There's a spectrum for them as well. And the guys somehow get a less stringent grading policy, which I believe is part of the reason Male Factor Infertility is less common. Let's look at another high tech chart, shall we?

Super Sperm Man is on the left, Male Factor Infertility on the Right

You'll see that on the chart, I actually did put a red mark on this one. Again, I don't think there's a light switch here or an either/or system at work, but rather I marked the line to show that it is way, way, way far away from the middle. That's my estimate for where the Male Factor diagnosis comes in... everything to the left is "normal". "Normal" in no way means average... something Sam and I failed to grasp in the beginning. Take morphology for example: morphology is the shape to the sperm. Any two headed, two tailed, freakishly large, or exceptionally small sperm are excluded from the count. The criteria says that a man's morphology is normal as long as 4% or more are normal. But that's far from average. A man with 4% morphology is in the 5th percentile, meaning 95% of men have higher morphology rates... but he's still considered normal. It's weird, I know. But it doesn't take a rocket scientist to see that the guy way on the extreme left has better chances than the guy closer to the red line. They're both "normal" and neither likely need treatment, but they don't have the same odds.

So how do you know? When do you FREAK THE HELL OUT and when do you swallow a massive dose of chill and wait it out? Good question. The text book answer: if you're under 35, wait a year. If you're over 35, give it six months. However, I think most of my infertile sisters would say there should be a few asterisks out beside those guidelines. So here are your asterisks:

* If you don't have a period, you don't ovulate regularly. End. of. story. If you don't ovulate, you can't get pregnant. So, if you haven't had a period in some 130 days, run, don't walk to your OB. If your OB says everything is fine, find a new one. It is not fine, and it is not normal to not have a period. It doesn't necessarily mean that the world is over and you will never conceive, but it does mean your months are being wasted... you can't give it twelve chances if you only have a few periods a year. You get me?

** If your average monthly cycle is well outside the norm, you should probably pay attention and think about talking with your doctor. 28 days is standard, but if you're cycle is 26 days and then 30 days, don't stress. If however your cycle is regularly 20 days or 40 days you should probably mention that to your doctor.

*** If by chance you actually know when you ovulate (based on OPKs, BBT charts, or other body indicators) and you regularly only have 10 or less days between ovulation and your next period, go see your OB. The luteal phase (post ovulation) must be long enough to give an embryo a chance to implant and send signals not to shed your lining. In similar fashion, if you're regularly ovulating waaayyyy late, like after day 20 of your cycle, you should talk to your doctor. Your lining (and the egg) are most likely less than stellar after three weeks.

**** And lastly if you have signs of other issues like Endometriosis, PCOS, or Hyperthyroidism, you should talk to your doctor. All of these conditions can affect your quality of life and health even outside of trying to conceive, so it's important to get an accurate diagnosis and to treat the issue. But treatment will also (most likely) help you conceive if that's your goal.

My ultimate goal here is to say to those who are worried that they will end up just like me, the odds are small... so small. Infertility is fairly common, so feel no shame if you find yourself with that diagnosis, but even with the diagnosis, there's a lot of ground to cover before you're me. However, while I'd like to ease some fears, I don't want to say "don't ask, research, or question". I had a hunch way before we reached the year mark that something was up... no one believed me. So if you have reason to believe that something is wrong, tell someone. Like I said, there's no reason to wait a year for help if you know you have stage IV endo, only one tube, and you have abnormal cycles. If you think somethings wrong, find out so you don't freak out unnecessarily.

And I have a feeling my infertile friends will have a few more asterisks of their own to add, so check the comments!