All about Menstruation and Fertility Cycles

Menstruation is the periodic & cyclical shedding of the uterine lining, i.e the Endometrium, in women, accompanied by  loss of blood. Usually, it takes place at an interval of 28 days, although this  interval may normally range from 21 to 35 days in some women. The blood flow lasts between 4-5 days, but again a variation in the duration between 2-7 days is considered normal.

The menstrual cycle is linked to the production of various hormones in the body, which regulate the various reproductive & other body functions including the preparation of the uterus for pregnancy. Menstruation thus represents the breakdown & casting off of  an endometrium prepared for pregnancy, which has not materialized. As such, menstruation has even been described as the ‘weeping of a disappointed uterus’.

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The cyclical occurrence of menstruation is controlled by the cyclical rise & fall of various hormones in the body. It is interesting to note that every girl is born with a certain fixed number, about 2 million, of eggs (Primary oocytes). This number further reduces by the time of puberty to about 300,000 to 500,000 due to the spontaneous atresia & destruction of oocytes. Out of these, it is estimated that no more than 500 oocytes will actually mature in a woman’s lifecycle & the rest will simply degenerate. The maturation, release & disintegration of oocytes as well as the growth and shedding of the endometrium during the menstrual cycle is controlled by hormones produced in the brain & the ovary.

In the first half of the cycle, under the influence of Follicle Stimulating Hormone ( FSH), produced by the Pituitary gland in the brain; the oocyte/egg begins to grow in the ovary. This growing oocyte produces more & more of the hormone Estrogen, which stimulates the growth of the uterine lining (Endometrium) and also affects the cervical mucus making it thin & stretchy. Estrogen also plays an important role in maintaining bone health & cardiac function. This phase of growth of the oocyte i.e the follicle,  is called the Follicular phase. It is also called the Proliferative phase from the perspective of the uterine lining as at this time the Endometrium grows and proliferates to prepare itself for the implantation of a pregnancy, if fertilization occurs.

It  takes an oocyte about 14-16 days (sometimes a little longer or lesser) to reach maturity & be ready for release by the ovary. At this time, it is surrounded by a capsule of Granulosa and Theca cells in the ovary. The process of release of oocyte from the ovary is called Ovulation. This process again is controlled by a complex interplay of hormones produced by the Pituitary gland & the ovary.

It is the sudden rise in Luteinising Hormone (LH), produced by Pituitary gland in brain, which is the principal trigger for ovulation. The released oocyte is picked up by the fimbriae of the Fallopian tubes and transported towards the uterine cavity. Once released, an oocyte can survive for approximately 24 hours.

Meanwhile, the remaining cells of the capsule of the oocyte in the ovary form a structure called the Corpus Luteum, which produces the hormone Progesterone. This hormone is responsible for further growth of the Endometrium and, along with Estrogen, makes it suitable for nurturing a pregnancy. Under the influence of Progesterone, the Endometrium becomes edematous, more vascular, the glands enlarge & secrete nutritious substances into the stroma so as to provide nourishment to a growing uterus & pregnancy. This phase, that occurs after ovulation, is called the Luteal phase or the Secretory phase of the menstrual cycle.

If the oocyte is fertilized within its survival period by a sperm, then the fallopian tube transports the zygote towards the uterine cavity where it gets implanted & the pregnancy  progresses. If  however,  the  oocyte  is  not fertilized, it degenerates after 24 hours. In the absence of fertilization, the Corpus luteum gradually disintegrates and the levels of Progesterone & Estrogen fall. This leads to a shrinkage and disintegration of the glands and superficial layers of the Endometrium. Eventually, the necrosed superficial layers of the Endometrium & the ends of blood vessels in these layers, breakdown &  the bleeding starts. This marks the beginning of the vaginal bleeding, which is counted as the first day of menstruation. Simultaneously the next oocyte starts to grow in the ovary and the whole cycle is repeated.

The cyclical production of hormones during the menstrual cycle leads to various cyclical changes in a woman’s body & these changes have been studied and used for predicting the ovulation & the fertile/unsafe or safe period while planning to achieve or avoid a  pregnancy.

Cervical mucus changes-  The cervix is the terminal part of the uterus which leads into the vagina. It is lined by several glands which secrete mucus under the influence of hormones. The cervical mucus plays an important role in fertility because it gets altered in character & amount depending on the influence of the hormones. In the days immediately after menstruation, the cervical mucus is dry & scanty. Gradually, under the effect of Estrogen, it becomes profuse, watery & stretchy. This happens around the time of ovulation & it facilitates the passage of sperms from the vagina into the uterus while also nourishing the sperm at the same time. This increases the chances of conception when the sperm fuses with the egg.  After ovulation, in the premenstrual phase, the mucus becomes sticky, dry & thick; thus preventing any further entry of sperms into the uterus. This change in character and amount of cervical mucus has been often used to predict the fertile period.

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Basal Body Temperature monitoring–  Basal body temperature is the body temperature at complete rest. It has been established that the Basal Body Temperature increases on ovulation. A woman is likely to be most fertile 2-3 days prior to the body temperature rise and around the time of ovulation. Hence , tracking the early morning basal body temperature daily is often used to predict ovulation. The temperature rises by about 0.5 deg F on ovulation & persists for about 3 days, thereafter it falls to normal values. A persistent rise in basal body temperature for 2 weeks or more can also be an early sign of pregnancy.

New boost to family planning methods

Injectable contraceptives could become more popular among women in India in the days to come, as part of the Government’s national family planning programme. More women may have the option of taking injectable contraceptives following the Government’s proposal to include injectable contraceptive Depot MedroxyProgesterone Acetate, or DMPA, in the national family planning programme.

Most gynaecologists come across many women who, due to limited access to contraceptives, face unwanted pregnancy – and, thereby, morbidity related to pregnancy and abortion. According to the World Health Organisation, every eight minutes a woman in a developing nation will die of complications arising from an unsafe abortion. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity, often with tragic consequences. Introduction of new contraception methods in the public health system will, therefore, allow women to select methods based on their specific needs and preferences.

An injectable contraceptive is a shot that can offer pregnancy protection for up to three months. It is a simple, safe, and reversible family planning method than can be administered discreetly. The method is especially convenient for women who cannot remember to take a pill everyday or negotiate with their partner for using a condom. However, it is essential to visit a doctor for the first screening and counselling on eligibility and potential side effects.

DMPA is a progestogen shot, usually administered in the arm, hip or buttocks. It thickens the cervical mucus which stops the sperms from reaching the egg. It also makes the womb lining thinner and prevents the release of an egg. Progestogen is similar to the natural hormone progesterone, which is released by a woman’s ovaries during her menstrual cycle.

Injectables are 99.7 per cent effective in preventing pregnancy. As per current WHO recommendations on the use of injectable contraception, for women aged 18 to 45 years of age, there should be no restrictions on the use of DMPA, including no restrictions on the duration of its use (medical eligibility criteria Category 1). Among adolescents (menarche to less than 18 years) and women over 45 years, the advantages of using DMPA generally outweigh the theoretical safety concerns regarding fracture risk (MEC Category 2). There are no restrictions on the use of hormonal contraceptives, including DMPA for women at high risk of HIV (MEC Category 1). Women and couples at high risk of HIV acquisition should also be informed about and have access to HIV preventive measures, including male and female condoms irrespective of the family planning method they choose.

These hormonal contraceptives are safe and suitable for nearly all women, including women who are breastfeeding, who have or have not had children, and even those who may just have had an abortion or miscarriage. DMPA has a high acceptability as it is provided by an injection every three months, which can be given outside clinical facilities. Women who are HIV positive can also safely use injectables. However, it should be noted that injectables do not provide protection against any sexually transmitted diseases including HIV. Therefore, a condom must be used for protection against these diseases.

This injection must be taken within seven days of menstrual bleeding or within the first seven days after a miscarriage or abortion. In case of breastfeeding mothers, the injection can be taken after six weeks of childbirth, and within six weeks after childbirth in case of non-breastfeeding mothers. Till the woman does not wish to have babies, she can continue to take these injections after every three months. An important point to note, however, is that the injection has to be discontinued nine to 10 months prior to planning a baby, as the conception may take some time.

All contraceptives have side effects. Therefore, women should be counselled about DMPA’s side-effects and provided a leaflet or other material to inform them about DMPA’s mode of action. Some women may experience lighter or irregular bleeding while in some cases there may be no menstruation. Other possible side effects may include headache, dizziness, breast tenderness, and weight gain. Most side effects usually become less or stop within the first few months of using the injectable.

Source : The Pioneer (via Syndication)

Influence of diet on conception

When trying to conceive, often even the smallest thing, like the food that one eats, makes a difference. What one eats certainly affects the sex drive. But it can also impact the chances and the quality of conception. Lifestyle factors, like the diet and ways of life, can greatly influence overall health and well-being, including fertility. The good things is that these can be easily modified to suit one’s objectives.

The results of a 8 year study covering over 18,000 women published in The Fertility Diet (McGraw-Hill) by Jorge E. Chavarro, M.D., Walter C. Willett, M.D., and Patrick J. Skerrett “uncovered evidence based suggestions for improving fertility”. Instead of the many traditionally suggested fertility food items like oysters, ginseng, yam and garlic, ovulatory infertility, which is the underlying cause in almost a quarter of all cases of infertility, is now believed to be prevented much more through a complete and balanced diet.

At least five servings of fruits and vegetables: Inclusion of fresh fruits and vegetables in the diet not only ensures overall health and fitness, but also fulfills the requirement of essential vitamins and minerals in the body, required for both male and female fertility. Some deficiencies, especially those of folic acid and certain minerals, can play havoc with the fertility of both sexes, reducing the quality of sperm in males and abilities to sustain a pregnancy in women.

Plenty of unrefined carbohydrates: Whole grain cereals in multi-grain breads, pasta or chapatti helps meet the requirement of carbohydrates while also providing the body with essential fiber. Sufficient carbohydrate is important not only to ensure adequate energy levels and overall fitness but also to maintain the appropriate biochemical balance in the body.

High quality proteins: While non-vegetarians can include fish, sea-foods and poultry, as sources of protein, in their diets, people with vegetarian diets also have a wide choice of pulses, soya products, milk and milk-products for sourcing their protein requirement. One should also include eggs in the diet if it is an option. It is advisable to include at least 2 servings of protein rich foods in the daily diet. Besides strengthening the muscles and improving stamina, some protein sources like certain pulses and meats also help in meeting the requirement of folic acid in the body.

Adequate water: The adequate intake of water per day depends on various factors like gender, activity level, health and of course the environmental conditions. Though there are various recommendations on the right quantity of water to be consumed per day, the Institute of Medicine recommendation, for temperate climates, is fluid intake per day of 3 liters for men and 2.2 liters for women. This is almost the same as the often mentioned thumb rule of “8 glasses” per day. Just remember that the intake covers all fluids.

But besides ensuring that one switches to a diet that is appropriate for supporting a healthy conception, one must also be aware of certain things that need to be avoided for the same.

AlcoholConsumption of alcohol, especially if not strictly regulated, affects not just the overall health and fitness but also both male and female fertility. Since it is not often easy to regulate, couples trying to conceive should attempt to completely stop alcohol consumption.

Smoking: Couples trying to conceive should abstain from smoking and generally any kind of tobacco use. Smoking inevitably affects both the sperm quantity and quality in males and thereby the chances of a conception. In women, smoking affects how receptive the uterus is to the egg.

Cessation of smoking and alcohol consumption are lifestyle modifications which apply to to both the partners if they are desirous of having a baby. For dads-to-be, limiting alcohol is even more important when compared to moms-to-be. According to a research study, ‘Effects of caffeine, alcohol and smoking on fertility’, published in the journal of The Fertility Society of Australia, the mechanisms by which alcohol impairs fertility are unclear, but in men it has been found to cause impotence, reduction of libido and poorer sperm quality.

Caffeine: Caffeine is present in tea, coffee and in some soft drinks. It is known to drastically reduce the chances of conception. Studies have shown that consumption of even 200 mg of caffeine per day almost doubles the average risk of miscarriage of 12.5%. This doesn’t mean that one has to altogether give up their coffee or tea if they want to conceive…just limit it to a reasonable level. While some experts suggest during pregnancy a limit of 100 mg of caffeine per day from all sources (1 cup of brewed coffee or 2 cups of tea), there is no specific basis for the same.

It is important to note here that alcohol consumption and smoking are undesirable not only during the phase of conception, but also throughout pregnancy. So when it comes to planning a baby, the first step should be a decision to abstain from both of them. According to National Health and Medical Research Council and National Institute of Clinical Studies, pregnancy is a time when smoking cessation advice has been found to be most effective.

Mercury: While it may sound a bit bizarre, we may unknowingly intake a lot of mercury by consuming certain soft water fishes, which are known to have high mercury content. High mercury levels can lead to Menamata disease, which interferes with fertility and can also cause miscarriage and preterm delivery.

To summarize… A healthy, complete and balanced diet, that includes lots of carbohydrates, good quality proteins, fruits and vegetables and less refined foods and fats, when combined with abstinence from alcohol and tobacco consumption and moderation with caffeine, can support a successful and healthy conception.

Ailments affecting conception & pregnancy

If one is facing difficulty in getting pregnant i.e. suffering from unexplained infertility, then probably it’s time to look at some underlying medical causes  like obesity, hypothyroidism and asthma, which can interfere with one’s reproductive health, in many more ways than imaginable. Addressing these conditions can not only improve an individual’s overall health and fitness but also increase the chances of successful conception and pregnancy:

  • Hypothyroidism– Despite the recent increase in the problem of under-active thyroid gland, little is understood when it comes to its implications on our body and its functioning. While hypothyroidism can be managed with the right medication and lifestyle modifications, it can be very challenging to attain the exact level of thyroid activity  required to achieve and sustain pregnancy.

Also, during pregnancy fetal growth and development is controlled by the hormones produced in the thyroid of the mother. Hence, it is advisable to get your thyroid checked, and if you are already on medication for thyroid, get it rechecked even after you have conceived, as levels can vary during the course of pregnancy.

  • Diabetes- The presence of diabetes on this list may take you by surprise, but the fact is that deranged blood glucose levels can seriously lower your chances of having a baby. While high blood sugar level itself does not prevent someone from getting pregnant, it hinders the retention of pregnancy. This is because diabetes can prevent the implantation of the embryo in the uterus, causing a miscarriage sometimes even before a woman can realize that she has conceived.

For the same reason, multiple miscarriages can be a red flag for undiagnosed diabetes in women. As per the American Diabetes Association, high blood glucose levels are reported to increase a woman’s chance of miscarriage by 30-60%.

  • Obesity- While there is no direct correlation between obesity and infertility, the extra body weight inflicts physical complications like insulin resistance and hormonal imbalances, which not just reduce the chances of getting pregnant but also of maintaining it. So, maintaining a healthy body weight should be your first priority if you are trying to get pregnant.
  • Asthma- According to a research paper by Juul Gade, Elisabeth et al. “Female asthma has a negative effect on fertility: what is the connection?.” ISRN allergy 2014 (2014), asthma in the lower airways in women, due to a systemic reaction, can simultaneously cause inflammation in the mucosa of their uterus. If not treated correctly, this inflammation can inhibit normal implantation of the fertilized ovum, thereby leading to infertility. Hence in cases of unexplained infertility, especially if you have asthma, a more effective management of the condition can help achieve pregnancy.
  • Lupus- Lupus is an autoimmune disorder that can negatively influence female fertility. Due to the potential risks to the mother and baby, until sometime back, doctors used to advise women with this condition to avoid getting pregnant. But with advanced medical technology, having a child while suffering from Lupus is not that difficult.

However, the first step towards getting pregnant, in this condition is to have a complete control over the disorder. Regular review of the medication and timely consultation with the experts is also important because few medications may need to be stopped just before pregnancy.

  • Migraines- The benign migraine, which apparently has no direct relation to fertility, also reduces the chances of getting pregnant. This is because the adverse effects of the medications used to treat migraine has not been clearly identified for pregnant and breastfeeding women. Hence women who are taking long-term suppressive therapy for migraine are first advised to stop the medications for a few weeks, after consultation with their doctor, before planning a pregnancy.

It is observed that women with endometriosis are more than twice as likely to suffer from migraine as compared to women without the condition. While recurrent migraine attacks and its medication could directly interfere with fertility, it could as well be a associated with undiagnosed endometriosis,

So if you suffer from frequent migraine attacks and have difficulty  in conceiving, then it is high time to get your migraine medication reviewed and to also get a diagnostic test done for endometriosis.  Endometriosis is a disease that involves growth of endometriotic tissue in places outside the uterus. Endometriosis may grow on the lining of the abdomen and pelvis, that may sometimes cause scarring, involving the ovaries and blocking the tubes, thereby leading to infertility.

  • Epilepsy- According to the study by Singh, Pratibha et al. “Effect of epilepsy on female fertility and reproductive abnormalities.” Journal of human reproductive sciences 4.2 (2011): 100., compared to the general population, reproductive abnormalities and infertility are two to three times more common in epileptic females. This is because epileptic seizures can lead to an increase in the serum prolactin level and fluctuation in women’s reproductive hormones (Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH). Around 50% of all epileptic women are also reported to have menstrual abnormalities and a higher frequency of anovulatory cycles, which also adversely impact fertility.

People with epilepsy desirous of conceiving, should talk to their doctors to get epilepsy medications prescribed that do not impair fertility, are safe in pregnancy and seek hormone therapy under proper medical advice, if required.  

  • Male Infertility – Even though women may obsess over their inability to conceive, the reason for the same may often lie in various degrees of male infertility in their partners. Obesity and Diabetes are well known for causing sexual disorders like erectile dysfunction, late ejaculation and low sperm counts. Lupus in males can also cause infertility. Epilepsy medication can reduce testosterone levels or cause impotency (reduction in amount or quality of sperms).

So, if you are facing problems in getting pregnant and you or your partner already have or suspect any of the above medical conditions, then it is high time to take some corrective steps, especially because the right medical advice and action can significantly increase your chances of conceiving. After all when it comes to becoming a parent you don’t want to leave any stone unturned.