Summer is upon us and I hope that you're all able to get in some serious R 'n R. It’s been a busy couple of months here at The AFA. We’ve welcomed a new Communications Director, Brian Armentrout, and a new Development and Administrative Associate, Vivian Rodriguez to the team with one goal in mind: to more effectively serve you. Brian, with his background as an on-air reporter for ABC will be handling all of our communications, including publications such as Getting Started. Vivian, with her background as a paralegal, writer, and researcher, and her multi-lingual skills will be assisting with grant writing and developing a more meaningful membership program. We are thrilled to have them with us as we continue to work to fulfill our mission. Now, on to the content.

In this edition of Getting Started, Dr. Jacqueline Guttman, one of only 800 physicians in the country board certified in obstetrics and gynecology and in reproductive endocrinology, talks about

The American Fertility Association wishes to gratefully acknowledge Ferring Pharmaceuticals for generously underwriting Getting Started, underscoring Ferring's commitment to advancing patient care through education.

the ups and downs of using store-bought kits to monitor ovulation. Dr. Guttman also reveals some steps you can take
without even leaving your home or spending a dime. It's valuable information for those of you who are thinking about growing your family.

Stop and smell the roses! Now that you're ready to start a family, has intimacy with your partner suddenly turned into a business proposition? Perhaps you feel like a receptacle, while your spouse has taken on the title of: Source of Semen. Dr. William Petok says you're not alone. Often times the romance and joy of sex get lost in the stressful shuffle of trying tohave a child. Dr. Petok has some tips on how to enjoy the ride and why you should keep it real.

So enjoy this issue of Getting Started. And if you're in the New York area October 5th, please plan on joining us for Family Matters New York, The AFA's Patient Education Conference. Family Matters provides a full day of expert speakers and panel discussions, all designed to help those who are getting started - or those already well along - on their family building journey. For more information, click here.

With my best regards,

Ken Mosesian
Acting Executive Director

If you’re reading this, it’s likely that you have been trying to get pregnant but have not yet met with success. Lucky for you, you can do some investigating on your own with an assortment of home tests to help you figure out why, and some to help you improve your conception odds. There are tests for ovarian reserve and kits to identify sperm in the ejaculate. There are kits designed to increase the likelihood of success—including urine tests to determine when you are ovulating.

There are, however, a number of situations where an appointment with your gynecologist or a reproductive endocrinologist would save you time and, ultimately, money. This would apply to women who are 35 years of age or older; women who have been trying to become pregnant for 6 months; and couples that have been pregnant before. Women with irregular cycles, a history of endometriosis or pelvic surgery, should not “try at home” for any significant time period, prior to seeking medical consultation. In addition, those men with a history of testicular injury, surgery or other problems, should not delay evaluation.

Predicting Ovulation
Pinpointing the time of ovulation enhances the likelihood of conception. There are several at-home tests that help determine when ovulation will occur.

Ovulation predictor kits (OPK) measure luteinizing hormone (LH) levels in the urine. LH is a hormone produced and secreted by a small gland in the brain (pituitary) that, when present at high levels, directs the ovary to complete the maturation and release of the egg. The LH in the urine will be elevated prior to ovulation. The urine test strip will turn color (or generate a smiley face) after being exposed to urine with high LH levels. This positive result suggests that ovulation will occur in 18-40 hours. Sexual activity, or other means of exposure to sperm, should occur on the day of, and the day after, the OPK is positive. There does not appear to be significant difference in outcome with the available products.

It is typically best to test in the afternoon and at approximately the same time everyday. Testing should begin 2-3 days prior to the earliest anticipated time of ovulation, which occurs approximately 14 days prior to the next menses. As an example, testing should begin on day 10 if your cycle occurs every 26-29 days. Women, such as some with polycystic ovarian syndrome (PCOS), who have baseline high LH levels, may have a positive OPK without ovulation (false positive). Women taking clomiphene citrate (Clomid) should not test until 3 days after the last pill, as the initial hormonal response to the medication can create a false positive result.

There are now more advanced kits that include a monitor to identify your peak fertility. These systems integrate information about your cycle length with results from the urine test strips. The monitors are quite expensive, and add little to counting your cycle length using just the test strips.

Mucus Tests
The nature of cervical mucus changes during the menstrual cycle. It is thick prior to and after ovulation, but becomes thin and watery around the time of ovulation, to allow the sperm to pass through the cervix. Women can assess the quality of the cervical mucus to help identify the approximate time of ovulation. This can be done by taking the mucus from the vagina and stretching it between the thumb and another finger. Mucus that is receptive to sperm will stretch for at least 2 inches.

Saliva changes in response to the hormonal changes of the menstrual cycle, at the same time that the cervical mucus thins. Some kits use a microscope to identify the changes that occur in the saliva prior to ovulation. This is done by taking a sample of saliva and looking for the fern-like patterns that happen as a result of the increase in estrogen that occurs prior to ovulation. Other tests measure the changes in the electrolyte concentration in the saliva (or cervical mucus) that appear prior to ovulation. These tests use electronic monitors placed in the mouth (or the vagina) to obtain a reading. Finally, there is a fertility watch that works on a similar principle. It is worn on the wrist and measures changes in electrolyte concentration in the perspiration.

The at-home tests to assess changes in the cervical mucus, saliva or perspiration are cumbersome, often expensive and less precise than the urine test strips.

Assessing Ovarian Reserve
Knowing how many good quality eggs remain in the ovaries would be helpful in predicting the likelihood of conception, and directing the course of treatment. There are tests available to help answer this question; that is, to assess ovarian reserve. One such test measures follicle stimulating hormone (FSH) on, or about, menstrual cycle day 3.

FSH is released from the pituitary to stimulate the maturation of the eggs. As the number and quality of eggs in the ovaries decline, the FSH often elevates. Women with an elevated FSH have a reduced likelihood of getting pregnant.

Recently, an at-home urine test to assess ovarian reserve (Fertell) has become available. The test measures FSH. There are other FSH test strips available, but the other products detect only very high levels of FSH and should not be used in assessing fertility. When using Fertell, testing should be performed on the third day of the cycle, with the first morning urine. If the test line is the same color or darker than the test line, the result is abnormal and ovarian reserve is reduced.

Unfortunately, having a normal FSH on day 3 does not ensure that the ovarian reserve is normal. This is the biggest shortcoming of using FSH, or any other test, as a measure of ovarian reserve. The caveat in using the at-home test, particularly for women in their late 30’s or 40’s, is that a normal result does not mean that the user has plenty of time to try at home without further evaluation or treatment.

Sperm Tests
Despite advances in technology, no pregnancy can be conceived without sperm. The presence of an ejaculate does not mean that sperm are present, or that they are motile. There are a few at-home tests to evaluate the semen.

Some of the tests rely on a microscope to evaluate the ejaculate. They come with a microscope and instructions. The microscope allows for direct visualization of the sperm, which allows for evaluation of sperm appearance (morphology). Performing the home semen analysis requires time, patience and practice for the results to be truly meaningful. These kits can also be quite expensive and are generally not worth the investment.

There are other tests that use a more simple approach, which is similar to the LH and FSH test strips. One such kit is called BabyStart. After a semen sample is collected, it is placed in wells with a special test solution. If the count is normal, a color change occurs. The test is easy and inexpensive, but provides no information about sperm motility or morphology. Another kit (Fertell) also provides information by using a chemical reaction to cause a color change. This kit requires the sperm to be motile to cause a color change and, hence, provides additional information. It is also more expensive.

Many of these at-home tests can be helpful in facilitating conception, particularly the OPK. The diagnostic tests (screening for FSH and sperm) can be helpful in screening for problems. However, they should not be used to replace more extensive testing and interpretation by your health care provider.

A graduate of Yale University School of Medicine, Dr Guttman is one of only approximately 800 physicians in the country who is board certified in obstetrics and gynecology and in reproductive endocrinology. She has published numerous articles on infertility, polycystic ovarian syndrome, assisted reproductive technology, and complementary and alternative medicine in infertility. Dr Guttman has held numerous leadership positions in local and national professional organizations, and is on the medical advisory boards of several patient advocacy groups. Dr Guttman is Clinical Associate Professor at Thomas Jefferson University and a physician at Northern Fertility and Reproductive Associates in Philadelphia, PA.

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When Pressure Eclipses Pleasure
By William Petok, PhD

Ah love! In the beginning there is an overwhelming sense of desire, respect, caring, desire, positivity and desire. Oh, and did I mention desire and lust? Falling in love and becoming committed to another person is usually infused with these feelings and acts of warmth, affection and caring. And sex. Sometimes it’s easy to confuse the two, sex and love, that is. Normally, relationships start out this way and at some point a shift takes place, usually after the commitment is formalized by moving in together, marrying or some other official act of dedication. Sometime thereafter “life” sets in and day to day routine can interrupt the desire/lust/sex continuum. Laundry, bills, household responsibility and other facts of living together preclude the more spontaneous romps that new relationships tend to produce more regularly.

At some point couples decide to enlarge their family and add children. Now the romps have a purpose other than relationship enhancement and pure enjoyment. They can become focused on baby-making. The joy of sex can evolve into the job of sex. With the transition some couples begin to lose the desire and fun of being together physically. They may forget that the window for making a baby is fairly narrow—3 days or so, leaving, on average, another 28 days each month to recapture the joy of being together.

The average couple takes more than a month or two to achieve a pregnancy. That knowledge may get lost when on a “mission,” particularly if a couple isn’t used to a bit of frustration. We do live in a culture that celebrates instant gratification. We have instant food, drive through windows for banking and digital everything when it comes to entertainment. In all likelihood you are reading this on a broadband connection with an internet service provider that promises you “blazingly fast” pages and downloads. And now you have to wait an agonizingly slow 28 days to discover if you’ve been successful on that mission. If not, it’s another “eternal” month before the next set of results is in. And while you’re waiting perhaps you forget that the purpose of the union, the reason you are together is about
the two of you. You might forget that “its la-la-la-la-love,” to steal a riff from the latest

Heineken commercial.

Ch-ch-ch-changes
Of course, there is a potential toll that targeted efforts at procreation can exact on a couple and their sexual life. First and foremost is the prospect of repeated “failures.” Sex that doesn’t achieve a pregnancy can feel like a “wasted effort” if the only time a couple makes love is during that narrow window of conceivability. Frustration, irritability, and feelings of being either a “receptacle” or a “source of semen,” can leave a couple unhappy and with the impression that one or the other is uncared for beyond their gametes. And since the solution is often beyond the control of either person a sense of helplessness can infuse the relationship, possibly leading to petty arguments and bickering. This is not always the case and many couples actually report that the challenge can pull them closer together.

It would be foolish to suggest that you relax, enjoy the scenery and the ride because when on that mission, most of us want the end point and we want it now! We tend to forget that sometimes the process can be a powerful creator of intimacy and connection. We tend to forget that those other 28 days can be for pleasuring, providing comfort and enjoyment that we, as humans, are privileged to have as part of our interpersonal repertoire. Nevertheless, that’s the best advice one can receive at this stage of getting started. Relish the opportunity to be average, to be normal, to anticipate with a positive attitude.

The Pleasure and the Play
Specifically, couples can return to the playfulness that was present early in their relationship and engage in things that were fun and exciting before. “Afternoon delight,” those non-traditional, mid-day sexual interludes that put pleasure before pressure, can be one of the activities that reintroduce playfulness. On the other hand, meet each other for a quick lunch but skip the food. Or hop in the shower and get each other really clean. The ideais to break up any routine that may have set in. Nothing puts a damper on fun like doing the same old same old all the time.

As couples get to know each other the seduction that took place early on can be lost. After all, there is no need for slow teasing and flirtation when you have “sealed the deal” with a formal commitment. It’s legitimate to take your clothes off and hop in bed, your bed in your house! And while it’s “legal” it might be more interesting to revert to sexual behavior that puts a premium on the slower route. Take time to touch, caress, kiss and linger. When you know that you can make love whenever you choose, the pressure to make love every time you are together is off. Maybe you’ll take an hour to give each other a sensual massage and relish the sensuality with out pushing each other over the edge. Many sex therapists recommend this Sensate Focus for couples who are having difficulties. But nothing precludes couples who are doing great, from enjoying the same sort of activity.

Finally, not all of good sexuality takes place between the sheets. Couples who take the time to pay attention to each other with compliments, attentiveness and other forms of thoughtfulness, tend to feel greater attraction that carries over into the bedroom. Remember to concentrate on those activities that build warmth and caring and the loving feeling will stay strong.

William Petok is a psychologist in private practice in Baltimore, Maryland. A past chair of the Mental Health Professional Group of the American Society for Reproductive Medicine and board member of AFA, Bill has provided services to individuals and couples with fertility problems for 25 years. His special interests are in male infertility issues and the interface of sexuality and fertility.

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