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Fertility is the natural capability of giving life. For some couples fertility and getting pregnant are as easy as eating cake. For others, the world of reproductive technology becomes the only hope for conception.

The collection of methods that uses the body’s natural and normal functioning to determine the days of the month a woman is most likely to get pregnant is called fertility awareness, the Ovulation Method, the Billings Method, the Natural Family Planning (NFP), or the Sympto-Thermal Method. The calendar, basal body temperature, and cervical mucus methods are combined to give you the awareness of when your body is most fertile. Becoming familiar with your body’s ovulation and fertile periods provides you the opportunity to abstain from sexual intercourse during that time or use one of the barrier methods.



The average menstrual cycle is between 28 days to 32 days. Before ovulation and after ovulation are the two parts that are related to your cycle. Below is an explanation of an average cycle:


  • Day one: The beginning of the calendar is the first day of your menstrual flow.
  • Day seven: By day seven, your egg is preparing to be fertilized by sperm.
  • Days 11-21 (based on a 28-day cycle): Around this time ovulation occurs, which is when hormones in your body cause the egg to be released from the ovary. The egg travels from the fallopian tube toward the uterus. The fertilized egg will attach to the lining of the uterus and begin to grow if sperm penetrates it. However, the egg will break apart if fertilization doesn’t occur.
  • Day 28: Around this day, your hormone levels drop and cause the lining of the uterus to be shed, making up your menstrual flow.


The first part of the menstrual cycle (before ovulation) is different in every woman, and it can even change in the same woman from one month to another. This variation usually occurs from 13 to 20 days long. There are about 14 days from the day of ovulation until the start of the next period, so the last half of the cycle is usually more similar for all women. To narrow down their most fertile time of the month, women are encouraged to track their cycles and count back 14 days from their LMP (last menstrual cycle).


Calendar tracking:

Your past menstrual cycles will work as a guide to estimate your fertile times. You can follow the steps below to track your menstrual cycle and to identify your expected ovulation:


  • Plan on tracking your menstrual cycle for 8 to 12 months
  • The first day you start menstruation will be day 1
  • Pick the longest and shortest of the cycles from your monthly tracking
  • Subtract 18 days from the length of your shortest cycle to determine the first day of your fertility period. If your shortest menstrual cycle was 26 days, take 26 and subtract 18 to come up with the number 8. This means that on the 8th day of your cycle starts the first day of your fertility window.
  • Subtract 11 from the length of your longest cycle to determine your last fertile day. If your longest menstrual cycle was 32 days, then take 32 and subtract 11 to reach the number 21. This means that the 21st day of your cycle is the last day of your fertility.


Your fertility window is the time in between these two days. In the example mentioned above, the woman’s fertility period would be from the 8th day of her cycle to the 21st day of her cycle. Her ovulation is expected during this time frame. She can’t get pregnant everyday during this period, but it’s sometime during this period that pregnancy may occur.


Basal body temperature method:

The change in temperature that occurs after ovulation is measured by your basal body temperature, which remains elevated until your next period. When you look at charting from a few cycles, the temperatures can reveal a pattern from which ovulation can be predicted. The steps below explain how you can begin to track your temperature and identify when you’re ovulating:


  • Before you become active each morning, take your temperature orally
  • Use a basal thermometer that recognizes small changes in your temperature. When you ovulate, your body temperature will rise only between 0.4 and 1 degree Fahrenheit.
  • Record your temperature every day on your fertility tracking calendar. When you record your temperature every day, you will notice that your temperature is rather consistent before your ovulation. You may have a slight decline when you get closer to ovulation, but it will be followed by a sharp increase after ovulation. The sign that ovulation has just occurred is this increase in temperature.


This method is best used by women who have time to track and study their charts for a couple of months to ensure the best chances of conception, because the increase occurs after you have ovulated. Your temperature could be affected and it could be difficult for you to establish an accurate reading in the case of an illness, lack of sleep, and alcohol or drug use.


Cervical mucus method:

During the menstrual cycle, the consistency of your cervical mucus changes. There are 3 to 4 dry days following a 5 day menstrual flow in an average cycle. The wetness of the mucus increases daily, and it lasts about 9 days until the wettest day. At this point, your mucus is easily recognized. It has been described as egg whites; it should be abundant, slippery, clear and very stretchy. When you have your peak day of stretchy mucus, which is usually within two days, ovulation occurs. You can follow these steps if you want to use the cervical mucus method to identify your ovulation flow.


  • Collect the mucus from your vaginal opening by wiping your fingers from front to back
  • By making note of the color (clear, white, cloudy, or yellow), consistency (sticky, thick, or stretchy), and the feel (dry, wet, stretchy, sticky), you should record it daily on your fertility calendar.
  • On the day that your mucus is clearest, slippery and most stretchy, ovulation is recorded.



Fertility awareness may reach effective rates of around 90% if it is used correctly and consistently. Your diligence to track and record your fertility pattern and your commitment to abstaining from sexual intercourse or using a barrier form of birth control during your fertility window will determine the effectiveness of this method.


Physical signs of ovulation:

  • Softening of the cervix
  • Experiencing a change in the cervix
  • Breast tenderness
  • Having a slight one-sided pain in the area of an ovary



When a mature egg is released from the ovary, pushed down the fallopian tube, and is available to be fertilized, ovulation occurs. The lining of the uterus will be thickened to prepare for a fertilized egg. The uterine lining will be shed in addition to blood in case conception doesn’t occur. The time of menstruation is when the unfertilized egg and the uterine wall are shed. Key facts of ovulation:


  • During ovulation, some women may experience some light blood spotting
  • After leaving the ovary, an egg lives 12 to 24 hours
  • Implantation of a fertilized egg usually occurs between 6 to 12 days after ovulation
  • Stress, illness or disruption of normal routines can affect ovulation
  • Only one egg is usually released each time of ovulation
  • Women are born with millions of immature eggs that are awaiting ovulation to begin
  • Even if a menstrual period hasn’t occurred, ovulation can occur
  • If an egg isn’t fertilized, it disintegrates and is absorbed into the uterine lining
  • Even if ovulation hasn’t occurred, a menstrual period can occur
  • During ovulation, some women may feel a bit of pain or aching near the ovaries called mittelschmerz, a German word that means middle pain.


The ovulation cycle:

There are two parts in the ovulation cycle:


  • Follicular phase is the name of the first part of the ovulation cycle. It starts the first day of the LMP and continues until ovulation. This first half of the cycle may last anywhere from 7 days till 40 days; meaning that it could be different in every woman
  • Luteal phase is the name of the second part of the ovulation cycle. It starts from the day of ovulation and lasts until the next period begins. This phase usually lasts only 12 to 16 days from the day of ovulation, and it has a more precise timeline. This means that the length of your cycle will be determined by the day of ovulation. However, this also means that stress, illness, disruption of normal routine and other outside factors could throw off your ovulation, resulting in changes in your time of period. So the old thought that stress can affect your period is partially true. Your ovulation can be affected by stress, which ultimately determines when your period will come; however, because the time of your period is already determined 12 to 16 days before your menstruation begins, stress around the time of an expected period won’t make it late.



When you go to a fertility specialist, the first test that he/she will perform will be measuring your follicle stimulating hormone (FSH) and luteinizing hormone (LH), to establish a baseline. This is performed on the third day of your cycle. During your first visit is when this test should be performed. On the day of the LH surge, which in most cases is before ovulation, you should go to your second visit. Your fertility specialist will probably perform the tests mentioned below during your first cycle:


Cervical mucus tests:

These tests involve a bacterial screening and a postcoital test (PCT), which determines if the sperm is able to penetrate and survive in the cervical mucus.


Ultrasound tests:

This test is done to check the condition of the uterus and ovaries, to assess the thickness of the lining of the uterus (endometrium), and to monitor the development of the follicle. In order to confirm that an egg has been released, an ultrasound may be conducted two to three days later.


Hormone tests:

These tests evaluate the various hormone levels that contribute to the reproductive process. Some of those hormone tests are:


  • Follicle stimulating hormone
  • Progesterone
  • Luteinizing hormone
  • Free T3
  • Androstenedione
  • Estradiol
  • Free testosterone
  • Total testosterone
  • Prolactin


Your fertility specialist will recommend additional tests in case both the semen analysis and the above testing reveal normal results. Those additional tests may be:


Hysterosalpingogram (HSG):

This test is an X-ray of your fallopian tubes and uterus. A blue dye is injected into the uterus and fallopian tubes through the cervix. If there’s blockage or any other problem, the dye will enable the radiologist to see.



In case the HSG indicated that there may be problems, this test can be used. To allow the fertility specialist to see any growths, abnormalities, or scarring in the uterus, a hysteroscope is inserted through the cervix into the uterus. The hysteroscope also enables the specialist to take pictures, which could be used for future references.



A narrow fiber optic telescope is used in this procedure. A laparoscope is inserted through a woman’s abdomen to look at the uterus, fallopian tubes, and ovaries. The physician will be checking for endometriosis, scar tissue, or other adhesions. Before this test, it’s quite important to confirm that the woman isn’t pregnant.


Endometrial biopsy:

In this procedure, a small amount of tissue is scraped from the endometrium just prior to menstruation. This biopsy is performed to determine whether or not there’s a hormonal imbalance. Before this test is performed, it’s quite important to confirm that the woman isn’t pregnant.


Prepared By: Dr. Mehyar Al-khashroum
Edited By: Miss Araz Kahvedjian


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