During this event, Professor Joyce Harper
, Author, Scientist & Educator; Founder of Reproductive Health at Work & Co-founder of the UK Fertility Education Initiative, discussed the aspects of understanding your fertility from puberty until menopause. Professor Harper has worked in the fields of fertility, genetics and reproductive science since 1987, written over 230 scientific papers and published three books.
Professor Harper is leading The International Fertility Education Initiative, which has been educating and doing research in the field of fertility education and fertility awareness. Professor Harper published a book called ‘Your fertile years’ last year, which includes all you need to know, so you can make informed decisions about your reproductive life.
The menstrual cycle
Professor Harper started her presentation by explaining and understanding the menstrual cycle. Normally, we all learn that there’s a 28-day cycle, and you ovulate around day 14, but the truth is, it’s not strictly true. There is estrogen and progesterone, and estrogen will rise as the follicle that’s growing the egg rises, so if you’re going through IVF, you’ll have lots of follicles growing, they’ll be producing lots of oestrogens, so that’s why you’ll sometimes have your estrogen checked, and on your ultrasound, they will measure how big those follicles are getting. The progesterone is preparing the womb for implantation, and if no implantation happens, everything will go down. FSH is stimulating the follicle, and the egg to start growing and produce estrogen and progesterone. There is also luteinizing hormone (LH) in the middle to do the final maturation of the eggs, but this is how it would happen in a natural cycle. The 2 key events of the menstrual cycle are period and ovulation, which is a fertile window.
There is a called Natural Cycles which can be used as a contraceptive app or as a plan a pregnancy app. It monitors the women’s period, so when they have a period, they put it in the app, so the app can learn about their menstrual cycles, but it also measures basal body temperature. We know that basal body temperature is what we call a marker of ovulation, it slightly rises on the day you ovulate. That Natural Cycles app had millions of women’s menstrual cycles, and if you look on the Internet, you can find papers and research that was looking at over 600 000 menstrual cycles, it was found that only 13% of the cycles that were analysed were 28 days and the vast majority 65% were 25 to 30 days.
The first take-home message is that if a woman’s not having a 28-day cycle, she doesn’t need to think there’s something wrong. There have been other studies looking at different sets of big data that have shown a very similar result between day 16 and 17 that this is the day that ovulation happens, not day 14.
Polycystic ovary syndrome (PCOS)
Some treatments can be done to help people with PCOS and unfortunately, normally a woman will only realize that she’s got this when she’s trying to get pregnant. It’s really good if we can try to identify this sooner rather than later and deal with some of these symptoms.
- 1 in 10 women
- affects menstrual cycle/appearance
- hormone imbalance – testosterone
- mood swings, irritability
- healthy lifestyle, contraceptive pill, weight loss
This is tissue from the womb, which is found outside the womb, and during your period, these bleed and they bleed into these other areas and create a huge amount of pain and as well as these symptoms.
- 1 in 10 women
- 14% of infertile women have endometriosis
- tissues from the womb found outside the womb
- During period
- physical, sexual, psychological and social wellbeing
- long-term – causes scar tissue
- pill, Mirena coil, and/or surgery
Period tracking apps
The next thing Professor Harper talked about was some research that she’s been doing called FemTech, which is a technology for women’s health, it’s mainly digital technology, but not necessarily, there are other non-digital technologies women use for their health. She has taken an interest to take a looking at apps that monitor the menstrual cycle, and there are 2 main types of apps: period tracker apps and fertility apps.
We surveyed women who were using apps, and period tracker apps, and we wanted to know their attitudes, ovulation prediction and the accuracy of the apps in predicting their period, and what they felt about this if their period was earlier or later than the app said. If we look, the biggest response was most of the time, it got it right, only a few said always got it right, there were a few less that said it never got it right, some said rarely, and some said about 50/50. About using the app, the highest answer was to know when my period is arriving, followed by helping me understand my body, and the third answer was to know when I am ovulating.
The next key message is that if your app is only looking at your calendar, the dates of your menstrual cycle, almost all of the apps tell you the day you’re ovulating, and it is a wild guess. The problem is that after the research, the date they give you is probably going to be just 14 days from the start of your period. If you have a shorter or longer cycle, it could be away from 14 days. Even if you have a 28-day cycle, it’s going to be from day 16 to day 17. It’s good to also use the basal body temperature, and that’s what we call a marker of ovulation.
Women have about 500 menstrual cycles give or take, in their lifetime and normally ovulate 1 egg per month, so that’s about 500 eggs. It’s important to remember that it’s not just the quantity, but the quality of the egg is as important. Men produce about 100 million sperm every time they ejaculate on average, they normally ejaculate about 2 ml of sperm, and an average count is about 50 million sperm per millilitre.
When you’re trying to get pregnant or not get pregnant, the most significant time is ovulation and our fertile window, that’s the time when you’re got to be thinking about that no matter what you’re trying to do. The fertile window is 6 days in your menstrual cycle, it’s the 5 days before ovulation, and that’s because sperm can survive for about 5 days in the female genital tract, and it’s also the day of ovulation because that’s when the egg’s released and it can be fertilized. However, it’s only viable for about 24 hours. Therefore, if we want to look at ovulation, we shouldn’t be looking at dates whether you’re using an app, or a diary, it’s not accurate, there are too many factors that can affect this. As Professor Harper mentioned before, basal body temperature rises very slightly around the day of ovulation, you can check your cervical mucus, but you need to be trained on how to do this, a really easy way is to use an ovulation stick which measures luteinizing hormone, and it rises 24 to 40 hours before ovulation. When you do your late-night injection when you’re having your IVF, it’s equivalent to having that surge of luteinizing hormone, it’s involved with the final maturation of the egg, and you have to have your egg collection about 36 hours later. If you left it at 40 hours, the eggs would become ovulated, so LH hormone is a really easy way to do it.
When it comes to fertility apps, we’ve done some research, and again the recent paper we released showed that over 50% of the apps only looked at dates which are not good, and only 39% looked at dates and basal body temperature, 5% looked at dates and mucus, and 1% looked at dates and luteinizing hormone. We did another study about period tracker apps and ovulation, but our take-home message is that the ovulation day is very varied, and monitoring dates only are inaccurate. If you want to look at your fertility, you need to measure a mark of ovulation.
It’s crucial to understand that men are most fertile from puberty to death. Although, we have to remember that men’s fertility is also decreasing. Female fertility has a limited lifespan and becomes infertile about 8 to 10 years before we go through menopause. It’s due to the quantity and the quality of female eggs.
- females are born with all the eggs they will have
- it’s about 1 to 2 million potential eggs at birth
- 400, 000 eggs at puberty
- from puberty – lose up to 1000 eggs each month
- menopause – all gone
Women are losing up to about 500 to 1000 eggs every month, so they ovulate 1 but the others just die. Even if you’re on any hormonal contraception, you’re only saving 1, the majority will die.
- eggs have fragile chromosomes
- increase the risk of miscarriage
- increase risk of chromosomally abnormal child
- decreased chance of conception
When it comes to checking your ovarian reserve, AMH (Anti-Müllerian hormone) test only looks at the quantity of the eggs, it doesn’t look at the quality, and the graph shown is from Professor’s Harper book where it clearly shows the age and the chance of getting pregnant, your fertility goes down as you get older. By 45, for the majority of women, it’s going to have gone, and the chance of miscarriage goes up mainly because of the chromosome abnormalities. A really important age in reproductive health is age 35, it’s when most women will start to be losing their fertility.
If we look at the data from the OECD, showing the mean age of a woman at first birth, this has got countries along the bottom, and then there’s the age, and you can see that when it goes to age 34, women start to have fertility problems and decrease their fertility. This graph shows that the black diamonds are from 1970, the white diamonds are from 1995, and the blue bars are from 2017, and you can see in almost every country the mean age of women at their first birth has gone up, and if we go across from age 30, you can see that over half of them the mean age of their first birth is actually over the age of 30.
One of the surveys done with one of Professor Harper’s students asked women about their attitudes and knowledge about having children. The graph shows that most women would like to have a child at around the age of 30 mainly because they’re developing their careers. The second most common reason was that they are ready to have children now, but most of them didn’t have a partner who’s ready to have children, and that’s an entirely different issue about men being ready as well.
What we call modern families are non-traditional families, so a traditional family would be a man and a woman and then the non-traditional families are becoming much more common now. We can help single women, and same-sex female couples have children, they probably hopefully have eggs and a womb, but they need some sperm which they ideally get from a fertility clinic.
Single men and same-sex male couples are increasingly having children now. They normally have the sperm, but they need eggs and a womb, so it’s a bit more complicated, but we can certainly help them.
- single women and same-sex female couples
- need sperm
- ideally from a fertility clinic
- single men and same-sex couples
Fertility for people who do not align or identify as their sex assigned at birth, so there may be non-binary or maybe transitioning they need:
- an egg, sperm and a womb
- it’s especially important if they’re medically transitioning (may be hormonal and/or it may be surgery)
- AFAB (assigned female at birth)
- may or may not wish to keep having periods
- if they keep their womb – they may or may not wish to carry a pregnancy
- AMAB (assigned male at birth) – can freeze sperm
- fertile window
- most should be pregnant within 6 months
- infertility – no pregnancy after 1 year
The International fertility education initiative recommends for people over 35 to only leave it to 6 months, don’t wait for a 1 year, leave it to 6 months and then it’s up to you but maybe start getting some tests.
- no more menstrual cycle
- no more periods
- no more pre-menstrual syndrome
- no more mood swings
- no more need for contraception
We did a lot of research, and one of the studies we’ve been doing was on: before the age of 40, how informed did you feel about menopause, and unfortunately, the majority felt not informed at all. The next one was some knowledge, and women should not be reaching this stage of their life not understanding what menopause is. The age women go through the menopause means they’ve gone for 1 year without having a period and remember they’re going to lose their fertility about 8 to 10 years before that, so the average age in the UK that women are post-menopausal is age 51, but this can start in your late 30s. It’s important that at these stages, we have educated women about the symptoms and treatments available for menopause, so they go into this really with knowledge.
In conclusion, we need to ensure that everyone is educated about everything from the menstrual cycle to the menopause