Restoring Fertility Naturally: Counseling Patients on Conception

Dr. Chapa:

For many patients, trying to get pregnant can be frustrating, and as providers, we have an opportunity to guide them and help them optimize natural fertility as they plan their future conception.

Welcome to Clinician's Roundtable on ReachMD. I'm your host, Dr. Hector Chapa, and here to discuss ways to maximize natural fertility is Dr. Naomi Whittaker, a private practice OB/GYN physician in Pennsylvania who has evolved her clinical practice to include a structured, evidence-based model to maximize fertility using NaProTECHNOLOGY.

Dr. Whittaker, welcome to the program.

Dr. Whittaker:
Thanks so much for having me.

Dr. Chapa:
This is very important because at a time that you would think would be, in general, a lot of fun trying to conceive, it could actually be very frustrating when results just aren't there. So, Dr. Whittaker, let's first clarify the difference between maximizing natural fertility and a set diagnosis of infertility. While they may sound similar, can you explain how they actually differ?

Dr. Whittaker:
The way that they sound similar is that both of these groups of people are trying to conceive. However, one group understands that they have issues conceiving and that they are having or experiencing infertility, and there's another group ready to conceive and they haven't yet tried to conceive yet and have made that decision and are ready to, you know, maximize fertility as in ready to achieve. And, of course, everyone has the goal of a healthy pregnancy.

Dr. Chapa:
Now, when it comes to maximizing this natural fertility, the American Society of Reproductive Medicine, or ASRM, actually references the importance of timed intercourse during a woman's ‘fertile window.’ But what does it actually mean? Can you help explain that a little bit more for us?

Dr. Whittaker:
Right. So, for the definition of infertility, we talk about a year of random acts of intercourse. Now, it's very different when a couple understands the actual fertile window, which is actually much more narrow, than the entire cycle. For men, they're always fertile, but for women, if they have a normal physiologic menstrual cycle, they should be ovulating once a month, and so this means there's one window of fertility. This window of fertility is actually approximately 6 days long. The six-day window includes days leading up to ovulation and these can be identified with the cervical mucous pattern. And so the cervical mucous actually is present there and changes as estrogen rises and it actually has a purpose to nourish sperm, provide channels for the sperm to flow to, to direct healthy sperm through these channels, towards the oocytes, as well as lengthen the lifespan of the sperm, which otherwise would die quickly in a hostile pH of the vagina, but this changes the pH to keep them alive for up to five days. Then the lifespan of the egg is 12 to 24 hours. So, if you combine the five-day window of mucous enhancing the lifespan of the sperm and the 12-to-24-hour lifespan of the egg, then you have a six-day window of fertility.

Dr. Chapa:
Now, so I think that's a very important point to clarify because, out of the entire, you know, say, typical 28-day cycle, which we know, of course, many women don't have, there's really a fertile window of only 6 days with a greatest chance of conception, as you said, really about 24 hours before ovulation, so that's the big difference. It leads me to my next point, which is, how many times should a couple have sex? Can you tell us what the data has regarding coital frequency in that fertile window and chance of conception?

Dr. Whittaker:
Some people state that seminal fluid parameters go down with daily intercourse, that's not the truth. Daily intercourse is not shown to reduce seminal fluid parameters. And, in fact, abstinence of five, especially up to 10 days can decrease, seminal fluid parameters, so daily intercourse is okay. Now, with the added component of the emotional and behavioral aspects and psychological aspects of infertility which we must take into account, which can affect, you know, even for men, erectile dysfunction potentially with the pressure of intercourse daily, it's okay according to the data as well if couples spaced every two to three days and really focus on that timing near ovulation instead of really coital frequency of every day and putting that pressure on that couple.

Dr. Chapa:
Right. And I think that's a good clarifying point there, because I'm often asked by our residents, ‘What do we say is the most appropriate frequency?’ and the most appropriate frequency is whatever they both choose to do, and that's where the art of medicine comes in. I mean, for sure we can talk about the data, and sperm parameters do not decrease with daily ejaculation or daily intercourse. That's the science. But the art of medicine is have that discussion with them. As long as they're having intercourse in that fertile window, whatever is correct number for them is the correct answer.

For those of you just tuning in, you're listening to Clinician's Roundtable on ReachMD. I'm Dr. Hector Chapa, and I'm speaking with Dr. Naomi Whittaker about NaProTECHNOLOGY, a model approach to maximize fertility.

Now, that's a great segue, Dr. Whittaker, to get into something that you've done extra work and extra training with, which is NaPro technology. What exactly is NaPro?

Dr. Whittaker:
It's a small subspecialty, and it stands for Natural Procreative Technology, so to contrast that with assisted or artificial reproductive technology, and its basis is on a woman charting with the cervical mucous method called the Creighton Model System of fertility awareness. And so she is taught through structured classes in a standard scientific way to do observations of bleeding patterns, mucous and other external observations, and she is able to objectively write this down in a standardized way on a chart. And so she's also given a lot of education about the physiology of the menstrual cycle, cervical mucous, and so she is able to plot this down. And I was trained in a fellowship to interpret this data to be able to use it for diagnostic purposes, so be able to do testing based on specific cycle days, especially based on her individual biomarkers. In addition, I'm able to use that data to treat cooperatively with the menstrual cycle to work with it to address underlying issues.

Dr. Chapa:
So, if a patient comes in and says, ‘I would like help. I'm in my preconception visit. I'm thinking about conceiving soon,’ how would you integrate NaProTECHNOLOGY or instruction, into a patient who's trying to get more information? How many classes—I mean, is this a big patient buy-in in terms of time, to do this? Is it hard to learn?

Dr. Whittaker:
It's not hard to learn. There is some time commitment, and there's more time up front. There is an hour introductory session, which is free, and we do offer it through our clinic. And there are practitioners, or Creighton Model practitioners, online all over the world who teach in various languages and can teach it through telemed. In some cases it's covered by insurance, especially if they are RNs.

Dr. Chapa:
So, is this an option of treatment in lieu of medication or to be used together with medication, or how do you make that distinction between NaPro applicable therapy? And when do you use medication?

Dr. Whittaker:
Sure. So I always like to start with the data, being able to see kind of their fifth vital sign, as ACOG calls it, of the menstrual cycle. I'm able to use it for women who are single and having issues with their menstrual cycle, and it helps me often predict that they may have fertility challenges. I like to use it for women who are starting to try to conceive, because they can time intercourse appropriately and they can plan their pregnancy, even their due date. And I like to use it for women having issues. And then we can see their cycles transform as they undergo treatment.

Dr. Chapa:
Is it also applicable to those undergoing letrozole, or clomiphene-assisted ovulation, or are those two different issues?

Dr. Whittaker:
Yes. So, for women who have difficulty conceiving, we will do an ultrasound series based on their mucous pattern, to do serial ultrasounds to see if they're truly ovulating. If they have an ovulation defect, we can proceed to ovulation medication agents is a huge component as well. So there's both medical and surgical approaches to diagnosis and treatment of these underlying issues.

Dr. Chapa:
So as always, with every medical condition or gynecological condition, it's another tool in a toolset, that we can use to try to maximize a couple's chance of conception. Is that fair?

Dr. Whittaker:
Exactly.

Dr. Chapa:
Now, what has been your results? While though may be anecdotal, does it follow other published data in terms of efficacy, in terms of results with conception?

Dr. Whittaker:
In general, time to conception does take slightly longer than conventional methods. For us it's a little different. Usually, you chart for two cycles, undergo testing and treatment potentially for about a year. The long-term, success tends to be higher. There is data published by Dr. Phil Boyle on couples who failed IVF therapy and success rates with this approach of restorative reproductive medicine or NaProTECHNOLOGY, and it has some cases it may have a longer time to conception but a higher success rate, also potentially an improvement in pregnancy outcomes. Pregnancies tend to be, you know, term healthy singleton pregnancies at a higher rate, and less maternal complications, less risk of preeclampsia, etc., that you see at a higher rate in the infertility population but especially high with IVF pregnancies, so it seems to be able to reduce those risks.

Dr. Chapa:
For sure. And before we close, Dr. Whittaker, do you have any final thoughts or takeaways or perhaps even just some personal success stories that you'd like to share with our audience?

Dr. Whittaker:
First, I just appreciate the opportunity to be able to present about restorative reproductive medicine, and so your listeners may be able to consider offering more options for patients, so there's a greater access to reproductive care. One of my favorite examples is I had a 40-year-old, G4P3 with amenorrhea, and she had secondary infertility, fibroid uterus, history of second trimester loss, and her FSH actually was up to 23, and so she was going through, ovarian insufficiency, and she also had male factor, high abnormal sperm and with NaProTECHNOLOGY, we were able to achieve a successful term pregnancy. We did have to use triggers and ovulation medications for her and surgery, but she was able to have a healthy baby.

Dr. Chapa:
And with that I think we'll leave it with our audience. So I want to thank my guest, Dr. Naomi Whittaker, for sharing her experience with NaProTECHNOLOGY to maximize patients' fertility. Dr. Whittaker, it was great having you and speaking with you today.

Dr. Whittaker:
It was great being here. Thanks so much for having me.

Dr. Chapa:
I'm Dr. Hector Chapa. To access this and other episodes in our series, visit reachmd.com/cliniciansroundtable, where you can Be Part of the Knowledge. Thanks for listening.