It's time to demystify a woman's fertility cycle. Like the biological vital signs temperature and pulse, periods and ovulation are key indicators of a woman's health. So much so that the American Academy of Pediatrics (AAP) advises health practitioners to consider the menstrual cycle the “fifth vital sign." 

In honor of global Fertility Care week on March 21st-27th, we hosted our virtual talk ‘Femtech Fes! SG’ with a mission to reconnect women with their monthly cycle. We brought together Dr. Huang Zhongwei, a Clinician-scientist and OB/GYN at the NUS Yong Loo Lin School of Medicine, and Kristina Cahojova, the founder and CEO of fertility startup, kegg, to uncover key fertility signs and how they can affect an individual’s overall health. Here are the highlights from the talk. 

What are Fertility Awareness-Based Methods (FABMs)? 

From a young age, our health education system taught us that sex always leads to pregnancy and that women are walking, talking fertility factories. That is simply not true. Another misconception that women grow up learning is that a normal cycle must be 28 days long. In reality, most individuals only have six fertile days per cycle (AKA the “fertile window”) and the rest of the time is considered infertile. Moreover, cycle length varies from one person to another and from cycle to cycle. What matters is finding your unique pattern of fertility so that you know what’s normal for you. 

Fertility awareness-based methods are practices of charting and understanding the signs of fertility and infertility so anyone can achieve their personal fertility goals. 

Practicing fertility awareness can come with a host of benefits — from mitigating painful premenstrual syndrome (PMS) to helping to diagnose a hormonal imbalance to increasing your chances of conception. They also come with no side effects, are free or inexpensive to use, and can be stopped or started without the help of a healthcare professional.

However, FABMs don’t protect against sexually transmitted infections (STIs), so they’re probably not right for people who are having sex with multiple and/or untested partners.

Dr. Huang also notes that for those trying to get pregnant, one shouldn’t obsess over tracking their fertility because stress can do more harm than the act of not tracking at all.

How effective is FABM? 

The Sensiplan study is what most people reference when they say that the Symptothermal Method has a perfect-use efficacy rate of 99.6% and a typical-use efficacy rate of 98.2%. However, it’s important to note that variability across the studied populations means that it is really not possible to make comparisons across different fertility awareness methods.

How does stress play a role in fertility? 

Dr. Huang: “The body reads anything that affects a woman’s homeostasis, the balance in the body. Once this balance is off, the body will send stress signals to the ovaries to let them know that she’s not ready. The ovaries will not respond accordingly because the body is recorded as stress and thus, she won't ovulate until the stress is addressed. Stress can be simple things like running through a project, sleeping late nights, or trying out a new weight loss program." 

Key fertility signs

Cervical mucus: What does this watery fluid indicate?

For a pregnancy to happen, you need an egg, sperm, and fertile cervical fluid. Cervical fluid allows sperm to enter your uterus and reach your egg at ovulation. Simply put, without the presence of cervical fluid, a woman cannot conceive.

Sperm cannot survive in the female reproductive tract unless cervical fluid is present. 

Once the egg is released from the ovary, it only has 12 to 24 hours to be fertilized. With the help of cervical fluid, sperm can be kept alive for up to 5 days.

At different times of your cycle, cervical fluid changes to make it difficult or easy for sperm to swim past the cervix into the uterus. Cervical fluid changes throughout your cycle from dry to wet, creamy to eggy, stretchy to sticky to indicate how close she is to ovulation.

 
(Images of real cervical fluid via The Cervical Mucus Project) 

On days leading up to ovulation, estrogen levels rise which causes the cervix to produce more fluid. At first, it might be thick and sticky or tacky, and become more wet and creamy, like lotion.

Near ovulation or on ovulation day itself, your vagina will likely start to feel much wetter, and fluid becomes more slippery and clear as water content rises. As estrogen peaks, 1–2 days before ovulation, cervical fluid often resembles a raw egg-white that you can stretch for inches between your thumb and finger. The amount of vaginal discharge at this time is different for everyone, but it can be up to 10–20 times more than other points in the cycle. 

As soon as ovulation is over, cervical fluid dries up. This makes the cervix a hostile environment for sperm, making it difficult for sperm to swim up to meet the egg. That is why in FABMs, this phase of the cycle called the luteal phase is considered your “infertile period.”

When you track your cervical fluid, you can distinguish between different types of discharge and you can ease your mind knowing that the stain on your underwear is not an infection, but a healthy, normal sign of approaching ovulation!  

Who is the method for? 

Kristina made a great point that, “fertility awareness is not only for women to connect with their bodies, but also for couples to connect with each other on a deeper level. That is, both partners learn how to track the woman’s fertility. It can take more than six months for couples to understand the method well, but the end result is worth it because the male partner can understand his partner better.” 

A woman’s mood and energy may shift, depending on where she is in her cycle. So, she may feel more tired and want to spend time with herself more when she’s on her period. That’s because of the sudden drop in hormones during this phase. But a few days after menstruation, her energy levels may heighten due to increased estrogen as ovulation approaches. She can even feel more creative, social, and confident during this time. 

For couples, imagine syncing your calendars to your partner’s hormonal changes so you can both optimize your date nights, house chores, and parenting schedule around her cycles. The power of cycle syncing is endless! 

PCOS and fertility

“In order to diagnose and treat PCOS, the patient needs to come off hormonal birth control in order to assess her true hormonal health.” - Dr. Huang 

The main cause of Polycystic ovary syndrome (PCOS) is excess male hormone (androgen) levels. This can cause women to experience infrequent or prolonged menstrual periods, as excess androgen levels can stop the egg from releasing from the ovaries, making it harder for women to time intercourse for conception.

Dr. Huang says that PCOS can be diagnosed six years after the first menses, which is on average around 18 years old. But today, young teens often go on hormonal contraceptives around that age, when they enter university, which suppresses ovulation. As a result, when a woman is taking birth control, she is not ovulating and when you experience a bleed it’s actually not a true period; it’s called a withdrawal bleed. He emphasized that, “in order to diagnose and treat PCOS, the patient needs to come off hormonal birth control in order to assess her true hormonal health.” 

So, how is PCOS treated? 

A common myth about PCOS is that you have to be overweight to have it. It’s true that obesity can make PCOS symptoms worse; however, PCOS does not discriminate and can affect women of all shapes and sizes.

Especially in Asia, where obesity is not prevalent, yet PCOS is still common here. So, while focusing on weight-loss can help improve the insulin resistance associated with PCOS for those overweight, it may not be the best way course of treatment for those with a healthy weight. 

Another common misconception is that women with PCOS cannot get pregnant. A sliver of truth lies in this myth, as trying to conceive with PCOS is more difficult than without. With PCOS, the body tries to ovulate but rarely succeeds. Still, don’t lose hope because many women still ovulate intermittently! 

To alleviate PCOS symptoms and improve fertility, Dr. Huang recommends avoiding alcohol and caffeine as those drinks can change the quality of cervical mucus. Drinking more water, on the other hand, can improve fertility as cervical mucus is made up of more than 96% water. With the help of cervical fluid and its high water content, the pathway to fertilize an egg is more accessible.

By improving your lifestyle and tracking your fertility, you can optimize your chances of conception and for a healthy pregnancy journey. 

Finding joy in the conception journey

There’s no one-size-fits-all answer to how long it takes to conceive, and everyone’s fertility journey is different. A woman’s cycle can be different from 

Often times, the burden falls solely on the female partner to deliver a healthy baby, when in fact, 40% of infertility issues are attributed to male-factor infertility.

Kristina highlights that, when it comes to fertility and trying to conceive, it really takes two to tango. Women need their male partner to support their journey and vice versa. That is why intimacy is so vital. 

“Having a child is a couple’s decision. As social beings, we are born with the mind and body to feel and give pleasure. We are intelligent, sensitive animals that enjoy being touched, loved, and trusted with others. Without trust, there cannot be intimacy because trusting someone is about being open with their worries and insecurities. This all goes back to prioritizing intimacy and not over-stressing, because stress is the main killer of ovulation.” - Kristina

Our fertility journeys are all very different. Try to be patient as it takes time, even for the healthiest couples. Instead, focus on positive things—your work, your hobbies, anything you enjoy. So, if you’re out there in the midst of your own conception journey, just know you’re not alone. 

Tune in to the virtual talk below: 

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