Male Infertility Research & Recommendations Long Overdue

Last month, I wrote about more enlightening research on male fertility and dietary factors. A lot of women may not admit it, but some are perfectly comfortable stepping up and saying, "It's about time!" So far, most research has focused on female fertility and obstacles to conceiving. A recent article -- "The Bad Daddy Factor" -- points to some possible societal reasons why this may be the case.

Article author Emily Anthes goes all the way back to the 1960's to mention the few researchers who were looking at the impact of men's contribution on both fertility and infant well-being. She describes how most of their scientific colleagues weren't equally concerned, so the burden of cause continued to fall mostly in women's laps for decades. The writer goes on to connect this historical lack of aggressive research with society's viewpoints on gender and even politics. The good news: those viewpoints seem to be evolving.

Like my own colleagues, I am thrilled every time I hear about new interest in reproductive research. The more we learn about the causes of infertility, the better able we are to both educate young men about prevention and to treat the later results of lifestyle choices that are not fertility-focused.

On behalf of Houston Fertility Center's staff, my wish this season is that you and yours reap the benefits from advancing research, technology, and compassionate fertility care -- and grow your family with love.

Getting Through the Holidays with Infertility However You Can

Seasonal holidays are tough on the spirit when you're trying to get pregnant and can't. The Web is full of places you can go to and read or chat with others about ways to cope. Here are a few that I recommend:

Thanksgiving: To Attend or Not To Attend: That Is the Question
The title says "Thanksgiving," but this piece by Lori Shandle-Fox on Fertility Blogs covers all family gatherings with a light heart.

Infertility and Holidays: Don't Just Survive - Thrive!
Tracy Morris on FertilityCommunity covers a lot of different emotional tactics that can help you view holidays from a different perspective.

The Season of Giving
An interview with Kathy Stern of Southwest Surrogacy Associates, LLC about the role of giving in third-party reproductive treatment, during the holidays and beyond.

The Perfect Storm of Holidays: Infertility and Christmas
Melissa Ford taps into a perfect analogy with "The Great Peanut Day". Use it to explain your emotions to those who just don't seem to 'get it.'

Tips for Facing Infertility During the Holidays
On ParentDish, Mary Beth Sammons interviews a woman who's been going through fertility treatment for six years. Her personal advice - "what helps most is 'to know that I'm not alone.'"

There are plenty more out there -- just search for "holidays and infertility" and you'll see that, indeed, you're not the only one.

Another Reason to Be Glad You're in America: Donor Supplies

Getting pregnant with the help of a third party, either an egg or sperm donor, is a tough decision to make. And how much to share with the resulting offspring about their beginnings is best left to the parents. At least, that's the American stance.

This piece in the Scottish paper, the Daily Record, illustrates how bad things have gotten in the UK since anonymity of donor records was made illegal. So few men step forward to donate sperm there now that the health system is helping out by importing semen from London. Many hopeful parents-to-be are spending time and money to go abroad, to countries where third-party supplies are more plentiful.

For patients at Houston Fertility Center, we collaborate with highly reputable agencies that have both sperm and egg donors available and waiting. The level of interaction between fertility patient and donor can vary with the agency and, most importantly, with the needs of all parties involved.

The U.S. may still have quite a few unsettled issues in the healthcare arena, but we can at least rest assured that supplies for third-party reproductive care are just fine.

Weight Issues & Fertility Not Just a Woman's Concern

Here we are again -- the end of year holidays. This time can have a real double whammy effect on people trying to conceive. First, there are the joyous gatherings... with babies everywhere. Then, there's the abundance of food, much of it rich and not-so-nutritious. You know, the kind that's so much fun to enjoy too much of...

Why is food a problem for people trying to get pregnant?

By now you've probably heard about the impact that weight has on a woman's fertility -- both too little and too much weight can result in ovulation disorders. Also, overweight women increase their surgical risks even for procedures as commonplace as egg retrieval. But there's more research now that says men need to keep an eye on their fatty food intake, too.

At this year's meeting of the American Society for Reproductive Medicine, researchers presented evidence that men with the highest intake of saturated fat had 41% fewer sperm than those who ate less. Also, men who ate more omega-6 and omega-3 polyunsaturated fats, specifically, had better sperm motility and morphology.

There is some good news on the research front for men who are overweight. The low testosterone levels that apparently go along with high BMI (body mass index) do respond positively to clomiphene citrate (Clomid).

But on this eve of one of our country's biggest binge-eating holidays, I'd recommend having a double helping of the carrots and lay off the gravy a little bit.

Also see:

When Fertility Really Is About Your Diet

Weight & Fertility (from my April 2007 newsletter)

Fertility Treatment for Cancer Patients Is Reality. Even If They Don't Know It Yet.

Houston is a major destination for people battling cancer. The city's medical center is renowned for providing the most advanced cancer care available, and patients come from around the world to access life-saving science and techniques. Besides the facilities in the centrally-located Texas Medical Center, there are also cancer treatment centers in outlying areas around Harris County where patients are receiving the benefits of cutting edge research put into clinical practice.

More cancer patients are surviving and going on to live healthy, happy lives. But many forms of cancer treatment result in infertility. Fortunately, the technology exists now to take steps to preserving a person's fertility for the future. Freezing embryos and freezing eggs top the list of techniques proving successful. And for patients who have types of cancer that are transmitted genetically, the technology is available to screen embryos for the related genes.

I've networked for several years now with organizations that assist cancer patients, groups like Livestrong's Fertile Hope program, the Young Survivors Coalition, and the Susan G. Koman Foundation. Speaking to groups about fertility preservation is always eye-opening for them and for me. I continue to hear the same sense of surprise and sometimes regret from participants who wish they had known before undergoing cancer treatment. I wish they had known, too.

If you know someone who's struggling with cancer, let them know that infertility doesn't have to be part of the result. Help me and other reproductive endocrinologists make fertility treatment available to cancer patients, by spreading the word about the hopeful possibilities.

Also see:

Women Want Working Options for Motherhood
On Lindsay Nohr Beck's presentation at ASRM 2009.


Fertility Preservation and Oncology
My thoughts about Jane Brody's column on how oncology is still behind the curve in addressing their patients' future fertility needs.

Why I Attend the Meetings of American Society for Reproductive Medicine

One of the reasons I felt compelled to move from straight OB/Gyn work to reproductive endocrinology-infertility (REI) is because of the constant advances in science. I find it exciting to apply techniques that have developed along a continuum from creative brainstorming on how to meet patients' fertility challenges all the way through validation in labs and clinics.

I'm heading to Denver this week with some of my Houston Fertility Center staff to attend the 66th Annual Meeting of the American Society for Reproductive Medicine. ASRM is always a great place to catch up with colleagues from around the world and hear about the latest ways to treat our patients. This year promises to be even more enjoyable as we'll be honoring two pioneers of IVF, Dr. Howard Jones, who performed America's first IVF procedure, and Professor Robert Edwards, who recently was awarded the 2010 Nobel Prize in medicine for his development of IVF.

Bestowing accolades on esteemed professionals is just part of the reason for gathering. More importantly, I look forward to returning to Houston Fertility Center with new ideas to share with patients on clearing their family-building hurdles. Sometimes, even a simple treatment can be years in the making. Once new technology is available, a whole new group of once-infertile men and women can find themselves parents, and that's why I do what I do.

When It Comes to Cancer, We're All On the Same Team

Did you know that many women who survive cancer are unable to have children later? That's because life-saving cancer treatments can result in complete sterility. Fortunately, cancer survivors are increasingly speaking out about what they want out of life after illness. I've been privileged to offer these women fertility-sparing options so they can choose life both ways.

This Saturday, October 2nd, one of my sons is running in the 2010 Komen Houston Race for the Cure. A couple of years ago, I spoke to a gathering of women who form the Education Committee of the Susan G. Komen for the Cure Houston, the nation's premiere advocacy and research organization. The questions from this particularly well-informed audience led me to realize that more general public education is needed.

Cancer survival increases steadily. Fertility treatments to allow survivors to become parents is available. What is still slowly developing is a pipeline of patient information and referral. Too many women find themselves on the infertile side of cancer treatment asking why they hadn't heard of fertility preservation before it was too late.

The Komen Foundation has funded great strides in research to help women survive cancer and go on to have fulfilled lives. I urge you to do what you can to continue supporting their mission. And spread the word yourself to friends affected by cancer: fertility preservation is not experimental science. It is medical care that is currently available.

Fertility Drug Company Offers IVF Miracles Education Funding

Once you've finally cleared your fertility hurdles to have that miracle baby, life's little related expenses start adding up fast. Educational costs aren't far behind those first birthday parties (and by the way, the staff of Houston Fertility Center really loves those party invitations!)

Since 2004, Ferring, manufacturer of fertility medications, has offered a chance at getting a little help to fund your child's academic needs. Houston Fertility Center patients who used Bravelle or Menopur can enter their essay in the My Little Miracle contest by December 31, 2010. This year's theme: If I Knew Then What I Know Now. The prizes: education funds of up to $10,000!

All the details can be found here, where you can also read the previous winners' entries for inspiration.

I'm honored to know my patients' miracle stories first-hand. I know some of them will make outstanding entries in the Ferring My Little Miracle contest.

Kneads Houston Brings Fertility Massage to Houston Fertility Center

You'll never hear me suggest that a fertility-challenged woman should "just relax"! There definitely are connections, though, between how a woman's body handles daily stress and how her reproductive system functions.

The mind-body connection to fertility is no longer new information. What IS new are the approaches to helping women find ways to relieve stress, soothe their bodies, and thereby enhance their ability to get pregnant.

Also new: Houston Fertility Center's connection with Kneads Houston. I asked Magen Weishut to talk a little about the services available to HFC patients:


What do you think about the connection between stress, fertility, and massage?

Fertility and pregnancy can be very stressful, and massage can significantly decrease your anxiety level. High stress levels alter signals to the brain's hormone center. As a result, the brain may not send out the reproductive hormones necessary to tell the ovaries when to release an egg, delaying ovulation.

Since stress has been shown to interfere with getting pregnant, it makes sense that reducing stress, through massage, improves odds of conceiving.

Is this a special 'kind' of massage for fertility?

The main goal of fertility massage is to get the full body relaxed, so the body can function at a more efficient rate. Fertility massage focuses on cleansing the body, enhancing the blood, opening the breath, and relaxing and integrating, respectively.

From the clients point of view, the main difference between a massage they may have had before and what they will recieve with us is massage of the abdomen. Massaging of the abdomen helps the circulation to the ovaries, uterus, and other organs.

The specialized therapists from Kneads Houston will see our patients either at Houston Fertility Center locations or home or office -- just ask!

European Women Happy to Freeze Eggs for Future

According to two studies presented at the annual meeting of the European Society of Human Reproduction & Embryology (ESHRE), European women are embracing the idea of egg freezing as a means of having more reproductive control over their lives.

A small Belgian study of women average age 38 years found that half of them planned to freeze their eggs to lessen the pressure they feel to find the best parenting partner. Most foresaw using their eggs for conception after age 40.

A larger study in the UK saw eight in 10 medical students would be willing to freeze their eggs so that career growth could continue to take a front seat.

Women in the U.S. are also warming up to the idea of using assisted reproductive technology even when infertility isn't an issue in their life. Advances in the technology have made egg freezing with IVF more affordable and even covered by some women's insurance plans.

http://www.bioedge.org/index.php/bioethics/bioethics_article/9085/

Why We Like Beautiful Babies

I've chosen to be a sponsor for the Beautiful Babies contest, a national contest where parents can submit their babies' photos and win up to $5k (not to mention just the simple thrill of bragging rights!)

It may seem awkward, the Houston Fertility Center connecting to a competition where the thing our patients long for -- a baby -- is being celebrated. But I like to think of it as a healthy way to interact with the world. After all, babies -- all babies -- ARE beautiful. That's why we strive so hard to have our own. Aside from their extreme "cuteness factor" we're geared instinctively to appreciate our own offspring over any other of our lives' creations.

The other side of our sponsorship is that after all these years serving infertility patients, many people who come to our Center now are doing so to have another baby. We have a wall full of happy faces, and we thought this would be a delightful way for our patients, past and present, to share their joy (and maybe win big!) It's a lighthearted contest where friends and family are asked to vote for their favorites.

If you'd like to join in the fun, you'll need to submit your child's photo by this Friday, June 25. You can find out more details through this link. http://kiah.tribunepromotions.com/babies/

How Old Is Too Old?

Recently, a local colleague of mine was quoted in the media about having an "an age cutoff" for fertility treatment, specifically IVF. I thought I'd enter the field to air my own thoughts on the question of "how old is too old" for becoming a mom.

In my practice at Houston Fertility Center, I don't use any particular age to determine whether a woman is "too old" to use IVF. Mother Nature will determine when a patient's body is unable to conceive. So we explore the same related variables -- egg reserve, uterine health, hormone levels -- with every patient.

Our primary emphasis is on the health of the hopeful mother-to-be.

As for IVF using donor eggs, which allows women with low ovarian reserve to become pregnant, I find that women in the age range of 48 to 50 are starting to think again about the impact (of carrying a pregnancy) on both their health and the outcome for the baby. We presently don't have enough data to clearly determine all health issues for women over 50 years old who become pregnant. Research has clarified, however, that children born to mothers in their later years have a higher risk of a number of health conditions.

As with virtually every other facet of the conception picture, a woman's age must be taken into consideration, but primarily in the context of her present health condition.

For more of my thoughts on a woman's age and her fertility, see these blogposts, too:

The Other Side of the Age & Fertility Message


Trying to Get Pregnant After 30 - Time to Panic?


ASRM Embryo Guidelines Should Improve Overall Picture for Fertility Patients

A Little Education For Concerned Onlookers

This quick-hit on MomLogic provides a good sampling of the things that
women who are struggling to get pregnant do NOT want to hear. Might be a
nice link to post on certain friends' Facebook walls...

10 Things Never to Say to a Woman Trying to Conceive

Could Your Fertility Problems Be Related to Diet?

May is Celiac Disease Awareness Month, so it's a good time to put the word out about how this rather invisible disease might impact a woman's fertility.

The Celiac Disease Foundation has a list of symptoms that could be considered if you're wondering.

The National Foundation for Celiac Awareness offers excellent primer info on the possible connections between the disease and infertility.

Generally, my fertility-focused advice to people diagnosed with celiac disease would include the recommended dietary changes plus any additional fertility treatments, depending on other factors like the woman's age.

Birth Control Pills: Not Necessarily The Culprit

The 50th anniversary of "the birth control pill" has come and gone recently (on Mother's Day, how coincidental!) and an article in U.S. News & World Report focused on the impact that oral contraceptives have had on our world.

Interestingly, the writer stated that, among other results, the pill is responsible for an "epidemic" of infertility.

It turns out that the author is referring to how the use of the pill resulted in delayed childbearing in our society -- on a grand scale, not in terms of individual women. More women are able to put off getting pregnant until it better suits their life, as a direct result of the pill. There's hardly anyone who would call that a bad thing!

But I do have patients who come to me, worried that their years of trying responsibly to not get pregnant have worked against them now that they want to have a baby.

The truth is that studies consistently indicate no direct connections between using oral contraceptives and later infertility. I know that a lot of women, especially those who are diagnosed with unexplained infertility, are still hesitant to believe what research tells us on this point. And to be sure, once they're in my office, it's rather moot.

It's normal to think back to what you might have done differently. It can also aid in diagnosis (and possibly treatment) to review your history thoroughly, looking for answers to your own baby-making dilemma. But dwelling on this particular "common sense" connection (between oral contraceptive use and later infertility) that continues to be denied as fact-based by researchers... just isn't helpful for you. We also have to be careful not to discourage young, responsible women from making smart choices for their reproductive lives.

Safe Versus Affordable: Are Couples Forced to Choose?

This article on Australia-based News-Medical.Net reports that increasing numbers of twins and triplets are being born as a result of the global economic crisis.

The increase (in Australia) is due to more infertility patients requesting the transfer of more than one embryo in each IVF cycle. Essentially, in an effort to save money, couples are trying to boost their odds of pregnancy per cycle.

This is an unfortunate state of affairs, since studies have for a long time pointed to several related facts, including the bottom line that multiples and their mothers are at greater risk for numerous precarious health conditions.

Because of the many complex variables at play in each IVF cycle and in each woman's own reproductive condition and functioning, some patients must undergo more than one IVF cycle before successfully achieving a healthy pregnancy. In some cases, one treatment cycle is all that's required.

Now that the combined work of embryologists and reproductive endocrinologists has arrived at a point of making single embryo transfer a viable option for many, and certainly transferring only one or two more embryos to counteract some infertility-causing conditions, my recommendation for struggling couples is to take advantage of seasonal discounts when available.

Rather than boosting your odds per pregnancy, which in turn may boost health risks for you and your hoped-for baby, I encourage patients to time their treatment around clinics' occasional specials. For example, Houston Fertility Center is currently offering IVF for $7,950 per cycle, until June 30, 2010. We've long offered summer price cuts so that patients who typically vacation during summer months can fill their off-time with baby-making. (It's especially popular with teachers, we've learned.) At the discounted rates, if getting pregnant requires more than one cycle of IVF, you'll still be receiving affordable treatment and at a much safer embryo transfer rate.

I know the anxiety that many patients feel, about time passing, about affording treatment, and about possibly never having a baby. But I also know that all of my patients, to a person, want a healthy baby over everything else. Boosting the odds of pregnancy by narrowing down to one IVF cycle with too many embryos is not the safest way to fulfill their dreams.

One Infertile Woman's Secret

The blog, RH Reality Check, most often focuses on political hot buttons in the reproductive health arena. But in this touching blogpost by writer and activist Robin Marty, we see how deeply intimate the infertility experience can be.

Regardless of her profession and whatever image she must present in that world, a woman who struggles to have a baby has a richly secret identity, too. Here, the writer discusses what it's like to interact with a relatively fertile world when your interior is crying out with longing.

As National Infertility Awareness Week approaches, Marty's story is a poignant reminder of the role that sharing with like-minded people, whether online or in person, can play in the life of an infertile woman.

Summer in Texas Means Heat -- & Babies

I've noticed in my years of practicing reproductive medicine that given every other factor, there does seem to be a calendar-based trend to conception. So I'm happy to find out about studies that point to what we've seen in our practice here in sub-tropical Houston. It appears that summer is a great time to try and conceive with IVF.

In this study, published in Human Fertility (Vol 9, No 4, 2006), the researchers looking at more than 2,700 IVF/ICSI cycles saw "significant improvement in assisted conception outcomes performed" in summer months.

They're not exactly sure of what causes the boost but they propose it may be related to production of melatonin, a light-inhibited hormone that regulates sleeping and waking cycles.

This bit of information turns out to be in many patients' favor, since summer is the traditional season to take time off from work for vacation.

We've always encouraged our patients with seasonal jobs, like teaching, to take advantage of those stretches on the calendar when they're likely to be less stressed and busy on a daily basis. IVF treatment is carefully timed, so fitting it into a more relaxed schedule is beneficial -- lessened stress has also been linked to better fertility treatment outcomes.

Not only do I consult with patients to determine best times to schedule fertility treatment, I've started offering discounts timed specifically so they can take advantage of summer months.

Another Dietary Connection to Fertility: Fish Oil

Add another notch to the belt of fish oil purveyors. A study recently published in Human Reproduction found that diets high in omega-3 fatty acids were less likely to develop endometriosis.

Endometriosis is a common, painful, and very demoralizing female medical condition. Long before it causes infertility in many patients, the "stray" endometrial tissue that is the hallmark of the disease makes everyday life a cycle-related struggle. Very painful periods are a common sign of endometriosis, and unfortunately, the related complaints of many teens and young women are dismissed.

Untreated endometriosis can continue undiagnosed for years until a woman finds out as a result of infertility. Accurate diagnosis is only accomplished with diagnostic laparoscopy. Many times during that diagnostic procedure itself, treatment can also be performed, in the form of removing the endometrial growths.

Research to learn more about the beginnings of endometriosis is ongoing. With this new information about links between diet and the disease's occurrence, women may be able to take a more active role in preventing this and other potential debilitating conditions.

Is Ovarian Transplant For Real?

The journal Human Reproduction reported last week on a Danish woman who has now become pregnant and given birth twice as a result of one ovarian tissue transplant procedure.

Ovarian tissue transplant is one of the most experimental methods for rescuing a woman's fertility prior to her undergoing sterility-causing treatment for cancer. The more usual ways to "set aside" a woman's fertility for later use are to freeze either embryos or egg cells.

Dr. Stinne Holm Bergholdt, 32, had cortical tissue from her one ovary removed and cryopreserved before going through chemotherapy for bone cancer. She survived cancer and used the frozen tissue, after transplanting it on to her existing ovary, to successfully conceive first one child (in 2007) and then another in 2009.

There have been only a few successful pregnancies resulting from ovarian transplant, and most of those have been among women who were twins. Being twins removes much of the tissue rejection risk inherent in the transplantation of any organ. Anti-rejection medications are required for tissue transplant procedures, though patients should be informed that they don't provide guarantees of success and aren't covered by insurance.

The thing that makes Dr. Berholdt's case newsworthy is that she's the first to have a second pregnancy with the same tissue, and spontaneously (that is, without medical assistance.)

Without much larger numbers of ovarian transplant patients to observe, it's nearly impossible to derive much from Dr. Bergholdt's story that would be of value to most infertility patients. There are so many variables of fertility for each individual person, it's simply impossible to gauge why this one was so successful.

The plausability of using transplanted ovarian tissue for most women is still an unanswered question.

The Other Side of the Age & Fertility Message

Just on the heels of a study declaring that 30-year-old women have lost most of their 'good' eggs, comes a report out of the UK that women in their 30's and 40's are winding up "accidentally" pregnant because they thought their chances at pregnancy were up.

The claims being made by the British Family Planning Association (FPA) are that messages about women's age and fertility are "overplayed" and leading to something like reverse anxiety. The organization, with a mission of enabling informed sexual health choices, is heading up a new public information campaign to remind women that unless they're willing to get pregnant without trying, contraceptives should be used until after menopause.

One of the messages in the FPA campaign: "Fertility. You'd be surprised how long it takes to disappear."

Menopause is defined as not having a period for at least a year. Perimenopause is what we call the years leading up to that final menstrual period. Perimenopause can last from a couple of years to more than five, and some women are fertile throughout that time.

I'm in agreement that women should remain vigilant about their chances for pregnancy until they are clearly no longer fertile. However, to imply that the messages being sent (about women's age and the natural decrease in fertility) are anything other than appropriate is itself an overstatement.

Translating Molecular Science: Marijuana Use Slows Down Sperm

This article in Scientific American is rather complex reading but reveals some important findings. One of the items in the piece, about study results just published in the journal Cell, is tucked in at the very end -- which is too bad, because it's a tidbit of data that even the least technical reader can grasp.

According to researcher Yurij Kirichok of the University of California at San Francisco, "Marijuana likely activates sperm prematurely, leaving them burnt out in a matter of hours."

Importantly, this study was not about marijuana's effects on male fertility. Rather, the researchers were investigating molecular components that impact how and when a sperm cell gets moving. Besides pinpointing a molecule (Hv1) that activates a resting sperm cell, they also found a few more pieces to the puzzle linking marijuana and male infertility, via endocabbinoids.

Too much medical geek talk? Just simplify it to what we typically recommend: avoiding toxins of all kinds can enhance fertility.

Trying to Get Pregnant After 30 - Time to Panic?

Good Morning America featured a Scottish study that concluded by the time a woman is 30 years old, she's already lost 90 percent of her eggs.

That's enough to make the typical young woman panic.

We've always known that female fertility is more dependent on age than any other variable. This study points to a sharper decline in fertility than we like to believe.

Before everyone rushes to assisted reproductive treatment, though, let's remember that stress can negatively impact fertility.

Next, it's easy enough to have a consultation and do a quick work-up to determine your baseline level of fertility. That won't provide the definitive answer as to whether or not you will have a baby later, but it can certainly help a woman determine if she has an unexpected, silent infertility condition. Then, a plan of action can be put together to promote her future fertility.

Panic won't help you get pregnant. A little foresight and action can.

"iPhone Baby" Not So New; More Fertility 101 Needed

Here's an eye-catching piece: an article about a young woman who finally conceived after years of infertility -- all because of an iPhone app.

Essentially all that happened here was good (and successful -- congratulations!) use of an old TTC standard done up in new technology. The app she downloaded was one of apparently several that counts a woman's cycle days and flags her when she should be at her most fertile.

Keyword here is "should"...

One of the most common reasons that some women don't get pregnant easily is ovulatory disorder. There are plenty of ways that a woman's ovulation can become disrupted, out of sync, or cease altogether. The important thing to know is that very often, the woman has no symptoms to clue her in to her body's fertility problem. Simply having a period, even regularly, doesn't necessary mean ovulation is occurring on target.

So, yes, timing is crucial in trying to get pregnant. But for a 30-year-old to have tried unsuccessfully for *four years* and still only then resort to counting the days in her cycle... that tells me our fertility educational efforts aren't getting out there like we hope, whether or not the technology is a calendar on the wall or an iPhone app.