There are a variety of ways in which combined oral contraceptive (COC) use can affect fertility, some more dramatically than others, but all worth discussing. Some are difficult to quantify by their nature, so this post won’t be full of shocking statistics – it is meant to provide some “food for thought” and to bring to light some of the barriers to future fertility that COCs often present.
Amenorrhea – the absence of menstruation – represents one such barrier and affects many women upon discontinuation of COCs. Amenorrhea implies anovulation (the absence of ovulation), which obviously presents an insurmountable obstacle to conception for as long as it persists. No ovulation, no egg, no conception. While it may only continue for a few cycles, in rare cases post-pill amenorrhea can plague women for years, and younger women are no exception. Anovulation can also go undiagnosed for a time, as anovulatory bleeding is not uncommon when transitioning off of COCs.
Allow me to explain. Normal menstrual bleeding is triggered by a decline in progesterone when pregnancy does not occur in a given cycle. Progesterone, the hormone responsible for maintaining the uterine lining in preparation for the implantation of a fertilized egg, is secreted by the corpus luteum (CL; the remnants of the ruptured ovarian follicle from which the egg was ovulated that cycle). The CL can only survive for a short time without support from the hormone hCG, which is only secreted by a successfully implanted embryo. Consequently, in the absence of pregnancy, the CL eventually dies away and progesterone levels decline with it. Without the support of progesterone the uterine lining begins to shed and recede, giving rise to progesterone withdrawal bleeding or menses.
But of course, in an anovulatory cycle there is no CL and therefore no progesterone rise or withdrawal. This is where estrogen comes into play – it is responsible for preparing and maintaining the uterine lining prior to ovulation, and for triggering ovulation itself. Without sufficient estrogen not only will ovulation be unlikely, but the uterine lining will also remain unstable and may shed at unpredictable times throughout the cycle. For a woman who is discontinuing COC use this bleeding can look like irregular menses, which seems plausibly normal for a transitional time, and so many women waste months waiting for their cycles to regulate – or worse – go on believing that they are ovulating (since they are bleeding) and spend months trying unsuccessfully to conceive. Not only can amenorrhea and anovulation present a serious obstacle to conception, they can also be deceptive and cause much undue stress and anxiety as a couple struggles to conceive. They are treatable conditions in most cases, but treatment can be expensive and may take weeks or months to be effective.
What saddens me the most about these potential complications is that many women are unaware of the possibilities. For example, my plan was always to “come off the Pill” about 3 months before we were ready to try to conceive (on the advice of my GYN provider). Given my educational timeline as a medical student, future intern/resident and future physician, my husband and I will be trying very hard to time any conceptions carefully. Of course there are many variables and it is often impossible to plan “down to the minute”, but the possibility that ovulation could be delayed by 3, 6, 9 months, even a year…? That would have been a HUGE unexpected obstacle that could have cost us a window of opportunity. Of course I always fall back on the knowledge that God will provide, and that His timing is truly all that matters at the end of the day, but what a heartbreaking turn of events that could have been.
The idea that the Pill has the potential to cause infertility issues is scary enough, but what is even more common is the masking of existing problems. One common setback, for example, is a short luteal phase – the time between ovulation and the onset of menstrual bleeding. As we discussed, progesterone secreted by the CL maintains the uterine lining in preparation for the implantation of a fertilized embryo. It is easy to imagine that, if the CL dies off prematurely and progesterone levels decline too quickly, a fertilized egg would not have time to successfully implant prior to the onset of menstrual bleeding and the conception would be lost without the woman’s knowledge that it had ever occurred. On the other hand, some women may have infertile cervical fluid, which significantly reduces the lifespan of sperm in the female reproductive tract and may hinder its passage into the cervix altogether, presenting another obstacle to conception. Another common “fertility problem” (which isn’t really a problem at all) in women who do not use ovulation predictor kits is late ovulation. There is a very common misconception out there that ovulation always occurs at mid-cycle, around day 14, which for many women simply isn’t the case. If you don’t ovulate until day 20 (which is completely normal for some women), having sex 14 times on day 14 does nothing to improve your chances of conceiving, and so many couples spend months of heartache trying unsuccessfully to conceive simply because they are unacquainted with the woman’s cycle.
The punch line here is that all of these conditions are masked while a woman is taking COCs. There is no luteal phase without ovulation, there is clearly no late ovulation without ovulation, and the quality of cervical fluid is dramatically altered by the progesterone component of COCs. These are all issues that a couple may encounter in their attempts to conceive, and they are all issues that can be uncovered and addressed through natural means (or medicinal means if necessary) far in advance, greatly reducing the time, effort, and stress associated with trying to conceive.
Another potentially serious medical condition often masked by COC use is primary ovarian ineffectiveness or POI, which is often the culprit behind the prescription of COCs for menstrual regulation. Women with particularly heavy or irregular flows or more severe menstrual symptoms (painful cramping, for example) are often prescribed COCs to correct the imbalance of hormones that causes these symptoms. POI can cause particularly heavy, light and/or irregular flows, and while COCs often do restore the proper hormone balance necessary to alleviate symptoms, the underlying ovarian insufficiency remains. When these women discontinue COCs, their ovarian hormones (estrogen and progesterone) will most likely still be insufficient to properly regulate their cycles (with the caveat that POI can come and go in some cases). Though not all women who experience heavy or irregular periods have POI, the disorder affects an estimated 1 in 100 women by the age of 40 – not terribly uncommon. The most disturbing fact is that POI, when left undiagnosed and improperly treated, can result in long-term infertility according to Dr. Lawrence Nelson of the National Institutes of Health. Dr. Nelson also notes that POI can trigger premature menopause in women as young as 30. Women on COCs with underlying POI can go through menopause without realizing it due to the masking effects of the Pill, and upon discontinuation discover that they are no longer able to bear children.
As POI is masked (and often improperly “treated”) by COC use, it is not uncommon for the disorder to cause unnecessary and devastating infertility problems in unsuspecting women. If you have been prescribed COCs for the kinds of cycle irregularities discussed here, I would encourage you to ask your doctor for a simple blood test that can screen for POI by evaluating your FSH levels (follicle stimulating hormone, which is secreted by the pituitary and is responsible for follicle maturation prior to ovulation).
Infertility is one of those subjects that really hits home for many women – particularly young women who have yet to begin or complete their families. I do not wish to employ fear tactics to scare women off of the Pill, but these are real concerns worth discussing openly. Most young, healthy women will never be touched by the heartbreak of infertility, thank the good Lord, but the gift of child bearing is one worth protecting through careful consideration of the risks. If you are interested in discontinuing COCs and becoming acquainted with your cycle prior to trying to conceive, I highly recommend charting (see Taking Charge of Your Fertility in Books I Recommend, or click here to learn more about Natural Family Planning online). It's worth taking a few extra months to sort out your cycle, look for any irregularities or potential challenges, and have a thorough understanding of your own cycle - and if all is well, charting is still worth its weight in gold as it will give you all the tools you need to conceive whenever you're ready!
If you're just joining us in this series and would like to read more, see the sidebar for links to previous posts, or start here at the intro. And stay tuned for the next post in the series (yeah, there's more!)...
Resources:
Taking Charge of Your Fertility by Toni Weschler, MPH (see Books I Recommend)
Beautiful and great information ... I like your way of thinking about pregnancy.
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Jenna: This is brilliant. I have been trying to get this message out to young women EVERYWHERE because there are few Gyns that will tell you about these risks with the pill and now that Egg Freezing programs are available, this is critical information. How do we "get the word out"? I fear it's a fight against the established pharmaceutical lobby, but it saddens me that more gyns are not up front about this and say, have your FSH level checked in your mid-20s and early 30s. This could save a lot of heartache in the long run.
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