Problems with conception

Trying for a baby without success, or losing pregnancies, is one of the loneliest experiences there is — and one where good information and a calm assessment can make a real difference. This page covers preparing for pregnancy, when to seek help if conception is taking longer than expected, and what happens when miscarriages recur.

Preparing for pregnancy

Preconception care is simply getting yourself in the best possible position before you start. It is worth doing whether or not you anticipate any difficulty, and ideally a few months ahead.

The essentials are well established. Folic acid is the clearest example: taking a supplement before conception and for the first twelve weeks reduces the risk of neural tube defects such as spina bifida, and the usual dose is 400 micrograms a day. A higher dose is advised for some women, including those with diabetes, those taking medication for epilepsy, and those who have previously had a baby with a neural tube defect.

• Folic acid, started before you conceive
• A review of any long-term condition — diabetes, epilepsy, thyroid problems, high blood pressure — to make sure it is well controlled
• A check that your current medicines are safe in pregnancy, and a plan to change any that are not
• Checking rubella immunity, and vaccination if you are not immune
• Stopping smoking and recreational drugs, and reducing alcohol — for both partners
• Reaching a healthy weight, which affects fertility in men as well as women
• Cervical screening brought up to date

How long is normal

Most couples conceive within a year. It is entirely normal for it to take several months, and the anxiety generated by a few unsuccessful cycles is often out of proportion to what is actually happening.

Guidance recommends assessment for a woman who has not conceived after a year of regular unprotected intercourse, where there is no known cause. Earlier assessment is sensible if you are 36 or over, or if there is a known reason to expect difficulty — irregular or absent periods, previous pelvic infection or surgery, endometriosis, or a known problem affecting your partner.

Having sex every two to three days across the cycle gives the best chance, and is a good deal less stressful than trying to time things precisely around ovulation.

What assessment involves

Fertility is a shared matter and couples are best seen together. Problems are found in the man in around a third of cases, in the woman in around a third, and in both — or in neither — in the remainder.

Initial assessment usually includes a detailed history from both partners, blood tests to confirm ovulation and check hormone levels, a semen analysis, and an ultrasound scan of the pelvis. Depending on the findings, a test of whether the fallopian tubes are open may follow.

It is worth saying plainly that in about a quarter of couples no cause is found. That is frustrating, but it is not the same as bad news.

Recurrent miscarriage

Miscarriage is common, and a single loss does not mean anything is wrong. Recurrent miscarriage is defined by the RCOG as three or more first trimester miscarriages — and importantly, under the 2023 guidance these no longer have to be one after another, so healthy pregnancies in between still count.

Clinicians are also encouraged to use their judgement and investigate after two losses where there is reason to suspect an underlying cause, rather than making women wait. Assessment is also recommended after a single second trimester loss.

Recurrent miscarriage affects around one in a hundred women.

What is looked for, and what can be done

Investigations are aimed at the causes for which something can actually be done:

• Antiphospholipid syndrome and other clotting problems, which are treatable
• Thyroid and other hormonal conditions
• The shape of the womb, assessed by scan
• Chromosomal testing of the pregnancy tissue where possible, and of both partners if indicated
• A review of age, weight, smoking and alcohol in both partners

When no cause is found

Around half of couples who are investigated do not receive a clear explanation. Understandably, that can feel like being sent away empty-handed.

The important counterbalance is the prognosis. Where recurrent miscarriage remains unexplained, the chance of a successful future pregnancy with supportive care alone is in the region of seventy-five per cent. Being offered close support and early scans in the next pregnancy is itself a form of treatment, and one that matters.

The emotional side

Difficulty conceiving and repeated loss take a genuine toll — on mood, on confidence, and often on a relationship. This is recognised in national guidance, which recommends that counselling be available before, during and after investigation, whatever the outcome.

If that would help, I can point you towards it. Nobody should be expected to manage this on determination alone.

What I can and cannot offer

I can provide preconception advice, initial fertility assessment, investigation of recurrent miscarriage, and treatment of gynaecological conditions such as endometriosis, fibroids or polyps that may be contributing.

I do not provide IVF or other assisted conception treatment. Where that is the appropriate next step, I will explain why and refer you to a specialist fertility unit — with the groundwork already done, so you are not starting again.