There is a lot of confusion out there about what is considered normal or ideal for the return of fertility after giving birth. Many women experience changes in their cycles after giving birth and aren’t sure where to turn for help or if they even need help in the first place.
Let’s start by honoring that there is a wide variety of normal as to when signs of fertility return after having a baby. Although, I’ll also note that women who choose to not breastfeed or pump at all (or are unable to) or those experiencing a loss should see signs of ovulation within 6-8 weeks after giving birth.
Please note: this article is geared towards those who are breastfeeding or pumping exclusively (or for most feedings) as that is the primary factor that delays the return of ovulation and fertility, unless there is another medical condition involved.
Some Return of Fertility Basics
After giving birth, there is a huge physiological shift that takes place. With the birth of the placenta, hormones drastically shift from progesterone and estrogen being very high to very low, while simultaneously prolactin levels increase. Prolactin has an inhibiting effect on ovarian function. Many new mothers won’t ovulate for several months after giving birth.
There is even a lot of variability on if mothers will ovulate before their first postpartum period. That is to say, many will have that first postpartum period as part of an anovulatory cycle as hormones begin to fluctuate again. This is all within the range of normal.
The majority of women will experience the return of their fertility and menstruation by 12 months postpartum, with many of those falling in the range of 6-12 months postpartum as baby increases solid food intake.
Some variables that affect when ovulation returns include:
- Nutritional status. Are there any deficiencies? Is the mother eating enough to support breastfeeding and fertility?
- Thyroid health. This is a common area of concern in the postpartum time and most definitely can be the cause of fertility or period issues in the few years after birth.
- Frequency of breastfeeding. This affects prolactin levels and therefore pituitary function in relationship to initiating ovarian activity.
- Stress and sleep. These are both common issues in the postpartum time that may cause the return of fertility to be delayed as the mother’s body conserves resources.
- Estradiol levels and sensitivity. We all have different levels of estradiol receptor site sensitivity, meaning that some can have lower levels of estradiol but respond with enough endometrial lining growth to initiate a bleed (possibly without ovulation). This is also true for ovarian function and how quickly or efficiently the ovaries respond to lower levels of FSH (follicle stimulating hormone) or LH (luteinizing hormone).
- Birth trauma or complications. If birth was challenging or had complications this will affect postpartum healing and the body’s capacity to utilize resources for fertility.
Signs that fertility is near
Monitoring fertility in the immediate postpartum time is usually not a priority and it really doesn’t need to be for the first few months postpartum. With postpartum bleeding and lochia there can be a shift in vaginal microbiome and discharge, which makes it difficult to get a clear read on one of the main signs of fertility: cervical fluid.
Monitoring cervical fluid, ideally by checking internally close to the cervical opening, is a great way to start to track the return of your fertility. You can record it in an app, like Kindara. Many new mothers will experience a period of cervical fluid dryness with breastfeeding and lower estradiol levels. It’s also important to note that it may take the body several attempts at ovulation before it returns so cervical fluid patterns may vary, which can be frustrating if you’re relying on that for contraception. If you’re not sure, it’s always a good idea to use a backup barrier method for sex!
As fertility increases, cervical fluid shifts from sticky to creamy to wet or slippery (commonly called egg-white for it’s stretchy quality). This is most definitely a sign that ovulation could be near but it doesn’t ensure ovulation. The best way to truly confirm ovulation is by tracking basal body temperature and noting when there is a rise of about 0.5 degree Fahrenheit or more. The trouble with that for contraceptive use is that it’s only visible in retrospect. So, again I recommend using a barrier method when you’re still not sure and you don’t want to conceive.
Along with cervical fluid changes, you may also notice other signs that your cycle is near. This can include an increase in libido or desire, womb sensations, ovarian discomfort or spotting.
Your first postpartum bleed
As was mentioned above, your first postpartum bleed may be anovulatory in nature; however, the longer you go without a bleeding time the more likely your first cycle will include ovulation. Your first postpartum bleeding time will often be heavier than is usual. In my opinion, this is often due to the endometrial lining being exposed to increasing estradiol levels for a period of time that is longer than a typical follicular phase. Usually this will resolve itself within 3 cycles, but if it doesn’t definitely get support to decrease your average blood loss each cycle.
For about half of all mothers, periods get easier after birth. This can mean less pain or clots and increased regularity overall. This has a clear explanation from the lens of East Asian Medicine. Birth clears out any stagnation, especially when it is allowed to unfold in a normal, physiological way and there is some basic postpartum care. Birth can act as a reset for the womb and hormonal landscape. With proper nutrition, warmth and care in the immediate postpartum time, fertility and vitality can actually increase! I see this as possible for all new mothers.
For the other half, things get more complicated or intense. They may experience more pain or clots, less regularity, prolonged heavy bleeding or other premenstrual issues. Often, this can be traced back to birth trauma or complications or lack of care in the early postpartum weeks. However, it’s also possible that it’s an underlying issue that has been revealed after birth. In East Asian Medicine, exposure to cold foods, drinks or environments in the early postpartum time can be detrimental to womb and menstrual health after baby.
As mentioned above, some common troubles that arise with menstrual health in the postpartum time include:
- Heavy bleeding
- Cramping, pain or clotting
- PMS symptoms
- Short luteal phase
While estradiol rises with increased ovarian activity, it can take three cycles or so for progesterone levels to come back to their ideal range. The return of fertility after birth has some similarities to menarche in this way; however, the postpartum body usually doesn’t clear estrogen with the same vigor as a teenage body does!
Lower levels of progesterone can be the underlying cause of the above problems. For many this will resolve without any intervention after a few initial postpartum cycles. However, if it doesn’t, there are natural ways to support your body and hormones and end postpartum menstrual health challenges!
The most important steps to addressing your postpartum hormonal resilience and menstrual health are ensuring that your basic needs are met. If you’re not getting enough to eat, drink or enough rest, it doesn’t matter what your lab results reveal! If you feel perpetually isolated, stressed and under-resourced, then it’s protective and intelligent for your body to not be fertile.
If you feel that your basic needs are covered and you’re doing well overall, then it may be time to get some blood testing. A complete blood count and comprehensive thyroid testing are a good place to start. I recommend working with a qualified practitioner for this. As mentioned above, thyroid health can be a common area of concern in the postpartum time and it will cause menstrual health issues in almost all cases.
I work with women often who experience menstrual health or fertility challenges in the first few years postpartum. The solutions are often simple but do require some diet and lifestyle adjustments and occasionally herbal medicine, supplements or consistent acupuncture to see lasting change.
The first and most important step is recognizing if what you’re experiencing is a variation of normal or is something that needs additional support. That’s why you’re here!
If you’re interested in working with me for your postpartum menstrual health or fertility, book a virtual session or office visit here!
A note on research in this area
I referenced some articles when preparing for this post; however, much of the research in this area is outdated, coming from the late 80’s and early 90’s. Funding is often an issue when it comes to maternal health and women’s health issues. You can have a look at some of the following articles, but I do not think the quality of research is very high. The content of this post has incorporated some of this research but is also largely based on my own clinical expertise.
Breastfeeding patterns and return of fertility in Australian women
Natural regulation of fertility
Contraceptive efficacy of lactational amenorrhea