Female Fertility Are You Ovulating?

Estrogen also stimulates the uterine lining (endometrium) to become thick, lush, and filled with nutrients for the embryo. The cervical mucus responds to elevated estrogen by becoming clear, watery, and stringy. Normally impervious to sperm, at midcycle the mucus welcomes the sperm and promises easy passage toward the egg. When dried on a slide, the "friendly" mucus shows a characteristic ferning pattern. (See figure 15-2)

When your estrogen level peaks at midcycle, the pituitary "knows" that the egg is ready to embark on its journey. The pituitary responds to the estrogen peak by producing a surge of LH, which releases the egg within eighteen to thirty-six hours. The outer wall of the ovary dissolves away from the bulging follicle, and within two to three minutes the ovum escapes into the woman's abdominal cavity. Surrounded by a sticky protective layer of cells (cumulus oophorus), the egg gently floats toward the fallopian tube. The expelled follicular fluid stimulates the fimbriated end of the fallopian tube to reach toward the ovum, grasp the ovary, and vacuum up the egg. The muscles and tiny hairs (cilia) lining the fallopian tube gently coax the egg on its three-to-four-day journey through the narrow passage. For conception to occur during this cycle, the sperm must fertilize the egg in the fallopian tube within twelve hours of ovulation. (See figures 10-1 and 15-1.)

During the egg's journey, the ruptured follicle begins an amazing transformation into the corpus luteum. Stimulated by LH from the pituitary gland, this yellow-pigmented, glandular, ovarian structure enlarges to make up nearly a third of the ovary. During the Luteal phase (latter half of the cycle), the corpus luteum produces progesterone, a hormone that prepares the uterine lining for implantation of the embryo. Progesterone also acts on your body's temperature-regulating mechanism by raising basal body temperature (BBT) approximately one-half degree. Thus shortly after ovulation, you will see a rise on your BBT chart. If fertilization does not take place, the corpus luteum deteriorates. Estrogen and progesterone levels decline rapidly in the week or so prior to menstruation. Deprived of these hormones, the endometrium atrophies and menstrual flow begins. At the site of the original follicle the corpus luteum degenerates and leaves a minute piece of scar tissue as a reminder of its brief existence. If fertilization takes place, a corpus Irwteum of pregnancy forms to maintain the uterine lining (endometrial bed) and support the implanted fertilized ovum (conceptus). I'll discuss more about fertilization and implantation in chapter 19.

The hypothalamus, pituitary, and ovary must all work in perfect harmony. When they do not, the most obvious symptom is abnormal menses. And the nature of the abnormality clues me into the source of the problem. Table 12-5, "Conditions That Can Interfere with Ovulation and Menstruation," gives an overview of which fertility problems are caused by malfunctions of the hypothalamus, pituitary, ovary, pituitary feedback system, and other related systems. The diagnosis and treatment for these disorders are discussed in the remainder of this chapter and in chapters 12 and 13 .

In the remainder of this chapter I will explain how I approach evaluating ovulation in the woman with a regular cycle. The next two chapters will explain how I approach evaluating women who have never had a period and women who have irregular periods or periods that have stopped.

"My period is so regular," Margaret B. explained, "that whether or not I've started, on the thirtieth day I insert a tampon before I go to work. By noon I'm always glad I did, because otherwise I would have had an accident." When I hear this type of menstrual history, I'm almost certain that the woman is ovulating each month. My attention turns immediately to diagnosing other fertility problems. However, on the outside chance that nature is tricking us into complacency, I ask the woman to keep a basal body temperature (BBT) chart for a couple of months or monitor her urine for an LH-surge. When accurately kept, the BBT will confirm the timing of ovulation and will help me properly schedule other tests.

Interpreting the Basal Bobby Temperature Chart

The normal ovulatory pattern: Measure your basal (resting) body temperature first thing in the morning—even before getting out of bed. During the f follicular phase (the first half of your cycle) the "normal" BBT pattern should show only slight variations in your temperature (under 98 degrees). In response to progesterone produced at midcycle by the corpus luteum, your BBT will rise about a half degree (to about 98.4) and should remain elevated until your next period begins. The two or three days preceding the temperature elevation are your most fertile. After your temperature rises, the odds of initiating a pregnancy become minimal. By reviewing this data over two to three months, you can usually predict your most fertile days. Failure to ovulate: If your temperature remains relatively constant throughout your cycle, you did not ovulate.

Short luteal phase: If you are undergoing ovulation induction treatment, you will want to pay particular attention to the fourteen days following ovulation. Should your period start within ten days of the temperature rise, you may have a progesterone deficiency (luteal phase defect). Without an adequate progesterone supply the uterine lining will not develop properly and the embryo will fail to thrive.

Sustained temperature rise: A sustained rise in your temperature—beyond the date for your next period—should make you jump for joy because you are probably pregnant!

Additional data: Variations in temperature levels aren't the only data recorded on BBT charts. You can also indicate the days you menstruate (with an X), the days you have sex, the day you feel mittleschmerz (the twinge of pain associated with ovulation), and days when you are ill or out of sorts. When kept with care, this record can provide valuable information for planning your fertility treatment. Table 11-1 explains how to keep your chart.

Don't get too uptight about keeping the BBT chart. If doing so causes you problems, discuss it with your doctor and consider urinary LH testing. Although the BBT can provide important supportive data, it isn't absolutely necessary. Your peace of mind is far more important than creating a graphic history of your sex and reproductive life.

Table 11-1

How to Keep Your Basal Body Temperature Chart

Begin taking your temperature on the morning your menstrual period ends.

Shake down the thermometer the night before and place it on a bedside table.

At your first waking moment take your temperature by inserting the thermometer in your mouth, vagina, or rectum for five minutes. Do not vary your procedure from day to day or month to month. Use a clock to time yourself. DO NOT smoke a cigarette, eat or drink, or get up to go to the bathroom or to go find your thermometer before taking your temperature.

Record the thermometer reading on your chart under the correct day of your cycle (day 1 is the first day of your period). Record the days you have sex by placing an arrow at the bottom of the column. Record the days of your menstrual flow with an X. Record mittleschmerz if you feel it. Note any exceptions on your chart—for example, if you are ill, did not get a good night's sleep, or are running a fever. Also mark when your doctor performs any tests and what they are.

Wash the thermometer with cool soapy water, rinse it, shake it down, and place it in its protective case beside your bed. Some people prefer to use alcohol or disposable plastic thermometer protectors.

Repeat this procedure every day until your next period begins. Each month start taking your temperature on the morning your menstrual period ends.

Take your charts to every doctor's appointment.

Living with BBT
Keeping the BBT chart is an inexpensive method for observing your menstrual cycle and hormonal system at work and an indirect method for ballparking when ovulation will occur. BBT charts will help indicate your most fertile days, so you can plan sex at the "right" time of the month.

I've had some women tell me in total frustration that they're ready to flush their thermometer down the toilet. "If I have to plot another flat line, I think I'll scream. Every morning the mercury reminds me that I'm a failure." I have a few suggestions that may help you put BBT charting into proper perspective:

1. Think of taking your temperature like brushing your teeth: you do it without even thinking. The BBT is more convenient because you don't even have to get out of bed to do it.

    

2. Make BBT charting into a game. See which one of you can guess the day that your temperature will rise. The one who wins gets taken out to eat (at the other's expense, of course!).

    

3. If you are the analytical type, use your calculator or personal computer to calculate median temperature during the follicular phase, percent difference to the luteal phase, and standard deviations. Where else could you find so much data to analyze?

    

4. Compare BBT charts at your fertility support group meetings. Award ribbons for those with the flattest line, for those with the highest midcycle temperature rise, and for those couples who had sex even during their infertile days.

Urinary LH testing
Although serum progesterone tests BBT's and endometrial biopsy can indicate whether you have ovulated, these do not help pinpoint the actual day of ovulation. The BBT is not helpful to tell you when you need to have sex or have an insemination in any particular month.

The urinary LH test is a test picks up the rise in LH that occurs about 24 hours before ovulation. While older kits required up to one hour to perform, newer tests are more accurate and can be performed in a few minutes. The test kit can be purchased without a prescription and can easily be carried in the woman's purse.

Testing begins a few days before expected ovulation. If you cycles last 28 days I recommend testing start on cycle day 12. When the woman is taking clomiphene testing can start four days after the last pill is taken. The testing is best carried out mid to late morning (for most kits). I ask my patients to save all the sticks so they can be compared from day to day, or they can be brought to the office if there is a question about when the surge really started.

If the LH surge stick does not change color after about six days, I recommend checking an ultrasound or blood progesterone levels to make sure the surge was not missed.

Taking an Endometrial Biopsy
By examining a tiny piece of uterine tissue, I can evaluate how well prepared your uterus is to accept an embryo. I use the LH surge test and your menstrual history to time the biopsy one to three days before your next period begins. I will have many patients call the office when they detect an LH surge. We will schedule the surge 12-13 days later. I recommend avoiding intercourse during the month the biopsy is scheduled or recommending that a blood pregnancy test be checked to insure that an early pregnancy won't be interrupted.

With few rare exceptions (where the egg remains trapped in the follicle, a condition called luteinized unruptured follicle or immunologic abnormalities), a normal endometrial biopsy confirms that you are ovulating, that you have an adequate luteal phase, and that your uterine environment will support an embryo. I'll discuss more about the endometrial biopsy in chapter 19.

If a woman's menstrual cycle appears normal, I proceed down different diagnostic paths. However, if any of these test results look suspicious, I treat her as I would a woman with abnormal menstrual periods. Read on to learn how I diagnose menstrual abnormalities.

For more information on your initial visit to your physician read the
INCIID Routine Fertility Workup or IVF.com Homepage.

Miracle Babies and Other Happy Endings
for Couples with Fertility Problems
Copyright © 1986 Mark Perloe M.D., and Linda Gail Christie.