from the book How to Have a Baby:
Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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Tubal Connection (Page 2)
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Table of Contents
Is BBT charting of any use ?
What about using fertility software programs ?
Of what use is an endometrial biopsy ?
Of what use is a D&C ( curettage) ?
How does testing for progesterone help ?
How can I find out when I am ovulating and use
this information to track my fertile time ?
How can I use cervical mucus monitoring to
monitor my ovulation ?
Normally, one of the ovaries releases a single mature egg every month,
and this is called ovulation. Women may notice pain or abdominal
discomfort at the time of ovulation and occasionally have some slight
vaginal bleeding. The presence of regular periods, premenstrual tension
and dysmenorrhoea (period pains) usually indicate that the menstrual
cycles are ovulatory.
Eggs are stored in the ovaries in follicles.
Follicles exist in two major categories – growing and non-growing (
primordial ). Eggs in the primordial follicle are in a very immature
form. In this state they are not capable of being fertilized by a sperm
until they undergo a maturing process which culminates in their release
from the ovary at the time of ovulation.
Egg maturation and ovulation is stimulated by two
hormones secreted by the pituitary - follicle stimulating hormone (FSH)
and luteinizing hormone (LH) . These two hormones must be produced in
appropriate amounts throughout the monthly cycle for normal ovulation to
occur.
Every month, at the start of the menstrual cycle, in
response to the FSH produced by the pituitary gland, about 30-40
primordial follicles start to grow. Of these, only one matures to form a
large fluid-filled structure, called a Graafian follicle which contains
a mature egg, while the others die ( a process called atresia). The
mature egg is released from the follicle when the follicle ruptures in
response to a surge of LH produced by the pituitary.
After ovulation has occurred, the follicle from which
the egg has been released forms a cystic structure called the corpus
luteum. This is responsible for progesterone production in the second
half of the cycle.
You can see an excellent animation ( which will open
in a new browser window) of the hormonal changes which occur during a
normal menstrual cycle at
Serono Fertility Lifecycle.
Most women who have regular periods have ovulatory
cycles. Women who fail to ovulate or who have abnormal ovulation usually
have a disturbance of their menstrual pattern. This may take the form of
complete lack of periods (amenorrhoea), irregular or delayed periods
(oligomenorrhoea) or occasionally a shortened cycle due to a defect in
the second part (luteal phase) of the cycle.
Fig 1. Schematic of the ovarian follicle during its development
(clockwise)
Fig 2. The hormonal changes which occur during a normal ovulatory cycle,
if pregnancy occurs. The purple line marks the point when the embryo
implants.
To determine the length of the menstrual cycle, one only needs to note
the date of the beginning of the menstrual period (first day of flow)
for two consecutive periods, and then count the day from one date to the
next. Keeping track of the length of menstrual cycles will help
determine the approximate time of ovulation, because the next period
begins approximately two weeks from the date of ovulation.
The rough rule to calculate the approximate date of
ovulation is : NMP minus 14 days, where NMP is the ( expected) date of
the next menstrual period. This is because the luteal phase for most
women is 14 days long.
Keeping track of the menstrual cycle by charting it
can indicate other ovulatory disturbances . For example, if a menstrual
cycle that is normally 28 days starts to occur every 35 or 40 days, this
may mean that ovulation is disturbed, and an evaluation is needed.
Is BBT charting of any use ?
During the luteal phase of the cycle, the corpus luteum produces the
hormone progestrone, which elevates the basal body temperature. When the
basal body temperature has gone up for several days, one can assume that
ovulation has occurred. However, it is important to remember that the
BBT chart cannot predict ovulation - it cannot tell you when it is going
to occur !
The basal temperature chart can be a useful tool. It
allows the patient to determine for herself if she is ovulating as well
as the approximate date of ovulation, but only in retrospect. Basal body
temperature charts are easy to obtain and the only equipment required is
a special BBT thermometer.
General instructions for keeping a basal body
temperature chart include the following :
- The chart starts on the first day of menstrual
flow. Enter the date here.
- Each morning immediately after awakening, and
before getting out of bed or doing anything else, the thermometer is
placed under the tongue for at least two minutes. This must be done
every morning, except during the period.
- Accurately record the temperature reading on the
graph by placing a dot in the proper location. Indicate days of
intercourse with a cross.
- Note any obvious reason for temperature variation
such as colds, or fever on the graph above the reading for that day.
The major limitation of the BBT is that it does not
tell you in advance when you are going to ovulate - therefore its
utility in timing sex during the fertile period is small. Interpreting
the BBT chart can be tricky for many patients - rarely do the charts
look like those you see in textbooks!
Also, keeping a BBT chart can be very stressful -
taking your temperature as the first thing you do when you get up in the
morning is not much fun. What is worse is that you start to let the BBT
chart dictate your sex life. This is why though the BBT chart used to be
a useful method in the past, it's utility is limited today - and newer
methods are available which are more accurate are available. We advise
our patients never to chart their BBTs - we feel they are just a waste
of time.
Manufacturers have now incorporated a microprocessor
along with the digital thermometer, to create an electronic fertility
management device , called The Bioself Fertility Indicator. This
makes calculation of the "fertile days" much easier, because it combines
and optimises both the basal body temperature and calendar method of
ovulation prediction.
What about using fertility software programs ?
Newer software programs ( easily available on the internet ) , such as
CycleWatch, help you learn about your body's fertility signs by giving
you the tools to document and analyze your observations. For women who
are comfortable with computers, this is a useful tool to organize your
cycle data and analyze your cycles to determine fertile times.
You can also use our
free online fertility calculator
to determine when you ovulate !
Of what use is an endometrial biopsy ?
After ovulation, the endometrium is prepared for implantation of the
fertilized egg by the progesterone secreted by the corpus luteum. In
order to determine if ovulation is occurring normally, an endometrial
biopsy used to be done in the past . During this procedure, a small amount of endometrium
from inside the uterine cavity is extracted surgically and sent for pathologic
examination under a microscope. This is a standard procedure usually
done just before the period begins. It can be done in the doctor's
office or in an operating theater. No anesthesia or hospitalisation is
needed. However, it does cause discomfort during the procedure (about as
much as a severe menstrual cramp) and an analgesic can be taken a
half-hour prior to the procedure to decrease this discomfort.
When examining the endometrial biopsy, the
pathologist looks for the influence of the estrogen and progesterone
hormones on the endometrial glands. If progesterone has been produced in
that cycle, the endometrial glands show secretory changes . In fact, the
effect of progesterone on the endometrium is so predictable, that the
biopsy can be "dated" - that is, the pathologist can predict on which
day the next period will start! If there is a "lag" between the
predicted day and the actual day, then this suggest a luteal phase
defect, which means that the production of progesterone is deficient. If
no progesterone at all has been produced, then the endometrium will be
reported as being proliferative (under the influence of only estrogen) -
which suggests that the cycles are anovulatory (i.e., ovulation did not
occur in that cycle).
Because an endometrial biopsy is painful and
provides limited information, few doctors use it anymore.
Of what use is a D&C ( curettage) ?
A curetting used to the commonest procedure done for infertile patients.
In fact, a number of infertile patients will request that a curetting be
done for them, since they feel that the curetting will "clean out" the
dirt they have in their uterus and allow them to conceive. This is an
old wive's tale and is based on " I know someone who got a baby after a
curetting".
The correct technical term for curetting is D and C
- dilatation and curettage - which means the cervix is stretched
(dilated) and the uterine cavity scraped (curetted) to collect the
endometrium) . This is an obsolete procedure for an infertile woman, and
can actually be harmful. The only use of a D&C is to provide endometrial
tissue which can be examined under the microscope to see if the woman is
ovulating or not. It has absolutely no fertility-enhancing role
whatsoever.
Since this endometrium can be obtained much more
easily, safely and cheaply with an endometrial biopsy (in which only a
strip of endometrium is removed) there should rarely be any need to do a
D&C for an infertile woman. Patients have often have repeated D&Cs - and
these can actually damage the cervix and even block the tubes, if
infection occurs after surgery. The only possible role for a D&C today
is when tuberculosis of the uterus is suspected.
How does testing for progesterone help ?
The progesterone level in the blood may be measured to confirm that
ovulation has taken place. This test is done on Day 21 of the cycle
(about 1 week after the expected date of ovulation) . A normal level is
between 10 ng/ml - 20 ng/ml and indicates that the corpus luteum is producing enough progesterone, and
is good retrospective evidence that ovulation occurred. A very low level
means that the cycle was most probably anovulatory. An intermediate
level may suggest a luteal phase defect (in which the corpus luteum does
not secrete enough progesterone).
How can I find out when I am ovulating and use
this information to track my fertile time ?
While the above tests will tell a women whether or
not she ovulates, the following symptoms and tests which can be used in
order to determine when you ovulate are of greater importance, since
they provide information which can be used to identify the "fertile
period" prospectively.
How can I use cervical mucus monitoring to
monitor my ovulation ?
By checking your cervical mucus daily, as described in the chapter on
the cervical factor, you can determine when you ovulate. Just before
ovulation, your cervical mucus is thin, profuse, clear and stretchy,
like raw egg whites. After ovulation, the mucus becomes thick, tacky,
scanty and sticky. You can learn to appreciate this change in your mucus
(by seeing and feeling it) and this allows you to predict when ovulation
occurs quite accurately. You can learn the technique for tracking your
cervical mucus in the
Chapter on The
Cervical Factor.
Approximately 25 percent of women may experience a pain on one side of
the abdomen that is associated with ovulation. This is called
mittelschmerz (a German word, which means midcycle pain) and is usually
related to the release of an egg from the rupturing follicle. It is a
good idea to mark the date when it occurs since this information is
helpful in determining when ovulation occurs.
continued . . .
Next page: Ovulation -- Normal and Abnormal (Page 2)
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