Cycle restoration with or without desire for children
Isabelle Ecochard
Introduction
For over more than 20 years now, the EIFLE (European Institute for Family Life Education) has been federating associations that focus on the recognition of the signs of fertility and infertility during the woman's cycle by the woman herself or by the couple. We may also acknowledge here the many efforts made in this field over the globe since the seventies by the IFFLP (International Federation for Family Life Promotion).
The expertise and competence of the EIFLE in the field of fertility is observation and self-observation. Indeed, the signs of fertility and their monitoring have been increasingly known and better used, not only by women and couples, but also by physicians and researchers. The objectives of this monitoring or of this knowledge are multiple. Monitoring the days of fertility and infertility in a woman's cycle is used as a real way of birth control. The methods that support this knowledge are now well codified and have been the object of numerous studies that have established their relevance.
This knowledge has served the aim of conceiving a child when conception is slow to arrive. In fact, there is a gap between normal and pathological cycles which is not often explored. This is the space of the present work.
In fact, there are numerous couples that find difficulties in using the natural methods because of the ill-known and poorly detectable latency period, because of a very long fertile period, or because of a too short non-fertile post-ovulatory period (usually called "short corpus luteum life span"). The object of the present work is the self-recognition of the non-fertile post-ovulatory period using the peak in cervical mucus or the temperature shift.
Material and method
The present study analyzed data already used for a previous study on various menstrual cycle parameters carried out in 1997 [1].
We considered here 107 women who were carrying out a daily monitoring of the signs of fertility: cervical mucus or temperature shift. At each cycle, an ovarian echography was made to identify the day of ovulation during the fertile period as identified by self-observation of cervical mucus. In addition, there were daily assessments of urine estrogens, progesterone, FSH, and LH.
The study focused on 283 cycles whose days of ovulation could be identified by echography and compared the duration of the non-fertile post-ovulatory period, as identified by ultrasound, to this duration, as identified by cervical mucus and/or temperature shift.
Results
1. True vs. self-determined duration of the non-fertile post-ovulatory period
The true duration of the infertile period was defined as the delay between the second day after ovulation (as determined by echography) and the day before the onset of menses of the next cycle. In 180 cycles with known lengths, the duration of the non-fertile post-ovulatory period was determined according to Billings method; this duration was < 9 days in 34 cycles (19%). In other 240 cycles, this duration was determined according to the sympto-thermal method, it was < 9 days in 66 cycles (27.5%). Figure 1 shows the durations of the true non-fertile post-ovulatory period as determined by echography (grey bars) and the durations as determined by the two above-mentioned natural methods (black bars).
|
|
Figure 1 - The left panel shows the durations of the non-fertile period as determined by Billings method. The right panel shows the durations of the non-fertile period as determined by the sympto-thermal method (with the "3 over 6" rule). The black bars represent the self-identified non-fertile days. The grey bars represent the true non-fertile days as identified by echography. The X-axis is for the number of days. The Y-axis is for the frequencies of the cycles with that number of days. |
Figure 1 suggests the following:
· There are few cycles whose true non-fertile post-ovulatory period (grey bars) are < 10 days. The most frequent periods last 13 or 14 days.
· The most frequent periods according to the natural methods (Billings or sympto-thermal) is 9 days.
The 4 to 5 days delay to the self-determination of the onset of the non-fertile post-ovulatory period is not surprising because ovulation is expected to occur close in time to the peak of cervical mucus (Billings method) or during the temperature shift (sympto-thermal method). By definition, the onset of that period is the evening of the 4th day after the peak of cervical mucus and the morning of the 3rd day of high temperature. In a certain number of cycles, the delay is shorter than 4-5 days; this is the case of cycles with 11 to 13 infertile days as determined by Billings or the sympto-thermal method. Yet, in many cases, the duration of the non-fertile post-ovulatory period is even shorter; i.e., 7 or 8 days, even less.
From this first analysis, we conclude that there are only a few really short non-fertile post-ovulatory periods in the study population but that the number of cycles with a few recognized non-fertile days is important. This means that the natural methods require "abnormally long" delays before indicating the infertile days.
2. Lateness to recognize the onset of the non-fertile post-ovulatory period
Figure 2 shows the number of non-fertile post-ovulatory days unrecognized by the natural methods. To ease the reading, we considered the three settings: short, medium, and important delays.
|
|
Figure 2 – Three settings: · In green, delays of less than 3 days. These delays are favourable for the recognition of the non-fertile period. · In red, delays of 3 or 4 days. These delays are in accordance with what is known of the performance of the natural methods. · In black, delays of 5 days or more; i.e., important delays. |
The important delays shown in Figure 2 are often at the basis of the erroneously called "short corpus luteum life span" whereas this apparent shortness is simply the result of a delay to the recognition of the onset of the non-fertile post-ovulatory period.
3. Search for hormonal factors associated with lateness to recognize the onset of the non-fertile post-ovulatory period
We are searching for two successive relationships:
· Estrogen and progesterone levels on the days of onset of self-recognized non-fertile post-ovulatory periods.
· Changes in the levels of FSH, LH, estrogen, and progesterone during the delay; i.e., during the days that separate ovulation from the self-recognition of the onset of the non-fertile post-ovulatory period.
a. Estrogen and progesterone levels at the onset of the self-recognized period.
Lateness with the sympto-thermal method
|
|
Figure 3 - Day 0, on the X-axis, is the first day self-recognized as non-fertile using the symptom-thermal method. The panels show the mean changes in temperature, progesterone (PDG) level, estrogen (E1G) level, and E1G/PDG ratio (hormone equilibrium). The green curves are relative to "no delay". The red dashed curves are relative to moderate delays. The black dashed curves are relative to important delays (5 days or more).
|
We notice that the onset of a self-recognized non-fertile post-ovulatory period through temperature shift is accompanied by high progesterone levels (thus, this is not a late increase in progesterone) but also by high estrogen levels! The E1G/PDG ratio reaches its lowest post-ovulatory level at the moment the onset of the non-fertile post-ovulatory period is self-recognized, whatever the delay. This delay is thus associated with a particularly high level of estrogens: for the non-fertile post-ovulatory period to be recognized, progesterone should thus increase even more.
Lateness with Billings method
|
|
Figure 4 – The same observation as in Figure 3: the onset of the non-fertile post-ovulatory period as self-recognized by cervical mucus corresponds to late and low E1G/PDG ratios, not to a late increase in progesterone but to a continuously high level of estrogens.
|
b. Changes in the levels of FSH, LH, estrogens, and progesterone during the delay
We are searching here for an exception, even an abnormality in the cycle, that would explain the late self-recognition of the non-fertile post-ovulatory period.
Lateness with the sympto-thermal method
|
|
Figure 5 – Changes in the levels of FSH and LH by the day of ovulation according to the delay between the onset of the non-fertile post-ovulatory period and its self-recognition. The green lines are for no delay. The red dotted lines are for moderate delays. The black dotted lines are for important delays (of five days or more).
|
The graphs of Figure 5 show that there is no delay for the peak of FSH but that LH keeps being at high level after ovulation. This was recently presented as a sign of lateness, or rather slowness, of the luteinization of the corpus luteum [1].
The late self-recognitions of the onset of the non-fertile post-ovulatory period would therefore reflect slow luteinization with persistence of estrogen activity during the increase in progesterone. The LH would stay at a high level until full maturation of the corpus luteum.
Lateness with Billings method
|
|
Figure 6 – There is a significant protraction of the peak of LH after ovulation in cycles with late recognition of the onset of the non-fertile post-ovulatory period by self-observation of the cervical mucus.
|
Conclusion
Short non-fertile post-ovulatory periods, as recognized through self-observation of fertility signs, are not due, in the majority of cases, to short corpus luteum life spans. They may be due to a slow luteinization of the follicle, which is characterized by an increase in estrogens at the start of the fertile period, by high levels of progesterone at the time of ovulation, and by high LH levels after ovulation. These late onsets are not due to progesterone insufficiency.
This indicates that it might be necessary to suggest, then to test, a candidate therapy for these particular cycles that might well be abnormal.
Reference
1 - Direito A, Bailly S, Mariani A, Ecochard R. Relationships between the luteinizing hormone surge and other characteristics of the menstrual cycle in normally ovulating women. Fertil Steril. 2013 Jan;99(1):279-85.