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Are You Actually Ovulating?
It may come as a surprise to read that a regular cycle is not proof that you are actually ovulating. It is possible for your body to bleed every month without actually ovulating, so one of the most important investigations to undertake is to check that you are actually ovulating.
How Can You Tell Whether You Ovulate
BBT Chart
If you chart for a month or two, you should be able to tell from your chart whether you ovulate – if you are ovulating the chart will have a classic biphasic appearance, with the temperatures of second half of the month registering at 0.5’F or 0.3’C above the temperatures of the first half of the month. This indicates that ovulation has occurred. If the chart is continually in the same range of temperatures, it suggests that you have not ovulated.
Day 21 Progesterone Blood Test
When a follicle is ready to be released, Luteinising Hormone is released by the pituitary gland which triggers the rupturing of the follicle to release the egg. The spent follicle goes through a process called luteinisation, quickly turning into something called a corpus luteum which pumps out progesterone. Progesterone is used to prepare the body for potential conception, ripen the uterus lining and upregulate the thyroid.
If progesterone is detected in your blood, it will have been produced by a corpus luteum, so in theory it is proof that you ovulated – however the amount of progesterone can also indicate the health of the corpus luteum and the potential quality of the egg released by the follicle. It is worth noting though that it is possible for a follicle to fail to release the egg, but to continue to luteinise and produce progesterone. The 21 Day Progesterone blood test is designed to test your progesterone level at the peak of production – but timing for this test is critical. The average cycle is 28 days long, and the average ovulation is at around 14 days, so the 21 Day Progesterone tests is designed to capture the progesterone level at the peak.
SHORTER CYCLES If your cycle is 23/24 days long, your progesterone level on Day 21 will probably register lower than your peak progesterone because the level may already be falling in preparation for your period. If your cycle is short, I would recommend you use a BBT chart for a month to get some information about whether you have a short follicular phase or a short luteal phase, and to work out the best time to measure your progesterone.
LONGER CYCLES If your cycle is 33 days long, it is possible that you haven’t even ovulated by Day 21, so your progesterone test would have a disappointing result that reveals nothing about your true progesterone cycle. If your cycle is regularly long, aim to test your progesterone level 6-7 days before your period is due which should be at around the peak of progesterone.
So Does Progesterone Always Indicate Ovulation?
No.
It is unlikely, but possible that you could have something called a Luteinising Unruptured Follicle – this is something that occurs in approximately 10% of normal menstrual cycles, but is thought to occur more frequently in women struggling with infertility. In this situation, the follicle fails to rupture, but does manage to luteinise into a corpus luteum so it is still able to generate progesterone and stimulate the thyroid to raise the body temperatures so that it would appear as though ovulation had occurred. An luteinised unruptured follicle can be detected on ultrasound but it is not easy to identify and you need to make sure you use an expert fertility sonographer. If your doctor suspects LUFS, it is possible to have a series of ultrasounds through your ovulation window to identify the maturing follicle and to double check that it actually ruptures; if it fails to rupture, it will shrink to about half the size and will contain fluid which can be picked up on the scan. There is some evidence to suggest that Clomid can increase the likelihood of Luteinising Unruptured Follicle Syndrome (Qublan et al, 2006).
Ultrasound Scan
If you are due to have an ultrasound scan in the second half of the month, your sonographer should be able to see a corpus luteum on one of your ovaries if you have ovulated. If you are having an ultrasound after you have ovulated, check whether they can identify a corpus luteum and check that there are no signs of a luteinised unruptured follicle.
But What About LH Test Sticks?
As the dominant follicle gets large enough, it secretes a significant amount of oestrogen which triggers the release of Luteinising Hormone (LH) from the pituitary gland. In some instances there multiple oestrogen generating follicles may cause high oestrogen levels which can trigger LH before an egg is really ready for release – so an LH surge could be detected, but no egg release is triggered. It is possible for LH release to be triggered more than once in a single cycle, as the feedback mechanism for LH release can be set off multiple times.
Some people also have a very high LH throughout the cycle, or wildly fluctuating LH throughout the cycle, both of which can make LH testing strips unreliable. When I have seen this in my clinic, further investigation has shown an elevated prolactin level, suggesting that the pituitary hormone regulation system was generally a bit out of kilter (prolactin, follicle stimulating hormone (FSH) and LH are all produced by the pituitary gland).
What About Cervical Mucus
Production of cervical mucus is a response to the rising oestrogen level, but it does not guarantee that there is a single, dominant follicle maturing and rupturing. It is possible for multiple smaller follicles to generate enough oestrogen to trigger cervical mucus production.
So What Can You Do About Absent Ovulation?
Lots.
Diet, lifestyle and acupuncture can all have an incredible impact on your menstrual cycle and help to turn a non-ovulatory cycle into an ovulatory cycle. I would recommend working with a Fertility Support Trained Acupuncturist who would be able to work with you to investigate what is happening and treat you to restore regular ovulation. We work in a particularly integrated way, blending western medicine diagnostics with ancient acupuncture knowledge to restore and rebalance your cycle and improve your fertility.
To Conclude
Even if you are sure you are ovulating, if you are starting to wonder about your fertility this is the first thing to investigate. Work with a Fertility Support Trained acupuncturist, let them help you to work out what is and what is not actually happening.
H. Qublan, Z. Amarin, M. Nawasreh, F. Diab, S. Malkawi, N. Al-Ahmad, M. Balawneh, Luteinized unruptured follicle syndrome: incidence and recurrence rate in infertile women with unexplained infertility undergoing intrauterine insemination, Human Reproduction, Volume 21, Issue 8, Aug 2006, Pages 2110–2113, https://doi.org/10.1093/humrep/del113