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What's the Best Way to Test for Ovulation?

21.07.2022
15_min_aa62827294

Despite the connotation that tracking ovulation is used exclusively by those aiming to conceive, understanding ovulatory patterns can help you better appreciate your monthly cycle. Ovulation tracking can help anticipate upcoming periods, identify, and monitor gynecological health problems (i.e., PCOS), periodize training schedules, and feel more comfortable understanding your body. Determining the best tracking method can be intimidating but understanding your goals and resources can help narrow down the best product for you.

Transvaginal Ultrasonography: Often considered the “gold standard,” transvaginal ultrasounds assess ovulation through consecutive images of the follicle. The exact time of ovulation is considered the time just before follicular collapse, and it is often indicated through several signs that must be assessed by an experienced professional (1). Being that assessment requires several clinic visits, this method of tracking is often time-consuming and expensive. Additionally, the necessity of a transvaginal probe makes it the most invasive form of ovulatory monitoring.

Transvaginal Ultrasound .jpeg

Image taken from The Cleveland Clinic (14)

Salivary Ferning: A somewhat less traditional method of ovulation tracking, salivary ferning involves careful analysis of saliva using a microscope. Ovulation is indicated when a pattern resembling a fern appears on the slide. It is thought that the rising hormone levels lead to crystallization of sodium chloride (NaCl), said to indicate ovulation (1).

Though the ease of this method of tracking is appealing, salivary ferning can be found in a variety of non-menstruating populations (1). One study indicated that over half of the slides were uninterpretable, while another study indicated that the test accurately predicted ovulation only 53% of the time (1,2). Further Berardono et al. concluded that ferning slides throughout the menstrual phases were not substantially different, and thus provided unreliable results (2).

Salivary Ferning .png

Image taken from Ersyari, R.M., Wihardja, R., & Dardjan, M. (2014). Determination of ovulation in women using saliva ferning test.

Slides A and B both represent no ovulation while the ferned pattern on slide C indicates ovulation.

Basal Body Temperature: Basal body temperature (BBT) exploits the temperature-changing effects induced by estrogen and progesterone. Using intravaginal, rectal, or oral thermometers, individuals are to take their temperature prior to participating in any physical activity. Just before ovulation, BBT dips slightly below 97-98°F (1). However, following the release of the follicle, rising progesterone levels increase temperature up to 1°F higher than pre-ovulatory levels (1). This higher temperature is sustained until just before menses.

BBT provides an inexpensive, less invasive, and easy method through which to monitor ovulation. However, body temperature can be heightened by a variety of factors outside of ovulation including stress, alcohol, illness, etc. (1). Additionally, temperature is thought to indicate a fertile window between -1 to +3 days of ovulation up to 94%, but struggles at indicating ovulation alone (2). When used in conjunction with other ovulatory symptoms, ovulation detection increases significantly. Thus, BBT alone provides a promising measure of fertility, but not necessarily ovulation.

BBT .jpeg

Image taken from Su et al. 2017 (1)

Cervical Mucus: Cervical mucus provides the most affordable option of all ovulation tracking methods, given that it requires no external equipment. Instead, simply monitoring the cervical discharge at the vulva provides indications of fertility and ovulation. During infertile periods the mucus is sticky and thick, due to a high concentration of sperm deterring glycoproteins (1). As the body transitions to a more fertile period, through ovulation, the viscosity of the mucus significantly decreases. A reduction of glycoproteins, and an increase in extracellular water leads to a slippery discharge at the vulva that is more accepting of sperm. Through retrospective analysis, individuals can monitor the transition from thick, sticky mucus to slippery, egg-white-like mucus to determine roughly the time of ovulation.

cervical mucus .jpeg

Image taken from The Cleveland Clinic (12)

Progesterone and its Derivatives: When aiming to track menstrual cycle patterns for overall health, in place of fertility, progesterone is a promising hormone. After follicular release, the corpus luteum forms to prepare the uterus for implantation of a fertilized egg. This group of cells releases progesterone to continue the development of the uteral environment (6). Increased progesterone levels, thus, represent confirmation of ovulation, though often signify the closure of a fertile window.

Progesterone measurements can be taken directly, i.e., through laboratory analysis of blood, or indirectly, i.e., measurements of basal body temperature or through the measurement of urinary pregnanediol 3-glucuronide (PDG). The authors of a 2013 investigation suggest that use of urinary PDG requires an additional indication of the fertile phase (i.e., peak cervical mucus) in order to maximize accuracy (7).

A more direct method of analyzing progesterone is to measure the hormone concentration in the blood. During the follicular phase, progesterone levels are relatively low; however, during the luteal phase, concentrations jump close to five times pre-ovulatory levels. According to a 1980 review by Drs Wallach and Moghissi, serum progesterone levels peak 8 days following an LH surge (8). Combining the serum panel with measurements of estrogen levels, that peak just a day before the LH surge, clinicians can confidently assess the phase of menstruation an individual is in.

Progesterone production .png

Image taken from Han et al. 2013 (11): Overview of the role of the Corpus Luteum in the production of progesterone when preparing the uterus for implantation of a fetus.

Urinary Luteinizing Hormone: Given the non-invasive, inexpensive, and accurate prediction of ovulation provided by LH kits, it is unsurprising that it is a highly relied upon method in ovulation tracking. Late in the follicular phase, estrogen transitions from an inhibitor to a promoter of LH production. This results in a drastic increase in LH concentration in the bloodstream which is more commonly referred to as the LH surge. Plasma detection of the LH surge is commonly seen 32-44 hours prior to ovulation (1,9). However, the urinary detection of the LH surge, particularly the peak, lags by nearly a day (10).

Though the accuracy of urinary LH tests has reached upwards of 100% in several studies, peak urinary LH detection of ovulation has been noted to fall close to 12 hours behind that of ultrasonography-detected ovulation (3). This is likely due to the urinary clearance delay noted above, but is an important variable to keep in mind, nonetheless. Due to this lag, it has been suggested that the initial rise in LH is a better predictor of ovulation than the LH peak itself.

Though at-home urinary LH tests appear to be the best method for ovulation tracking, it is important to acknowledge their practical downfalls. In order to accurately predict the date of ovulation, individuals must record several consecutive menstrual cycles. Beginning close to half way through a “typical”* length cycle (10-14 days), or roughly 4 days before estimated ovulation, users are instructed to test their LH levels 1-2 times daily (1). A majority of LH surges are found to occur between midnight and 8 AM, so the best practice is to measure LH levels immediately upon waking (1).

LH .webp Image taken from Mira Care Blog (13)

  • The “typical” cycle is assigned an arbitrary length of 28-days. However, cycle lengths are largely variable.

Ovulation Table .png

References

[1] Su, Hsiu-Wei, et al. “Detection of Ovulation, a Review of Currently Available Methods” Bioengineering & Translational Medicine, vol. 2, no. 3, 2017, pp. 238–46, https://doi.org/10.1002/btm2.10058.

[2] Berardono, B., et al. “Is the Salivary ‘Ferning’ a Reliable Index of the Fertile Period?” Acta Europaea Fertilitatis, vol. 24, no. 2, Apr. 1993, pp. 61–65.

[3] Owen, Martin. “Physiological Signs of Ovulation and Fertility Readily Observable by Women.” The Linacre Quarterly, vol. 80, no. 1, 2013, pp. 17–23, https://doi.org/10.1179/0024363912Z.0000000005.

[4] Guida, Maurizio, et al. “Efficacy of Methods for Determining Ovulation in a Natural Family Planning Program.” Fertility and Sterility, vol. 72, no. 5, 1999, pp. 900–04, https://doi.org/10.1016/S0015-0282(99)00365-9.

[5] Fehring, Richard J. “Accuracy of the Peak Day of Cervical Mucus as a Biological Marker of Fertility.” Contraception, vol. 66, no. 4, 2002, pp. 231–35, https://doi.org/10.1016/S0010-7824(02)00355-4.

[6] “Corpus Luteum: Development, Anatomy & Function.” Cleveland Clinic, https://my.clevelandclinic.org/health/body/21849-corpus-luteum. Accessed 8 June 2022.

[7] Ecochard, R., et al. “Use of Urinary Pregnanediol 3-Glucuronide to Confirm Ovulation.” Steroids, vol. 78, no. 10, Oct. 2013, pp. 1035–40, https://doi.org/10.1016/j.steroids.2013.06.006.

[8] Wallach, Edward, and Kamran S. Moghissi. “Prediction and Detection of Ovulation.” Fertility and Sterility, vol. 34, no. 2, 1980, pp. 89–98, https://doi.org/10.1016/S0015-0282(16)44888-0.

[9] Jacobs, Ellis, et al. Laboratory Medicine Practice Guidelines: Evidence-Based Practice for Point-of-Care Testing. American Association for Clinical Chemistry, 2006, https://www.aacc.org/-/media/Files/Science-and-Practice/Practice-Guidelines/Point-of-Care-Testing/POCT-Entire-LMPG.pdf?la=en&hash=FAB661858E6C81B5467B641C99E2EE6BA29D50F6.

[10] Krotz, Stephan, et al. “Prevalence of Premature Urinary Luteinizing Hormone Surges in Women with Regular Menstrual Cycles and Its Effect on Implantation of Frozen-Thawed Embryos.” Fertility and Sterility, vol. 83, no. 6, 2005, pp. 1742–44, https://doi.org/10.1016/j.fertnstert.2004.11.078.

[11] Han, Kyung & Kim, Mi-kyung & Kim, Hee & Chung, Hyun & Song, Yong. (2013). Protective Effect of Progesterone during Pregnancy against Ovarian Cancer. Journal of cancer prevention. 18. 113-22. 10.15430/JCP.2013.18.2.113.

[12] Cervical Mucus. (2021, October 14). Cleveland Clinic. https://my.clevelandclinic.org/health/body/21957-cervical-mucus

[13] Kang, S. (n.d.). How to Read an Ovulation Test: Faint Lines & Types. Mira Insights. Retrieved July 20, 2022, from https://www.miracare.com/blog/how-to-read-an-ovulation-test/

[14] Transvaginal Ultrasound. (2022, May 23). Cleveland Clinic. https://my.clevelandclinic.org/health/diagnostics/4993-transvaginal-ultrasound

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15_min_aa62827294

Despite the connotation that tracking ovulation is used exclusively by those aiming to conceive, understanding ovulatory patterns can help you better appreciate your monthly cycle. Ovulation tracking can help anticipate upcoming periods, identify, and monitor gynecological health problems (i.e., PCOS), periodize training schedules, and feel more comfortable understanding your body. Determining the best tracking method can be intimidating but understanding your goals and resources can help narrow down the best product for you.

Transvaginal Ultrasonography: Often considered the “gold standard,” transvaginal ultrasounds assess ovulation through consecutive images of the follicle. The exact time of ovulation is considered the time just before follicular collapse, and it is often indicated through several signs that must be assessed by an experienced professional (1). Being that assessment requires several clinic visits, this method of tracking is often time-consuming and expensive. Additionally, the necessity of a transvaginal probe makes it the most invasive form of ovulatory monitoring.

Transvaginal Ultrasound .jpeg

Image taken from The Cleveland Clinic (14)

Salivary Ferning: A somewhat less traditional method of ovulation tracking, salivary ferning involves careful analysis of saliva using a microscope. Ovulation is indicated when a pattern resembling a fern appears on the slide. It is thought that the rising hormone levels lead to crystallization of sodium chloride (NaCl), said to indicate ovulation (1).

Though the ease of this method of tracking is appealing, salivary ferning can be found in a variety of non-menstruating populations (1). One study indicated that over half of the slides were uninterpretable, while another study indicated that the test accurately predicted ovulation only 53% of the time (1,2). Further Berardono et al. concluded that ferning slides throughout the menstrual phases were not substantially different, and thus provided unreliable results (2).

Salivary Ferning .png

Image taken from Ersyari, R.M., Wihardja, R., & Dardjan, M. (2014). Determination of ovulation in women using saliva ferning test.

Slides A and B both represent no ovulation while the ferned pattern on slide C indicates ovulation.

Basal Body Temperature: Basal body temperature (BBT) exploits the temperature-changing effects induced by estrogen and progesterone. Using intravaginal, rectal, or oral thermometers, individuals are to take their temperature prior to participating in any physical activity. Just before ovulation, BBT dips slightly below 97-98°F (1). However, following the release of the follicle, rising progesterone levels increase temperature up to 1°F higher than pre-ovulatory levels (1). This higher temperature is sustained until just before menses.

BBT provides an inexpensive, less invasive, and easy method through which to monitor ovulation. However, body temperature can be heightened by a variety of factors outside of ovulation including stress, alcohol, illness, etc. (1). Additionally, temperature is thought to indicate a fertile window between -1 to +3 days of ovulation up to 94%, but struggles at indicating ovulation alone (2). When used in conjunction with other ovulatory symptoms, ovulation detection increases significantly. Thus, BBT alone provides a promising measure of fertility, but not necessarily ovulation.

BBT .jpeg

Image taken from Su et al. 2017 (1)

Cervical Mucus: Cervical mucus provides the most affordable option of all ovulation tracking methods, given that it requires no external equipment. Instead, simply monitoring the cervical discharge at the vulva provides indications of fertility and ovulation. During infertile periods the mucus is sticky and thick, due to a high concentration of sperm deterring glycoproteins (1). As the body transitions to a more fertile period, through ovulation, the viscosity of the mucus significantly decreases. A reduction of glycoproteins, and an increase in extracellular water leads to a slippery discharge at the vulva that is more accepting of sperm. Through retrospective analysis, individuals can monitor the transition from thick, sticky mucus to slippery, egg-white-like mucus to determine roughly the time of ovulation.

cervical mucus .jpeg

Image taken from The Cleveland Clinic (12)

Progesterone and its Derivatives: When aiming to track menstrual cycle patterns for overall health, in place of fertility, progesterone is a promising hormone. After follicular release, the corpus luteum forms to prepare the uterus for implantation of a fertilized egg. This group of cells releases progesterone to continue the development of the uteral environment (6). Increased progesterone levels, thus, represent confirmation of ovulation, though often signify the closure of a fertile window.

Progesterone measurements can be taken directly, i.e., through laboratory analysis of blood, or indirectly, i.e., measurements of basal body temperature or through the measurement of urinary pregnanediol 3-glucuronide (PDG). The authors of a 2013 investigation suggest that use of urinary PDG requires an additional indication of the fertile phase (i.e., peak cervical mucus) in order to maximize accuracy (7).

A more direct method of analyzing progesterone is to measure the hormone concentration in the blood. During the follicular phase, progesterone levels are relatively low; however, during the luteal phase, concentrations jump close to five times pre-ovulatory levels. According to a 1980 review by Drs Wallach and Moghissi, serum progesterone levels peak 8 days following an LH surge (8). Combining the serum panel with measurements of estrogen levels, that peak just a day before the LH surge, clinicians can confidently assess the phase of menstruation an individual is in.

Progesterone production .png

Image taken from Han et al. 2013 (11): Overview of the role of the Corpus Luteum in the production of progesterone when preparing the uterus for implantation of a fetus.

Urinary Luteinizing Hormone: Given the non-invasive, inexpensive, and accurate prediction of ovulation provided by LH kits, it is unsurprising that it is a highly relied upon method in ovulation tracking. Late in the follicular phase, estrogen transitions from an inhibitor to a promoter of LH production. This results in a drastic increase in LH concentration in the bloodstream which is more commonly referred to as the LH surge. Plasma detection of the LH surge is commonly seen 32-44 hours prior to ovulation (1,9). However, the urinary detection of the LH surge, particularly the peak, lags by nearly a day (10).

Though the accuracy of urinary LH tests has reached upwards of 100% in several studies, peak urinary LH detection of ovulation has been noted to fall close to 12 hours behind that of ultrasonography-detected ovulation (3). This is likely due to the urinary clearance delay noted above, but is an important variable to keep in mind, nonetheless. Due to this lag, it has been suggested that the initial rise in LH is a better predictor of ovulation than the LH peak itself.

Though at-home urinary LH tests appear to be the best method for ovulation tracking, it is important to acknowledge their practical downfalls. In order to accurately predict the date of ovulation, individuals must record several consecutive menstrual cycles. Beginning close to half way through a “typical”* length cycle (10-14 days), or roughly 4 days before estimated ovulation, users are instructed to test their LH levels 1-2 times daily (1). A majority of LH surges are found to occur between midnight and 8 AM, so the best practice is to measure LH levels immediately upon waking (1).

LH .webp Image taken from Mira Care Blog (13)

  • The “typical” cycle is assigned an arbitrary length of 28-days. However, cycle lengths are largely variable.

Ovulation Table .png

References

[1] Su, Hsiu-Wei, et al. “Detection of Ovulation, a Review of Currently Available Methods” Bioengineering & Translational Medicine, vol. 2, no. 3, 2017, pp. 238–46, https://doi.org/10.1002/btm2.10058.

[2] Berardono, B., et al. “Is the Salivary ‘Ferning’ a Reliable Index of the Fertile Period?” Acta Europaea Fertilitatis, vol. 24, no. 2, Apr. 1993, pp. 61–65.

[3] Owen, Martin. “Physiological Signs of Ovulation and Fertility Readily Observable by Women.” The Linacre Quarterly, vol. 80, no. 1, 2013, pp. 17–23, https://doi.org/10.1179/0024363912Z.0000000005.

[4] Guida, Maurizio, et al. “Efficacy of Methods for Determining Ovulation in a Natural Family Planning Program.” Fertility and Sterility, vol. 72, no. 5, 1999, pp. 900–04, https://doi.org/10.1016/S0015-0282(99)00365-9.

[5] Fehring, Richard J. “Accuracy of the Peak Day of Cervical Mucus as a Biological Marker of Fertility.” Contraception, vol. 66, no. 4, 2002, pp. 231–35, https://doi.org/10.1016/S0010-7824(02)00355-4.

[6] “Corpus Luteum: Development, Anatomy & Function.” Cleveland Clinic, https://my.clevelandclinic.org/health/body/21849-corpus-luteum. Accessed 8 June 2022.

[7] Ecochard, R., et al. “Use of Urinary Pregnanediol 3-Glucuronide to Confirm Ovulation.” Steroids, vol. 78, no. 10, Oct. 2013, pp. 1035–40, https://doi.org/10.1016/j.steroids.2013.06.006.

[8] Wallach, Edward, and Kamran S. Moghissi. “Prediction and Detection of Ovulation.” Fertility and Sterility, vol. 34, no. 2, 1980, pp. 89–98, https://doi.org/10.1016/S0015-0282(16)44888-0.

[9] Jacobs, Ellis, et al. Laboratory Medicine Practice Guidelines: Evidence-Based Practice for Point-of-Care Testing. American Association for Clinical Chemistry, 2006, https://www.aacc.org/-/media/Files/Science-and-Practice/Practice-Guidelines/Point-of-Care-Testing/POCT-Entire-LMPG.pdf?la=en&hash=FAB661858E6C81B5467B641C99E2EE6BA29D50F6.

[10] Krotz, Stephan, et al. “Prevalence of Premature Urinary Luteinizing Hormone Surges in Women with Regular Menstrual Cycles and Its Effect on Implantation of Frozen-Thawed Embryos.” Fertility and Sterility, vol. 83, no. 6, 2005, pp. 1742–44, https://doi.org/10.1016/j.fertnstert.2004.11.078.

[11] Han, Kyung & Kim, Mi-kyung & Kim, Hee & Chung, Hyun & Song, Yong. (2013). Protective Effect of Progesterone during Pregnancy against Ovarian Cancer. Journal of cancer prevention. 18. 113-22. 10.15430/JCP.2013.18.2.113.

[12] Cervical Mucus. (2021, October 14). Cleveland Clinic. https://my.clevelandclinic.org/health/body/21957-cervical-mucus

[13] Kang, S. (n.d.). How to Read an Ovulation Test: Faint Lines & Types. Mira Insights. Retrieved July 20, 2022, from https://www.miracare.com/blog/how-to-read-an-ovulation-test/

[14] Transvaginal Ultrasound. (2022, May 23). Cleveland Clinic. https://my.clevelandclinic.org/health/diagnostics/4993-transvaginal-ultrasound

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