Efficacy of methods for determining ovulation in a natural family planning program

The effectiveness of cervical mucus electrical impedance compared to basal body temperature to determine fertility window

BACKGROUND

Serial serum hormone measurements and transvaginal ultrasound are reliable measures to predict ovulation. These measures are inconvenient and expensive therefore, basal body temperature charting (BBT) and urine ovulation predictor kits (OPK) for luteinizing hormone are often used to determine the 6-day fertile window. However, BBT does not clearly change until 1-2 days after ovulation. Additionally, while OPK can indicate positivity prior to ovulation, false readings are common. A novel alternative approach involves measuring electrolyte trends in cervical mucus using electrical impedance spectroscopy. Cervical mucus electrolyte measurements are associated with hormone level changes during the menstrual cycle. The purpose of this study was to compare the effectiveness of cervical mucus electrical impedance and basal body temperature. We sought to determine if cervical mucus electrolyte measurements provided improved detection of the ovulation day and therefore, improve fertility timing for women.

METHODS

14 healthy women between 18 and 44 years of age with normal menstrual cycles were enrolled in the Observational Study. Participants measured BBT and cervical mucus electrical impedance daily for 3 menstrual cycles using Kegg (Lady Technologies Inc. San Francisco, California, USA). Ovulation date for each cycle was confirmed by measuring hormone levels in urine and serum, and by vaginal ultrasound.

RESULTS

Electrical impedance was significantly different between the follicular phase versus ovulatory date (p = 0.007) and between the luteal phase versus the ovulatory date (p = 0.007). A significant difference in the rate of change of cervical impedance measurements in the pre-ovulatory follicular phase was found compared to BBT (p = 0.0225). The sensitivity (+ 7.14%), specificity (+ 20.35%), and accuracy (+ 17.59) to determine the 1-day fertility window was significantly higher using cervical mucus impedance compared to BBT.

CONCLUSIONS

BBT is considered unreliable for evaluating ovulatory function. Cervical mucus electrical impedance offers a novel measure of electrolyte changes associated with hormone levels. We report that pre-ovulatory electrical impedance patterns demonstrated higher sensitivity, specificity, and accuracy for determining the fertility window when compared to BBT. These findings suggest that changes in electrical impedance may provide an accurate method for predicting ovulation and for measuring ovulatory function.

Can Wrist-Worn Medical Devices Correctly Identify Ovulation?

(1) Background: Hormonal fluctuations across the menstrual cycle lead to multiple changes in physiological parameters such as body temperature, cardiovascular function, respiratory rate and perfusion. Electronic wearables analyzing those parameters might present a convenient alternative to urinary ovulation tests for predicting the fertile window. (2) Methods: We conducted a prospective observational study including women aged 18-45 years without current hormonal therapy who used a wrist-worn medical device and urinary ovulation tests for a minimum of three cycles. We analyzed the accuracy of both the retrospective and prospective algorithms using a generalized linear mixed-effects model. The findings were compared to real-world data from bracelet users who also reported urinary ovulation tests. (3) Results: A total of 61 study participants contributing 205 cycles and 6081 real-life cycles from 3268 bracelet users were included in the analysis. The mean error in identifying ovulation with the wrist-worn medical device retrospective algorithm in the clinical study was 0.31 days (95% CI -0.13 to 0.75). The retrospective algorithm identified 75.4% of fertile days, and the prospective algorithm identified 73.8% of fertile days correctly within the pre-specified equivalence limits (±2 days). The quality of the retrospective algorithm in the clinical study could be confirmed by real-world data. (4) Conclusion: Our data indicate that wearable sensors may be used to accurately detect the periovulatory period.

Predicting serum hormone concentration by estimation of urinary hormones through a home-use device

STUDY QUESTION

Can a home-use device be used to predict serum hormone levels?

SUMMARY ANSWER

A home-use device can predict urinary hormone values which are well-correlated to serum concentrations of respective hormones and hence can be used as a proxy for serum measurements.

WHAT IS KNOWN ALREADY

Home-use devices that predict ovulation are calibrated against the actual day of ovulation. However, the correlation of any quantitative system to serum hormone concentrations has not been established.

STUDY DESIGN SIZE DURATION

A total of 73 data points obtained from 20 participants across different phases of the menstrual cycle, i.e. bleeding days, follicular phase and luteal phase were used to establish the correlation between serum hormones and urinary metabolite values. Single data points from 20 random users were used to assess the correlation established.

PARTICIPANTS/MATERIALS SETTING METHODS

Participants were women in the fertile age groups and only current users of the home-use device. Selection was done based on inclusion and exclusion criteria. Blood hormones were tested using chemiluminescent immunoassays and urinary measurements were taken on the home-use device at home.

MAIN RESULTS AND THE ROLE OF CHANCE

Serum estradiol (E2), progesterone (P4) and LH were correlated with urinary estrone-3-glucuronide (E3G), pregnanediol glucuronide (PdG) and LH with an R ² of 0.96, 0.95 and 0.98, respectively. Repredicted serum concentration obtained by using the correlation equation had a correlation of 0.92, 0.94 and 0.93 in unknown samples.

LIMITATIONS REASONS FOR CAUTION

The study was designed to include women who have normal cycle lengths regularly; therefore, the values obtained were in the normal range. Certain infertility conditions may cause the values to be higher and correlation in such cases needs to be established.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study imply a new tool that can be used by fertility specialists as a proxy for blood tests whenever required. Extended study on this system can enable its use in assisted reproductive techniques as well.

STUDY FUNDING/COMPETING INTERESTS

No funding was received for this study. S.P. and D.D. are employees of the research and development division of Samplytics Technologies Pvt. Ltd. which is a forwarder for Inito Inc., USA. A.R. and V.A.V. are co-founders of Inito Inc., USA.

TRIAL REGISTRATION NUMBER

The trial was registered at the International Standard Randomised Controlled Trial Number (ISRCTN) registry (Identifier: ISRCTN15534557).

Deep Learning-Enabled Technologies for Bioimage Analysis

Deep learning (DL) is a subfield of machine learning (ML), which has recently demonstrated its potency to significantly improve the quantification and classification workflows in biomedical and clinical applications. Among the end applications profoundly benefitting from DL, cellular morphology quantification is one of the pioneers. Here, we first briefly explain fundamental concepts in DL and then we review some of the emerging DL-enabled applications in cell morphology quantification in the fields of embryology, point-of-care ovulation testing, as a predictive tool for fetal heart pregnancy, cancer diagnostics via classification of cancer histology images, autosomal polycystic kidney disease, and chronic kidney diseases.

Descriptive analysis of the relationship between progesterone and basal body temperature across the menstrual cycle

OBJECTIVE

Describe the relationship between basal body temperature (BBT) and pregnanediol-3 alpha-glucuronide (PDG, the urine metabolite of progesterone) across the menstrual cycle.

DESIGN

Observational study.

SETTING

Study carried out from 1996 to 1997 in eight European family planning clinics.

PARTICIPANT(S)

One hundred and seven normally fertile and cycling women.

MAIN OUTCOME MEASURE(S)

BBT and PDG level on each day of 283 cycles and ultrasound determination of the day of ovulation.

RESULT

(s): In comparison with previous end-of-cycle levels, decreases in PDG and BBT on the first day of menses were seen in nearly 90% and 80% of cycles, respectively. In a non-negligible percentage of cycles, luteolysis would continue during menses: between the second and the third day after menses, small but significant decreases in PDG and BBT were seen in 76% and 48% of cycles, respectively. During the peri-ovulatory phase, between the third and the second day before ovulation, PDG and BBT began to rise in 56% and 41% of cycles, respectively. There was a medium degree of correlation between PDG levels and BBT (r = 0.53; 7,279 days with available measurements). The relationship between PDG levels and BBT was linear at low PDG levels but BBT increased no longer when PDG levels continued to rise above a threshold of nearly 10 mcg/mg Cr.

CONCLUSION

(s): PDG and BBT had parallel increases at low PDG rates but diverged at higher rates.

Diagnostic tests based on pattern formation in drying body fluids - A mapping review

There are numerous diagnostic tests based on pattern formation in desiccating body fluids, where the pattern or some of its characteristics constitute the diagnostic test outcome. However, partially due to the development in different time periods, and partially due to publications in languages different from English, most of these diagnostic tests exist as separate approaches and have never been grouped, systematized, nor compared with each other. In the present mapping review, we performed a wide literature search with the aim to collect all diagnostic tests based on pattern formation in desiccating body fluids. Furthermore, we grouped the identified diagnostic tests according to their experimental protocols, type of body fluids investigated, and target conditions, and propose so for the first time a classification of different diagnostic tests based on pattern formation in desiccating body fluids. The literature search revealed 1603 publications, out of which 141 were included into the review. Following three main classification criteria (way of deposition of the fluid for desiccation, addition of reagents, and spatial restrictions during evaporation), we identified six different methods; following a further classification concerning the analyzed body fluid we identified 30 different diagnostic tests based on pattern formation in evaporating body fluids. Amongst these tests are well-known procedures such as ferning tests (tear ferning for the assessment of tear film quality, saliva and cervical mucus ferning for the detection of the fertile period, and amniotic fluid ferning for the diagnosis of fetal membrane rupture), whereas other tests are less well-established. In the latter group, the most frequently investigated body fluids were serum, saliva, and blood; the most frequently addressed target conditions were cancer, inflammation, and benign tumors. We recommend conducting further systematic reviews and meta-analyses concerning groups of methods addressing the same target condition.

Preparation of the Endometrium for Frozen Embryo Transfer: A Systematic Review

Despite the worldwide increase in frozen embryo transfer, the search for the best protocol to prime endometrium continues. Well-designed trials comparing various frozen embryo transfer protocols in terms of live birth rates, maternal, obstetric and neonatal outcome are urgently required. Currently, low-quality evidence indicates that, natural cycle, either true natural cycle or modified natural cycle, is superior to hormone replacement treatment protocol. Regarding warmed blastocyst transfer and frozen embryo transfer timing, the evidence suggests the 6th day of progesterone start, LH surge+6 day and hCG+7 day in hormone replacement treatment, true natural cycle and modified natural cycle protocols, respectively. Time corrections, due to inter-personal differences in the window of implantation or day of vitrification (day 5 or 6), should be explored further. Recently available evidence clearly indicates that, in hormone replacement treatment and natural cycles, there might be marked inter-personal variation in serum progesterone levels with an impact on reproductive outcomes, despite the use of the same dose and route of progesterone administration. The place of progesterone rescue protocols in patients with low serum progesterone levels one day prior to warmed blastocyst transfer in hormone replacement treatment and natural cycles is likely to be intensively explored in near future.

Development of a Permanent Device for Fertility Period Detection by Basal Body Temperature and Analysis of the Cervical Mucus Potential of Hydrogen

Background

Sometimes, women find it difficult to conceive a baby and others use contraceptives that often have side effects. Researchers have already established the importance of measuring basal body temperature (BBT) and the potential of hydrogen (pH).

Method

We have designed and realized a device that allows the simultaneous measurement of the BBT and the pH. We used an Arduino Uno board, a pH sensor, and a temperature sensor. The device communicates with a smartphone, can be integrated into all e-health platforms, and can be used at home. We validated our ovulation detector by a measurement campaign on a group of twenty women. If the pH is >7 and at the same time, the BBT is minimum and <36.5°C, the women is in ovulation phase. If the pH is ≤7 and in the same time, the BBT is between 36.5°C and 37°C, the women are in preovulation or follicular phase. If the pH is ≤7 and in the same time, the BBT is >36.5°C, the women are in postovulation or luteal phase.

Results

We tested the contraceptive aspect of our ovulometer on a set of seven women. We also tested the help of conceiving babies by having intercourse during the ovulation period fixed by our ovulation detector. The results are satisfactory.

Conclusions

In the final version of our device, we displayed just in "fertility period" if the pH is ≥7 and the BBT is <36.5°C else we displayed in "nonfertility period."

Predictive Factors of Conception and the Cumulative Pregnancy Rate in Subfertile Couples Undergoing Timed Intercourse With Ultrasound

The aim of this study was to determine predictive factors for pregnancy and assess the cumulative pregnancy rate (CPR) and live birth rate (CLBR) in subfertile couples undergoing timed intercourse (TI) using ultrasound. This retrospective cohort study included 285 women (854 cycles) who started TI with ultrasound between January 2017 and October 2019. The overall clinical pregnancy rate was 28.1% (80/285) per couple and 9.4% (80/854) per cycle. Pregnant women had a higher body mass index (BMI), higher percentage of irregular menstrual cycles, a shorter duration of subfertility, lower serum follicle-stimulating hormone levels, and higher anti-Müllerian hormone levels than non-pregnant women. A longer duration of subfertility (≥24 months vs. <12 months; odds ratio: 0.193; 95% confidence interval: 0.043-0.859) and endometriosis (vs. ovulatory factors; odds ratio: 0.282; 95% confidence interval: 0.106-0.746) as causes of subfertility were unfavorable factors that independently affected clinical pregnancy. In subgroup analysis, old age ≥ 35 years [vs. < 35 years; odds ratio: 0.279; 95% confidence interval: 0.083-0.938), a longer duration of infertility ≥24 months (vs. <24 months; odds ratio: 0.182; 95% confidence interval: 0.036-0.913) and a higher BMI ≥ 25 kg/m²(vs. >25 kg/m²; odds ratio: 3.202; 95% confidence interval: 1.020-10.046) in couples with ovulatory factor and a longer duration of infertility ≥24 months (vs. <24 months; odds ratio: 0.185; 95% confidence interval: 0.042-0.819) in couples with non-ovulatory factors were significant independent predictive factors for pregnancy. No significant differences were found in the cycle characteristics between pregnant and non-pregnant women. The CPR substantially increased during the first three cycles and significantly increased until the sixth cycle. No significant increase was observed in the CPR after the sixth cycle. The CLBRs substantially increased during the first three cycles and significantly increased until the fourth cycle. No significant increase was observed in the CLBRs after the fifth cycle. When comparing CPRs and CLBRs according to subfertile causes, CRPs was significantly different and CLBRs was different with borderline significance. Our findings may indicate that women with a longer duration of subfertility or subfertility due to endometriosis have poor outcomes during TI with ultrasound. Women who failed to achieve conception by the fourth or fifth cycle of TI with ultrasound may be encouraged to consider advancing to the next treatment strategy.

On Attenuated Interactions, Measurement Error, and Statistical Power: Guidelines for Social and Personality Psychologists

The replication crisis has seen increased focus on best practice techniques to improve the reliability of scientific findings. What remains elusive to many researchers and is frequently misunderstood is that predictions involving interactions dramatically affect the calculation of statistical power. Using recent papers published in Personality and Social Psychology Bulletin (PSPB), we illustrate the pitfalls of improper power estimations in studies where attenuated interactions are predicted. Our investigation shows why even a programmatic series of six studies employing 2 × 2 designs, with samples exceeding N = 500, can be woefully underpowered to detect genuine effects. We also highlight the importance of accounting for error-prone measures when estimating effect sizes and calculating power, explaining why even positive results can mislead when power is low. We then provide five guidelines for researchers to avoid these pitfalls, including cautioning against the heuristic that a series of underpowered studies approximates the credibility of one well-powered study.

Modulation of saliva pattern and accurate detection of ovulation using an electrolyte pre-deposition-based method: a pilot study

We developed an electrolyte pre-deposition-based saliva pattern modulation method to detect ovulation with high accuracy and reliability. Ovulation tests using human saliva have advantages in terms of the earlier ovulation detection and more convenient sample collection procedure; however, accuracy is low, which is a critical limitation given that the concentrations of salivary constituents can vary depending on the health status of the tested individual and subjective user judgement of the test result. In this study, we quantitatively analyzed saliva patterns according to the concentrations of electrolytes and proteins in the ovulation test and found that changes in the saliva pattern during the ovulatory period can be controlled by sodium chloride (NaCl) pre-deposition, which directly affects the accuracy of ovulation detection. The 100 nmol NaCl pre-deposition condition proved optimal, being two-fold more sensitive to changes in saliva pattern versus the non-pre-deposition condition (accuracy of ovulation detection = 66.6% and 33.3%, respectively). Although accuracy remained insufficient for actual applications compared to the urine-based ovulation detection method, we expect that the electrolyte pre-deposition method will greatly contribute to enhancing the performance of saliva-based ovulation detection tests, toward a commercially satisfactory level of accuracy.

Comparison of woman-picked, expert-picked, and computer-picked Peak Day of cervical mucus with blinded urine luteinising hormone surge for concurrent identification of ovulation

BACKGROUND

Previous research has demonstrated that women instructed in fertility awareness methods can identify the Peak Day of cervical mucus discharge for each menstrual cycle, and the Peak Day has high agreement with other indicators of the day of ovulation. However, previous studies enrolled experienced users of fertility awareness methods or were not fully blinded.

OBJECTIVE

To assess the agreement between cervical mucus Peak Day identified by fertile women without prior experience on assessing cervical mucus discharge with the estimated day of ovulation (1 day after urine luteinising hormone surge).

METHODS

This study is a secondary analysis of data from a randomised trial of the Creighton Model FertilityCareTM System (CrM), conducted 2003-2006, for women trying to conceive. Women who had no prior experience tracking cervical mucus recorded vulvar observations daily using a standardised assessment of mucus characteristics for up to seven menstrual cycles. Four approaches were used to identify the Peak Day. The referent day was defined as one day after the first identified day of luteinising hormone (LH) surge in the urine, assessed blindly. The percentage of agreement between the Peak Day and the referent day of ovulation was calculated.

RESULTS

Fifty-seven women with 187 complete cycles were included. A Peak Day was identified in 117 (63%) cycles by women, 185 (99%) cycles by experts, and 187 (100%) by computer algorithm. The woman-picked Peak Day was the same as the referent day in 25% of 117 cycles, within ±1 day in 58% of cycles, ±2 days in 84%, ±3 days in 87%, and ±4 days in 92%. The ±1 day and ± 4 days' agreement was 50% and 90% for the expert-picked and 47% and 87% for the computer-picked Peak Day, respectively.

CONCLUSIONS

Women's daily tracking of cervical mucus is a low-cost alternative for identifying the estimated day of ovulation.

Wearable Sensors Reveal Menses-Driven Changes in Physiology and Enable Prediction of the Fertile Window: Observational Study

Background

Previous research examining physiological changes across the menstrual cycle has considered biological responses to shifting hormones in isolation. Clinical studies, for example, have shown that women’s nightly basal body temperature increases from 0.28 to 0.56 ˚C following postovulation progesterone production. Women’s resting pulse rate, respiratory rate, and heart rate variability (HRV) are similarly elevated in the luteal phase, whereas skin perfusion decreases significantly following the fertile window’s closing. Past research probed only 1 or 2 of these physiological features in a given study, requiring participants to come to a laboratory or hospital clinic multiple times throughout their cycle. Although initially designed for recreational purposes, wearable technology could enable more ambulatory studies of physiological changes across the menstrual cycle. Early research suggests that wearables can detect phase-based shifts in pulse rate and wrist skin temperature (WST). To date, previous work has studied these features separately, with the ability of wearables to accurately pinpoint the fertile window using multiple physiological parameters simultaneously yet unknown.

Objective

In this study, we probed what phase-based differences a wearable bracelet could detect in users’ WST, heart rate, HRV, respiratory rate, and skin perfusion. Drawing on insight from artificial intelligence and machine learning, we then sought to develop an algorithm that could identify the fertile window in real time.

Methods

We conducted a prospective longitudinal study, recruiting 237 conception-seeking Swiss women. Participants wore the Ava bracelet (Ava AG) nightly while sleeping for up to a year or until they became pregnant. In addition to syncing the device to the corresponding smartphone app daily, women also completed an electronic diary about their activities in the past 24 hours. Finally, women took a urinary luteinizing hormone test at several points in a given cycle to determine the close of the fertile window. We assessed phase-based changes in physiological parameters using cross-classified mixed-effects models with random intercepts and random slopes. We then trained a machine learning algorithm to recognize the fertile window.

Results

We have demonstrated that wearable technology can detect significant, concurrent phase-based shifts in WST, heart rate, and respiratory rate (all P<.001). HRV and skin perfusion similarly varied across the menstrual cycle (all P<.05), although these effects only trended toward significance following a Bonferroni correction to maintain a family-wise alpha level. Our findings were robust to daily, individual, and cycle-level covariates. Furthermore, we developed a machine learning algorithm that can detect the fertile window with 90% accuracy (95% CI 0.89 to 0.92).

Conclusions

Our contributions highlight the impact of artificial intelligence and machine learning’s integration into health care. By monitoring numerous physiological parameters simultaneously, wearable technology uniquely improves upon retrospective methods for fertility awareness and enables the first real-time predictive model of ovulation.

Rationale and study design of an intervention of increased energy intake in women with exercise-associated menstrual disturbances to improve menstrual function and bone health: The REFUEL study

Purpose

Exercising women who consume inadequate energy relative to expenditure are at risk for downstream health consequences, such as menstrual cycle disturbances and poor bone health. Collectively, these conditions are known as the Female Athlete Triad (Triad). Clinicians often prescribe hormonal contraceptives to address this issue; however, the recommended treatment is reversal of the energy deficit. This paper describes the design of the REFUEL study, a randomized controlled trial (RCT) that explored the effectiveness of a 12-month intervention of increased energy intake on the reversal of an unhealthy energetic status and menstrual dysfunction and subsequent improvements in bone health in exercising women with severe menstrual cycle disturbances.

Methods

Women between the ages of 18–35 years and participating in at least 2 h/week of purposeful exercise were recruited. Those who reported irregular or absent menstrual cycles and were determined to have an exercise-associated menstrual disturbance (EAMD) were randomized into either the treatment group (EAMD + Cal), which was instructed to increase caloric intake throughout the intervention, or a control group (EAMD Control). Women who reported eumenorrhea were eligible for the ovulatory (OV) Control group. Repeated measures of energetic and metabolic status, reproductive status, and skeletal health were obtained.

Discussion

The REFUEL study is the first RCT to explore a non-pharmacological treatment approach among exercising women with the Triad. 118 women were randomized, and 55 women completed the entire study. The findings of this study have the potential to inform and alter clinical practice for exercising young women who present with this condition.

A clinic-based tablet application to support safer conception among HIV serodiscordant couples in Kenya: feasibility and acceptability study

BACKGROUND

HIV serodiscordant couples are at heightened risk of HIV transmission when attempting to conceive, yet reproductive goals can outweigh concerns about HIV exposure. Safer conception strategies support fertility desires while minimizing HIV transmission risk and novel mHealth tools can optimize their use. The objective of this analysis is to examine the feasibility and usability of short message service (SMS) messages and a mobile application to support safer conception for HIV serodiscordant couples.

METHODS

We enrolled 74 heterosexual HIV serodiscordant couples with immediate pregnancy desires into a pilot safer conception intervention study in Thika, Kenya. Prior to pregnancy, women received daily 6-item SMS surveys to capture fertility indicators (e.g., menses, basal body temperature) and sexual behavior. The intervention also provided daily oral pre-exposure prophylaxis (PrEP) for the HIV-negative partner and in-depth counseling to accompany publicly-provided antiretroviral therapy (ART) for the HIV-infected partner. Couples attended monthly visits until pregnancy occurred. We measured PrEP use with medication event monitoring system (MEMS) caps and ART use via quarterly viral load quantification. We imported SMS, MEMS, and viral load data into an Android tablet application designed specifically for this setting for couples to view during clinic visits and included predictions of peak fertility days using SMS data. We used descriptive statistics to summarize SMS response data and developed a Google Analytics platform to monitor tablet application usage during follow-up. We also conducted semi-structured interviews with a purposive sample of 5 healthcare providers and 19 couples. Qualitative data were analyzed using a modified constant comparative approach to identify themes related to mHealth intervention feasibility and acceptability.

RESULTS

In our sample, 34 (45.9%) couples had an HIV-infected female partner. The median age of the female partner was 30 years [interquartile range (IQR), 27-35 years], education was 10 years (IQR, 8-12 years), and partnership duration was 3 years (IQR, 2-7 years). Couples were followed for a median of 218 days (IQR, 116-348 days) prior to pregnancy. Participants completed 13,181 of 16,905 (78.0%) SMS surveys surveys sent with a median of 167 completed surveys (IQR, 74-299) per participant. Most participants completed at least 75% of the total SMS messages received (N=58; 77.3%). The tablet application was opened by counselors 1,806 times during the study period (March 2016 through April 2018). In qualitative interviews, the SMS messages were reportedly easy to respond to and "part of the daily routine". Few participants had concerns about message confidentiality. mHealth tools were also found to be acceptable for tracking fertility indicators and enhancing provider-patient communication.

CONCLUSIONS

mHealth strategies are feasible to use and acceptable to support the delivery of safer conception intervention services among HIV serodiscordant couples in Kenya.

Modern fertility awareness methods: wrist wearables capture the changes in temperature associated with the menstrual cycle

Core and peripheral body temperatures are affected by changes in reproductive hormones during the menstrual cycle. Women worldwide use the basal body temperature (BBT) method to aid and prevent conception. However, prior research suggests that taking one's daily temperature can prove inconvenient and subject to environmental factors. We investigate whether a more automatic, non-invasive temperature measurement system can detect changes in temperature across the menstrual cycle. We examined how wrist skin temperature (WST), measured with wearable sensors, correlates with urinary tests of ovulation and may serve as a new method of fertility tracking. One hundred and thirty-six eumenorrheic, non-pregnant women participated in an observational study. Participants wore WST biosensors during sleep and reported their daily activities. An at-home luteinizing hormone (LH) test was used to confirm ovulation. WST was recorded across 437 cycles (mean cycles/participant = 3.21, S.D. = 2.25). We tested the relationship between the fertile window and WST temperature shifts, using the BBT three-over-six rule. A sustained 3-day temperature shift was observed in 357/437 cycles (82%), with the lowest cycle temperature occurring in the fertile window 41% of the time. Most temporal shifts (307/357, 86%) occurred on ovulation day (OV) or later. The average early-luteal phase temperature was 0.33°C higher than in the fertile window. Menstrual cycle changes in WST were impervious to lifestyle factors, like having sex, alcohol, or eating prior to bed, that, in prior work, have been shown to obfuscate BBT readings. Although currently costlier than BBT, the present study suggests that WST could be a promising, convenient parameter for future multiparameter fertility awareness methods.

An inexpensive smartphone-based device for point-of-care ovulation testing

The ability to accurately predict ovulation at-home using low-cost point-of-care diagnostics can be of significant help for couples who prefer natural family planning. Detecting ovulation-specific hormones in urine samples and monitoring basal body temperature are the current commonly home-based methods used for ovulation detection; however, these methods, relatively, are expensive for prolonged use and the results are difficult to comprehend. Here, we report a smartphone-based point-of-care device for automated ovulation testing using artificial intelligence (AI) by detecting fern patterns in a small volume (<100 μL) of saliva that is air-dried on a microfluidic device. We evaluated the performance of the device using artificial saliva and human saliva samples and observed that the device showed >99% accuracy in effectively predicting ovulation.

[Natural Family Planning methods and Barrier: CNGOF Contraception Guidelines]

OBJECTIVE

To develop clinical practice recommendations for the use of natural contraception and female and male barrier methods.

MATERIALS AND METHODS

A systematic review of English and French literatures related to the safety and effectiveness of natural contraceptive methods based on PubMed, Cochrane Library, practice recommendations issued by international scientific societies and guidelines provided by the World Health Organization (WHO) as well as updates from the Center for Disease Control and Prevention (CDC).

RESULTS

Natural contraceptives methods include fertility awareness-based methods, lactational amenorrhea method (LAM) and withdrawal method. The prevalence is low (4.6% of users) and remains stable over the years. Identification of the fertile period can be symptom-based cervical mucus (Billings), two-day method, basal body temperature, symptom-thermal method or based on calendar calculation (Ogino-Knauss, standard day method). Pregnancy rate after one-year utilization varies from 0.4% to 5% in perfect use but 8% in common practice. Effectiveness increases with absence of vaginal sex and decreases when combined to barriers method inadequately implemented. Data is scarce on reliability and effectiveness of ovulation predictor kits readily available on internet. Lactational amenorrhea method (LAM) can be very effective (98%) provided three conditions are fulfilled: within 6 months after birth, amenorrhea is effective, and breastfeeding is exclusive or quasi exclusive (day/night). Withdrawal method is constraining and of limited effectiveness. Male and female condom, diaphragm, cervical cap and spermicides are mechanical and chemical barrier methods, preventing spermatozoids from passing through the cervix into the uterus and therefore preventing fecundation. Female and male condoms offer a double protection to avoid pregnancy and prevent STD's. They are effective provided strict conditions of use are fulfilled. Male condom is favored by teenagers (45.6% among 15 to 19 years old), sometimes in combination with contraceptive pill (16% of cases). Women on the pill decreases according to their age. Pregnancy rates within the first year of consistent and correct use of these methods vary between 5 to 26% and reach 20 to 32% in practical use. Diaphragm and cervical cap need to be used in combination with spermicides. Spermicides have limited effectiveness when used alone.

CONCLUSION

In common practice, natural and barrier contraceptive methods are more constraining and less effective than modern contraceptive method. They can be an alternative at given time and/or in situations where the women or the couple accept the possibility of an unexpected pregnancy which might be terminated or not. Women/couples need to be properly informed on how to use such methods, on their disadvantages and possible failures in common practice. Reminders are to be given on emergency contraceptive methods (IUD, hormonal) after unprotected sex.

Self-Monitoring of Fertility Hormones: A New Era for Natural Family Planning?

Natural family planning (NFP) methods have served many generations well, and in particular, the symptothermal or symptohormonal methods. The comparison of daily mucus and temperature records for individual cycles with daily hormone measurements, which is now possible, shows that some of the assumptions underlying NFP may not be completely accurate. The various methods are inadvertently depending on an element of chance, which, of course, cannot be known by the NFP user. However, it is statistically inevitable that such errors will result eventually in an unexpected pregnancy, and these discrepancies are the likely reason for the method failures. Further research and integration of home hormone measurements with NFP symptoms are needed. Summary: Traditional NFP methods, based on the observations of temperature, mucus, and luteinizing hormone, can work well. However, these data are sometimes difficult to interpret, and significant changes in the variables are sometimes "missing" from some cycles. Changes in these variables are elicited by the estrogen and progesterone released from the ovaries. It follows that the direct measures of events in the ovaries are the levels of estrogen and progesterone or their derivatives in blood or urine. Measurements of urinary derivatives of estrogen and progesterone can be used to monitor the ovaries directly and are clearer indicators than traditional NFP methods.

Detection of ovulation, a review of currently available methods

The ability to identify the precise time of ovulation is important for women who want to plan conception or practice contraception. Here, we review the current literature on various methods for detecting ovulation including a review of point‐of‐care device technology. We incorporate an examination of methods to detect ovulation that have been developed and practiced for decades and analyze the indications and limitations of each—transvaginal ultrasonography, urinary luteinizing hormone detection, serum progesterone and urinary pregnanediol 3‐glucuronide detection, urinary follicular stimulating hormone detection, basal body temperature monitoring, and cervical mucus and salivary ferning analysis. Some point‐of‐care ovulation detection devices have been developed and commercialized based on these methods, however previous research was limited by small sample size and an inconsistent standard reference to true ovulation.

Pulse Rate Measurement During Sleep Using Wearable Sensors, and its Correlation with the Menstrual Cycle Phases, A Prospective Observational Study

An affordable, user-friendly fertility-monitoring tool remains an unmet need. We examine in this study the correlation between pulse rate (PR) and the menstrual phases using wrist-worn PR sensors. 91 healthy, non-pregnant women, between 22-42 years old, were recruited for a prospective-observational clinical trial. Participants measured PR during sleep using wrist-worn bracelets with photoplethysmographic sensors. Ovulation day was estimated with "Clearblue Digital-Ovulation-urine test". Potential behavioral and nutritional confounders were collected daily. 274 ovulatory cycles were recorded from 91 eligible women, with a mean cycle length of 27.3 days (±2.7). We observed a significant increase in PR during the fertile window compared to the menstrual phase (2.1 beat-per-minute, p < 0.01). Moreover, PR during the mid-luteal phase was also significantly elevated compared to the fertile window (1.8 beat-per-minute, p < 0.01), and the menstrual phase (3.8 beat-per-minute, p < 0.01). PR increase in the ovulatory and mid-luteal phase was robust to adjustment for the collected confounders. There is a significant increase of the fertile-window PR (collected during sleep) compared to the menstrual phase. The aforementioned association was robust to the inter- and intra-person variability of menstrual-cycle length, behavioral, and nutritional profiles. Hence, PR monitoring using wearable sensors could be used as one parameter within a multi-parameter fertility awareness-based method.

Natural conception rates in subfertile couples following fertility awareness training

PURPOSE

To analyze cumulative pregnancy rates of subfertile couples after fertility awareness training.

METHODS

A prospective observational cohort study followed 187 subfertile women, who had received training in self-observation of the fertile phase of the menstrual cycle with the Sensiplan method, for 8 months. The women, aged 21-47 years, had attempted to become pregnant for 3.5 years on average (range 1-8 years) before study entry. Amenorrhea, known tubal occlusion and severe male factor had been excluded. An additional seven women, who had initially been recruited, became pregnant during the cycle immediately prior to Sensiplan training: this is taken to be the spontaneous pregnancy rate per cycle in the cohort in the absence of fertility awareness training.

RESULTS

The cumulative pregnancy rate of subfertile couples after fertility awareness training was 38% (95% CI 27-49%; 58 pregnancies) after eight observation months, which is significantly higher than the estimated basic pregnancy rate of 21.6% in untrained couples in the same cohort. For couples who had been seeking to become pregnant for 1-2 years, the pregnancy rate increased to 56% after 8 months. A female age above 35 (cumulative pregnancy rate 25%, p = 0.06), couples who had attempted to become pregnant for more than 2 years (cumulative pregnancy rate 17%, p < 0.01), all significantly reduce the chances of conceiving naturally at some point.

CONCLUSIONS

Training women to identify their fertile window in the menstrual cycle seems to be a reasonable first-line therapy in the management of subfertility.

Standardized protocols for characterizing women's fertility: A data-driven approach

Experts are divided on whether women's cognition and behavior differs between fertile and non-fertile phases of the menstrual cycle. One of the biggest criticisms of this literature concerns the use of indirect, imprecise, and flexible methodologies between studies to characterize women's fertility. To resolve this problem, we provide a data-driven method of best practices for characterizing women's fertile phase. We compared the accuracy of self-reported methods and counting procedures (i.e., the forward- and backward-counting methods) in estimating ovulation using data from 140 women whose fertility was verified with luteinizing hormone tests. Results revealed that no counting method was associated with ovulation with >30% accuracy. A minimum of 39.5% of the days in the six-day fertile window predicted by the counting methods were non-fertile, and correlations between counting method conception probabilities and actual conception probability were weak to moderate, rs=0.11-0.30. Poor results persisted when using a lenient window for predicting ovulation, across alternative estimators of the onset of the next cycle, and when removing outliers to increase the homogeneity of the sample. By contrast, combining counting methods with a relatively inexpensive test of luteinizing hormone predicted fertility with accuracy >95%, but only when specific guidelines were followed. To this end, herein we provide a cost-effective, pragmatic, and standardized protocol that will allow researchers to test whether fertility effects exist or not.

Comparison of Abstinence and Coital Frequency Between 2 Natural Methods of Family Planning

INTRODUCTION

The length of periodic abstinence, due to overestimation of the fertile phase of the menstrual cycle, is often a cause for dissatisfaction, discontinuation, and user error with natural family planning (NFP) methods. The objective of this research was to compare the length of required abstinence (ie, estimated fertility) and coital frequency between 2 NFP methods.

METHODS

This was an analysis of data from a 12-month prospective comparison study in which participants were randomized into either an electronic hormonal fertility monitor (EHFM) group or a cervical mucus monitoring (CMM) group-both of which included a fertility algorithm as a double check for the beginning and end of the estimated fertile window. The number of days of estimated fertility and coitus was extracted from each menstrual cycle of data, and t tests were used to compare the means of these 2 variables between the 2 NFP methods.

RESULTS

The study involved 197 women (mean [SD] age 29.7 [5.4]) who used the EHFM to estimate the fertile window and 160 women (mean [SD] age 30.4 [5.3]) who used CMM to estimate the fertile window. They produced 1,669 menstrual cycles of data. After 12 months of use, the EHFM group had statistically fewer days of estimated fertility than the CMM group (mean [SD] days, 13.25 [2.79] vs 13.68 [2.99], respectively; t = 2.07; P = .039) and significantly more coitus (mean [SD] coital acts, 4.22 [3.16] vs 4.05 [2.88], respectively; t = 1.17; P = .026).

DISCUSSION

The use of the EHFM seems to provide more objectivity and confidence in self-estimating the fertile window and using nonfertile days for intercourse when avoiding pregnancy.

The tear ferning test: a simple clinical technique to evaluate the ocular tear film

A healthy tear film is very important for many major functions of the ocular surface. Dry eye disease is a significant clinical problem that needs to be solved but the poor correlation between clinical signs and reported symptoms makes it difficult for the clinician to apply a scientific basis to his clinical management. The problem is compounded by the difficulties of evaluating the tear film due to its transparency, small volume and complex composition. Practical insight into tear film composition would be very useful to the clinician for patient diagnosis and treatment but detailed analysis is restricted to expensive, laboratory-based systems. There is a pressing need for a simple test. The tear ferning test is a laboratory test but it has the potential to be applied in the clinic setting to investigate the tear film in a simple way. Drying a small sample of tear fluid onto a clean, glass microscope slide produces a characteristic crystallisation pattern, described as a 'tear fern'. This test is currently not widely used because of some limitations that need to be overcome but several studies have demonstrated its potential. Such limitations need to be resolved so that tear ferning could be used in the clinic setting to assess the tear film.

Comparison between the different methods developed for determining the onset of the LH surge in urine during the human menstrual cycle

PURPOSE

To determine whether an optimal method exists for the detection of the luteinising hormone (LH) surge onset in research datasets of urinary hormonal profiles of menstrual cycles.

METHODS

The scientific literature was searched to compare published methodologies for detection of the LH surge onset in urine. Their performance was tested using complete hormonal profiles from 254 ovulatory cycles from 227 women attempting pregnancy (normal regular menstrual cycles; no known infertility).

RESULTS

Three major methodologies to determine the onset of the LH surge in urine were identified. The key difference between these methods is how the cycle days that contribute to LH baseline assessment are determined: using fixed days (method #1), based on peak LH day (method #2), based on a provisional estimate of the LH surge (method #3). Method #1 requires no prior cycle information, whereas methods #2 and #3 need to consider complete cycle data. The most reliable method for calculation of baseline LH was using 2 days before the estimated surge day, plus the previous 4/5 days.

CONCLUSIONS

Different methods for identification of the urinary LH surge can provide very different determinations of LH surge day, thus care must be taken when comparing between studies that apply different methodologies. The optimal method for determining the onset of the LH surge in urine requires retrospective estimation of day of LH surge to identify the most appropriate part of the cycle to consider as the baseline. This method can be adopted for application in population studies.

Reclaiming fertility awareness methods to inform timed intercourse for HIV serodiscordant couples attempting to conceive

INTRODUCTION

Increased life expectancy of HIV-positive individuals during recent years has drawn attention to their quality of life, which includes fulfillment of fertility desires. In particular, heterosexual HIV serodiscordant couples constitute a special group for whom the balance between desired pregnancy and the risk of viral transmission should be carefully considered and optimized. Although advanced assisted reproductive technologies are available, such treatments are expensive and are often unavailable. Moreover, standard viral load testing and antiretroviral therapy may not be accessible due to structural or individual barriers. To reduce the risk of HIV transmission, a lower cost alternative is timed condomless sex combined with other risk-reduction strategies. However, timed condomless sex requires specific knowledge of how to accurately predict the fertile window in a menstrual cycle. The aim of this study was to summarize inexpensive fertility awareness methods (FAMs) that predict the fertile window and may be useful for counselling HIV-positive couples on lower cost options to conceive.

METHODS

Original English-language research articles were identified by a detailed Medline and Embase search in July 2014. Relevant citations in the included articles were also retrieved.

RESULTS AND DISCUSSION

Calendar method, basal body temperature and cervicovaginal mucus secretions are the most accessible and sensitive FAMs, although poor specificity precludes their independent use in ovulation detection. In contrast, urinary luteinizing hormone testing is highly specific but less sensitive, and more expensive. To maximize the chance of conception per cycle, the likelihood of natural conception needs to be assessed with a basic fertility evaluation of both partners and a combination of FAMs should be offered. Adherence to other risk-reduction strategies should also be advised, and timely referral to reproductive medicine specialists is necessary when sub/infertility is suspected.

CONCLUSIONS

FAMs provide effective, economical and accessible options for HIV serodiscordant couples to conceive while minimizing unnecessary viral exposure. It is important for health care providers to initiate conversations about fertility desires in HIV-positive couples and to educate identified couples on safer conception strategies.

A pilot study comparing the DuoFertility(®) monitor with ultrasound in infertile women

Background

The purpose of this study was to assess the accuracy of ovulation detection by the DuoFertility^® monitor compared with transvaginal ultrasound in infertile women with regular menstrual cycles.

Methods

Eight infertile patients, aged 27–40 years, with a body mass index of 19–29, regular menses, normal ovaries on pelvic ultrasound scan, and normal early follicular luteinizing hormone (LH), follicle-stimulating hormone, and prolactin were recruited from infertility clinics in primary and secondary care for this pilot, prospective, observational study. The patients were asked to use the DuoFertility monitor for the whole cycle, with investigators and patients blind to DuoFertility data. Daily urine LH monitoring commenced on cycle day 8, with daily transvaginal ultrasound following the first positive LH until ovulation was observed. Ovulation was further confirmed by serum progesterone. The main outcome measure was detection of ovulation by the DuoFertility monitor, and correlation between day of ovulation assessed by DuoFertility and ultrasound.

Results

DuoFertility identified ovulation as having occurred within one day of that determined via ultrasound in all cycles. The sensitivity of ovulation detection was 100% (95% confidence interval 82–100). The specificity could not be concluded from the data.

Conclusion

In infertile women with regular cycles, the DuoFertility monitor appears to accurately identify ovulatory cycles and the day of ovulation.

Physiological signs of ovulation and fertility readily observable by women

INTRODUCTION

Confirmation of ovulation can be difficult in clinical practice, as gold standard methods including serial transvaginal ultrasonography, serum luteinizing hormone (LH) measurements, or laparoscopic follicular observation are impractical. Numerous surrogate markers have been proposed and evaluated in relation to these gold standards that have more practical clinical applications.

PURPOSE

To review the evidence on physiological signs of ovulation timing and fertility in order to determine valid markers that can be easily identified by women.

METHODS

A literature review of primary resources in Ovid Medline was undertaken to identify studies examining physiological signs as they relate to gold standard assessment of ovulation. Studies examining the efficacy/effectiveness of different types of natural family planning were excluded.

RESULTS

The most commonly encountered physiological signs were urine LH, cervical mucus, and basal body temperature (BBT). Urine LH as assessed by home monitoring systems indicated ovulation 91 percent of the time during the 2 days of peak fertility on the monitor and 97 percent during the 2 peak days plus 1. Cervical mucus peak characteristics were identified 78 percent of the time ±1 day, and 91 percent of the time ±2 days of LH surge indicating ovulation. Further research supports the importance of cervical mucus in overall fertility, as conception rates were more closely related to mucus quality than to timing of intercourse related to ovulation. As a lone indicator of ovulation, BBT is at best a retrospective marker, and functions best in conjunction with other signs of ovulation. Additionally, salivary ferning, salivary and vaginal fluid electrical potential, finger-finger electrical potential, and differential skin temperature were postulated as possible indicators, but were not found to be temporally related to ovulation. The research on differential skin temperature is promising, but minimal thus far in number, and has not been evaluated as an adjunct to BBT as yet.

CONCLUSION

Home urinary LH monitors are becoming more widely available and less expensive giving women the potential to assess the ovulatory status of their cycle in real time. Cervical mucus observation is an effective and cost-efficient method, but requires some teaching to increase the confidence of users. In conjunction, LH monitors and cervical mucus can give the best indication of fertility and ovulation timing.

Development of a new grading scale for tear ferning

PURPOSE

This paper reports on the development of a new tear ferning (TF) subjective grading scale, and compares it with the Rolando scale.

METHOD

TF patterns obtained from tear film samples collected from normal and dry eye subjects in previous studies were collated into a large image library. From this library, 60 images were selected to represent the full range of possible TF patterns, and a further sub-set of 15 images was chosen for analysis. Twenty-five optometrists were asked to rank the images in increasing order between extreme anchors on a scale of TF patterns. Interim statistical analysis of this ranking found 7 homogeneous sub-sets, where the image rankings overlapped for a group of images. A representative image (typically the mean) from each group was then adopted as the grade standard. Using this new 7-point grading scale, 25 optometrists were asked to grade the entire 60 image library at two sessions: once using the 4-point Rolando scale and once using the new 7-point scale, applying 0.25 grade unit interpolation.

RESULTS

Statistical analysis found that for the larger image set, the Rolando scale produced 3 homogeneous sub-sets, and the 7-point scale produced 5 homogeneous sub-sets. With this refinement, a new 5-point TF scale (Grades 0-4) was obtained.

CONCLUSIONS

The Rolando grading scale lacks discrimination between its Type I and II grades, reducing its reliability. The new 5-point grading scale is able to differentiate between TF patterns, and may provide additional support for the use of TF for both researcher and clinician.

Men Smelling Women: Null Effects of Exposure to Ovulatory Sweat on Men's Testosterone

Males of many species, humans included, exhibit rapid testosterone increases after exposure to conspecific females. Female chemical stimuli are sufficient to trigger these responses in many nonhuman species, which raises the possibility of similar effects in humans. Recently, Miller and Maner (2010) reported that smelling T-shirts worn by women near ovulation can trigger testosterone responses in men; however, men were aware that they were smelling women's scents, and thus mental imagery associated with that knowledge may have contributed to the hormone responses. Here, we collected axillary sweat samples from women on days near ovulation. In a crossover design, men who were not explicitly aware of the specific stimuli smelled the sweat samples in one session and water samples in a second session. There were no differences in testosterone responses across the experimental conditions. Our null findings suggest that the relevant chemical signal is not found in axillary sweat, and/or that knowledge of the stimulus source is necessary for hormone responses. These results thus suggest boundary conditions for the effects reported in Miller and Maner (2010) , and recommend further research to define the precise circumstances under which men's testosterone may respond to chemosensory cues from women.

Accuracy of perception of ovulation day in women trying to conceive

BACKGROUND

The likelihood of conception is increased if intercourse is timed to coincide with the fertile period (5 days up to ovulation). However, to be effective, this requires good awareness of the day of ovulation. The aim of this study was to examine the accuracy of women's perceived ovulation day, compared with actual fertile days, in a cohort of women trying to conceive.

MAIN OUTCOME MEASURES

Comparison of women's estimated day of ovulation with their actual ovulation day (determined by detecting luteinising hormone).

METHODS

This was a sample collection study and volunteer women were recruited via online advertising. At recruitment volunteers reported the cycle day they believed they ovulated. They then used a home urine fertility monitor to test their daily fertility status to time intercourse to try and achieve conception, in addition to collecting early morning urine samples for laboratory analysis. The main outcome measure was a comparison of women's estimated day of ovulation with their actual ovulation day, as determined by urine detection of luteinising hormone.

RESULTS

Three hundred and thirty women were recruited onto the study and data was available for 102 volunteers who became pregnant. Thirteen women (12.7%) correctly estimated their ovulation day; median difference +2 days, range -10 to +27 days. The most common days for estimation of ovulation were day 14 (35.5%) and day 15 (15.7%). Only 55% of estimated ovulation days fell within the volunteers' fertile window; only 27% on days of peak fertility.

CONCLUSIONS

Women trying to conceive may benefit from using a prospective method to identify their fertile phase, as a significant proportion could be incorrectly estimating their fertile days. These observations were made on women who were actively looking for knowledge on fertility and considered only cycles where conception occurred, inaccuracy could be greater if a broader population is considered.

Psychological and neuroendocrine reactivity to ostracism

This study used the ostracism detection theory to investigate how ostracism impacts individuals in two ways: (1) immediate poststressor needs, mood, ruminative thoughts, and desire to affiliate, and (2) short-term affective and cortisol reactivity. A total of 58 college students were randomly assigned to the inclusion or ostracism conditions of Cyberball, a virtual ball-tossing game. Immediately following the experimental manipulation, ostracized participants reported more thwarted psychological need states, more negative mood, and fewer positive ruminative thoughts, relative to their included counterparts. Ostracized participants reported a greater interest in affiliating with others in online or in-person settings. In the short-term, ostracized males reported more hostility than included males, although the scores were within expected norms for most males. There was no relation between Cyberball condition and gender across time for depression, anxiety, or positive affect. Approximately 20 min after the onset of the stressor, women in the luteal phase and women taking oral contraceptives in the ostracized group displayed higher cortisol than their counterparts in the included group. Relative to baseline, however, cortisol did not reliably increase after the onset of the stressor. Ostracized females taking oral contraceptives showed the greatest decline in cortisol, compared to included oral contraceptive users. Overall, results suggest that most of the negative effects of ostracism are immediate and limited to psychological, not neuroendocrine, responses.

Comparison of a digital ovulation test with three popular line ovulation tests to investigate user accuracy and certainty

OBJECTIVES

To determine the accuracy and certainty with which volunteers interpreted results of a digital ovulation test, Clearblue digital ovulation test (CB-DOT), compared with three home use non-digital visual ovulation tests: Clearblue ovulation test (CB-OT), First Response (FR) and Answer (AN).

METHODS

A total of 72 female volunteers aged 18 - 45 years interpreted test results from each of the four ovulation tests to determine the day of the luteinising hormone surge in 40 individual menstrual cycles. We used urine previously collected from 25 volunteers. The accuracy with which volunteers interpreted the test results was calculated by comparing their results with results obtained by trained technicians using a blinded test regime. For each of the four tests, volunteers were also asked to rate seven attributes of certainty and eight attributes of preference. The primary objective was to compare the accuracy with which volunteers read results from CB-DOT when compared to three visual-based line ovulation tests.

RESULTS

A significantly higher percentage of volunteers/technicians agreed on the interpretation of the results from CB-DOT (97.3%) than for CB-OT (83.5%; p = 0.0153), AN (73%; p = 0.0011) or FR (64.3%; p = 0.0001). CB-DOT was also found to have significantly better Likert scores than CB-OT, FR and AN for all seven attributes of certainty and was the test that 97.2% of volunteers preferred.

CONCLUSIONS

Women can misread the results of line ovulation tests. Over 97% of volunteers correctly read the result of CB-DOT. CB-DOT was also the test that women read with most certainty and the test that most users preferred.

Return of ovulation and menses in postpartum nonlactating women: a systematic review

OBJECTIVES

To estimate, from the literature, when nonlactating postpartum women regain fertility.

DATA SOURCES

We searched PubMed and Cochrane Library databases for all articles (in all languages) published in peer-reviewed journals from database inception through May 2010 for evidence related to the return of ovulation and menses in nonlactating postpartum women. Search terms included "Fertility" (Mesh) OR "Ovulation" (Mesh) OR "Ovulation Detection" (Mesh) OR "Ovulation Prediction" (Mesh) OR fertility OR ovulat* AND "Postpartum Period" (Mesh) OR postpartum OR puerperium AND Human AND Female.

METHODS OF STUDY SELECTION

We included articles assessing nonlactating women's first ovulation postpartum. Studies in which women breastfed for any period of time or in whom lactation was suppressed with medications were excluded.

TABULATION, INTEGRATION AND RESULTS

We identified 1,623 articles; six articles reported four studies met our inclusion criteria. In three studies utilizing urinary pregnanediol levels to measure ovulation, mean day of first ovulation ranged from 45 to 94 days postpartum; 20%-71% of first menses were preceded by ovulation and 0%-60% of these ovulations were potentially fertile. In one study that used basal body temperature to measure ovulation, mean first ovulation occurred on day 74 postpartum; 33% of first menses were preceded by ovulation and 70% of these were potentially fertile.

CONCLUSION

Most nonlactating women will not ovulate until 6 weeks postpartum. A small number of women will ovulate earlier, potentially putting them at risk for pregnancy sooner, although the fertility of these early ovulations is not well-established. The potential risk of pregnancy soon after delivery underscores the importance of initiating postpartum contraception in a timely fashion.

High-tech family planning: reproductive regulation through computerized fertility monitoring

Issues related to family planning have profound public health significance as they directly impact individuals, couples, and families throughout the world. A new method of family planning is now available using a computerized fertility monitor that accurately measures urinary surges in estrone-3-glucuronide (E3G) and luteinizing hormone (LH) prior to ovulation, thus identifying the short-lived fertile phase of the cycle and providing women with the choice to achieve or avoid conception. As well as ease of use and instruction, hand-held computerized fertility monitors are accurate and effective and can be used indefinitely. An algorithm for computerized monitoring is presented for use in situations of infrequent or irregular ovulation such as with polycystic ovarian syndrome and the post-partum period. Hormone-based fertility monitoring is compared to other computerized fertility monitoring techniques. A case series of seven reports reflecting varied clinical backgrounds and medical histories demonstrates broad-based success and high satisfaction with computerized monitoring for regulation of reproductive potential. Limitations of fertility monitoring are also discussed.

Detecting evidence of luteal activity by least-squares quantitative basal temperature analysis against urinary progesterone metabolites and the effect of wake-time variability

OBJECTIVE

To assess computerised least-squares analysis of quantitative basal temperature (LS-BT) against urinary pregnanediol glucuronide (PdG) as an indirect measure of ovulation, and to evaluate the stability of LS-QBT to wake-time variation.

STUDY DESIGN

Cross-sectional study of 40 healthy, normal-weight, regularly menstruating women aged 19-34. Participants recorded basal temperature and collected first void urine daily for one complete menstrual cycle. Evidence of luteal activity (ELA), an indirect ovulation indicator, was assessed using Kassam's PdG algorithm, which identifies a sustained 3-day PdG rise, and the LS-QBT algorithm, by determining whether the temperature curve is significantly biphasic. Cycles were classified as ELA(+) or ELA(-). We explored the need to pre-screen for wake-time variations by repeating the analysis using: (A) all recorded temperatures, (B) wake-time adjusted temperatures, (C) temperatures within 2h of average wake-time, and (D) expert reviewed temperatures.

RESULTS

Relative to PdG, classification of cycles as ELA(+) was 35 of 36 for LS-QBT methods A and B, 33 of 34 (method C) and 30 of 31 (method D). Classification of cycles as ELA(-) was 1 of 4 (methods A and B) and 0 of 3 (methods C and D). Positive predictive value was 92% for methods A-C and 91% for method D. Negative predictive value was 50% for methods A and B and 0% for methods C and D. Overall accuracy was 90% for methods A and B, 89% for method C and 88% for method D. The day of a significant temperature increase by LS-QBT and the first day of a sustained PdG rise were correlated (r=0.803, 0.741, 0.651, 0.747 for methods A-D, respectively, all p<0.001).

CONCLUSION

LS-QBT showed excellent detection of ELA(+) cycles (sensitivity, positive predictive value) but poor detection of ELA(-) cycles (specificity, negative predictive value) relative to urinary PdG. Correlations between the methods and overall accuracy were good and similar for all analyses. Findings suggest that LS-QBT is robust to wake-time variability and that expert interpretation is unnecessary. This method shows promise for use as an epidemiological tool to document cyclic progesterone increase. Further validation relative to daily transvaginal ultrasound is required.

Levels of urinary human chorionic gonadotrophin (hCG) following conception and variability of menstrual cycle length in a cohort of women attempting to conceive

OBJECTIVES

To define the variability of menstrual cycle length and contribution of follicular and luteal phases to overall cycle variability, and to examine the rise in urinary hCG in early pregnancy.

METHODS

Menstrual cycle study. Urine samples from 101 women (recruited from two south-east counties in the UK) were assayed to determine day of luteinising hormone (LH) surge, lengths of follicular and luteal phases and correlations with total menstrual cycle length. HCG study. Daily urine samples collected from 86 women prior to conception until 43 days post-conception were assayed for hCG and examined versus time since LH surge, determined using fertility test kits.

RESULTS

Mean menstrual cycle length was 27.7 +/- 3.4 days, mean follicular phase length was 14.5 +/- 3.4 days and mean luteal phase length was 13.2 +/- 1.9 days. Total cycle lengths varied between and within women. There was a significant correlation (r(2) = 0.70) between follicular phase length and total cycle length; luteal phase length was less variable and showed no association with total cycle length. Concentrations of hCG were significantly similar between women when referenced against the day since LH surge. Three thresholds were determined to indicate time since conception as 1-2 weeks, 2-3 weeks and 3+ weeks.

CONCLUSIONS

Total cycle length variation is mainly determined by follicular phase variation and predicting menses onset to estimate time of pregnancy testing is unreliable. Evaluating concentrations of hCG relative to LH surge results in consistent increases between women up to 21 days after conception. Therefore, urinary hCG concentration can be used to accurately estimate time since conception.

Differences in gait across the menstrual cycle and their attractiveness to men

We investigated variations in gait between women at high and at low conception probability, and how men rated those variations. Women participated in a motion capture study where we recorded the kinematics of their walking patterns. Women who were not using hormonal contraception (n = 19) repeated the study during the late follicular stage and the luteal stage of their menstrual cycle. Using a discriminant function analysis, we found significant differences in walking behavior between naturally cycling women at their follicular and luteal phases, with 71% of the walks classified correctly. However, there was no difference between walks of women in their follicular stage and women using hormonal birth control (n = 23). We compared structural and kinematic characteristics of the women's walking patterns that appeared to be characteristic of women in the specific conception risk groups, but found no significant differences. In a second study, 35 men rated the walks of women not using hormonal contraception as slightly more attractive during the luteal stage of the cycle compared to the late follicular stage. Thus, for women not using hormonal birth control, it would appear that some information regarding female fertility appears to be encoded in gait.

Devices for home evaluation of women's health concerns

PURPOSE

Devices used for home evaluation of fertility, pregnancy, menopause, colon cancer, breast cancer, and urinary-tract and vaginal yeast infections are discussed.

SUMMARY

Ovulation-prediction devices monitor natural changes in a woman's body during the menstrual cycle, including changes in basal body temperature, urinary luteinizing hormone, and urinary estrone-3-glucuronide concentrations. Also available are devices that identify changes in the content of sodium chloride and other electrolytes in saliva and cervical-vaginal mucus. Home pregnancy tests are designed to detect human chorionic gonadotropin in the urine. Both urine and saliva tests are available for home evaluation of menopause; the most common devices use urine to measure follicle-stimulating hormone. The saliva tests measure estradiol, progesterone, and testosterone. Devices for home screening for colon cancer use either the guaiac test or the fecal immunochemical test. For aid in breast self-examination, patients may use a simulated-breast product designed to train them to detect lumps or a thin, silicone-containing pad intended to increase the sensitivity of the fingers to abnormalities. Urine-dipstick tests can be used to screen for urinary-tract infection, and a swab or panty liner can be used to detect vaginal pH changes indicative of vaginal yeast infection. Home-based tests may be convenient and economical but also have limitations; pharmacists can help educate patients and clinicians.

CONCLUSION

Many devices are available to help evaluate women's health concerns at home.

Bayesian selection of optimal rules for timing intercourse to conceive by using calendar and mucus

OBJECTIVE

To find optimal clinical rules that maximize the probability of conception while limiting the number of intercourse days required.

DESIGN

Multicenter prospective study. Women were followed prospectively while they kept daily records of menstrual bleeding, intercourse, and mucus symptom characteristics. In some cycles, women sought to conceive, whereas in other cycles, they sought to avoid pregnancy.

SETTING

Four centers providing services on fertility awareness.

PATIENT(S)

One hundred ninety-one healthy women using the Billings Ovulation Method. Women were invited to enroll by their instructors if they satisfied the entry criteria. We excluded cycles in which mucus was not recorded on a day with intercourse.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Clinically identified pregnancies. There were 161 clinically identified pregnancies in 2,536 menstrual cycles from 191 women.

RESULT(S)

Our approach relies on a statistical model that relates daily predictors, such as type of mucus symptom, to the day-specific probabilities of conception. By using Bayesian methods to search over a large set of possible clinical rules, focusing on rules based on calendar and mucus, we found that simple rules that are based on days within the midcycle calendar interval that also have the most fertile-type mucus symptom present have high utility.

CONCLUSION(S)

Couples can shorten their time to pregnancy efficiently by timing intercourse on days that the most fertile-type mucus symptom is observed at the vulva.