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

Using Hormone Data and Age to Pinpoint Cycle Day within the Menstrual Cycle

Background and Objectives: Menstrual cycle tracking is essential for reproductive health and overall well-being. However, there is still an over-reliance on estimations that standard cycles are 28 days long, divided evenly between the follicular and luteal phases. Due to the variability of cycle length and cycle phase lengths, common methods of identifying where an individual is in their cycle are often inaccurate. This study used daily hormone monitoring obtained through a remote hormone-monitoring platform to evaluate hormone levels across a menstrual cycle to identify nuances in the follicular and luteal phases in individuals of different age groups. Materials and Methods: This study used a remote fertility testing system that quantitatively tracks luteinizing hormone (LH) and pregnanediol-3-glucuronide (PdG) through urine tests read by an AI-powered smartphone app. The study analyzed cycle data from 1233 users with a total of 4123 evaluated cycles. Daily levels for LH and PdG were monitored across multiple cycles. Results: This study determined that calculated cycle lengths tended to be shorter than user-reported cycle lengths. Significant differences were observed in cycle phase lengths between age groups, indicating that follicular phase length declines with age while luteal phase length increases. Finally, the study found that if an individual's age, first cycle day, and current hormone levels are known, population-level hormone data can be used to pinpoint which cycle phase and cycle day they are in with 95% confidence. Conclusions: At-home hormone monitoring technologies can allow patients and clinicians to track their cycles with greater precision than when relying on textbook estimations. The study's findings have implications for fertility planning, clinical management, and general health monitoring. Prior to this study, no standard existed for pinpointing where a person was in their cycle through only one measure of LH and PdG. These findings have the potential to fill significant gaps within reproductive healthcare and beyond.

Complete Cycle Mapping Using a Quantitative At-Home Hormone Monitoring System in Prediction of Fertile Days, Confirmation of Ovulation, and Screening for Ovulation Issues Preventing Conception

Background and Objectives: To achieve pregnancy, it is highly beneficial to identify the time of ovulation as well as the greater period of fertile days during which sperm may survive leading up to ovulation. Confirming successful ovulation is also critical to accurately diagnose ovulatory disorders. Ovulation predictor kits, fertility monitors, and tracking apps are all available to assist with detecting ovulation, but often fall short. They may not detect the full fertile window, provide accurate or real-time information, or are simply expensive and impractical. Finally, few over-the-counter products provide information to women about their ovarian reserve and future fertility. Therefore, there is a need for an easy, over-the-counter, at-home quantitative hormone monitoring system that assesses ovarian reserve, predicts the entire fertile window, and can screen for ovulatory disorders. Materials and Methods: Proov Complete is a four-in-one at-home multihormone testing system that utilizes lateral flow assay test strips paired with the free Proov Insight App to guide testing of four hormones-FSH, E1G, LH, and PdG-across the woman's cycle. In a pilot study, 40 women (including 16 with a fertility-related diagnosis or using fertility treatments) used Complete for one cycle. Results: Here, we demonstrate that Proov Complete can accurately and sensitively predict ovarian reserve, detect up to 6 fertile days and confirm if ovulation was successful, in one easy-to-use kit. Ovulation was confirmed in 38 cycles with a detectable PdG rise. An average of 5.3 fertile days (from E1G rise to PdG rise) were detected, with an average of 2.7 days prior to LH surge. Ovulation was confirmed via PdG rise an average of 2.6 days following the LH surge. While 38/40 women had a PdG rise, only 22 had a sustained PdG level above 5 μg/mL throughout the critical implantation window, indicating ovulatory dysfunction in 16 women. Conclusions: Proov Complete can detect the entire fertile window of up to 6 fertile days and confirm ovulation, while also providing information on ovarian reserve and guidance to clinicians and patients.

The Fertility Indicator Equation Using Serum Progesterone and Urinary Pregnanediol-3-Glucuronide for Assessment of Ovulatory to Luteal Phase Transition

Background and Objectives: The Fertility Indicator Equation (FIE) has been shown to signal the fertile phase during the ovulatory menstrual cycle. It was hypothesized that this formulation, a product of two sequential normalized changes with a sign indicating direction of change, could be used to identify the transition from ovulatory to luteal phase with daily serum progesterone (P) and urinary pregnanediol-3-glucuronide (PDG) levels. Materials and Methods: Day-specific serum P levels from two different laboratories and day-specific urinary PDG levels from an additional two different laboratories were submitted for FIE analysis. These day-specific levels included mean or median, 5th, 10th, 90th and 95th percentile data. They were indexed to the day of ovulation, day 0, by ultrasonography, serum or urinary luteinizing hormone (LH). Results: All data sets showed a clear "cluster"-a periovulatory sequence of positive FIE values with a maximum. All clusters of +FIE signaled the transition from the ovulatory to luteal phase and were at least four days in length. The start day for the serum P and urinary PDG FIE clusters ranged from -3 to -1 and -3 to +2, respectively. The end day for serum P and PDG clusters went from +2 to +7 and +4 to +8, respectively. Outside these periovulatory FIE-P and FIE-PDG clusters, there were no consecutive positive FIE values. In addition, the maximum FIE-P and FIE-PDG values throughout the entire cycles were found in the clusters. Conclusions: FIE analysis with either daily serum P or urinary PDG levels provided a distinctive signature to recognize the periovulatory interval. The Fertility Indicator Equation served to robustly signal the transition from the ovulatory phase to the luteal phase. This may have applications in natural family planning especially with the recent emergence of home PDG tests.

A Novel Fertility Indicator Equation Using Estradiol Levels for Assessment of Phase of the Menstrual Cycle

Background and Objectives: Urinary hormone home monitoring assays are now available for fertility awareness methods (FAMs) of family planning, but lack sensitivity and precision in establishing the start of the fertile phase. We hypothesized that with a suitable algorithm, daily serum or blood estradiol (E2) levels could serve as a better analyte to determine the phase of the ovulatory cycle and the fertile start day (FSD). Materials and Methods: Published day-specific serum E2 levels, indexed to the serum luteinizing hormone (LH) peak, were analyzed from three independent laboratories for a threshold for a FSD. A fertility indicator quation (FIE) was discovered and tested with these data and a FSD was determined using the mean or median and variance ranges of the day-specific E2 data. Results: The considerable variance of day-specific serum E2 levels made an absolute serum E2 indicator for phase of cycle problematic. However, a FIE was discovered which maps the day-specific E2 levels of the ovulatory cycle enabling the fertile phase and transition to the luteal phase to be signaled. In this equation, FIE(D) is the value of FIE on day, D, of the cycle and has both a magnitude and sign. The magnitude of FIE(D) is the product of the normalized change in day-specific E2 levels over two consecutive intervals, (D-2, D-1) and (D-1, D), multiplied by 100, and is formulated as: (E2 (on D-1) - E2 (on D-2))/E2 (on D-2) × (E2(on D) - E2 (on D-1))/E2 (on D-1) × 100. The sign of FIE(D) is either + or - or ind (indeterminate) and is assigned on the basis of the direction of this product. Using a FIE threshold of ≥2.5 as the start of the fertile phase, the FSDs were Day -5 or Day -6, with FSD Day -4 for an outlier set of E2 levels. The maximum FIE value ranged 9.5-27.8 and occurred most often on Day -2. An inflection point with a large change in FIE magnitude and change in sign from + to - always occurred at Day 0 for all sets of day-specific E2 data signaling transition to the luteal phase. Conclusions: The fertility indicator equation, a product of two sequential normalized changes in serum E2 levels with a sign indicating confidence in direction of change, is powerful in identifying the fertile phase and subsequent transition to the postovulatory phase and may serve as a useful algorithm for FAMs of family planning.

The Use of Estrone-3-Glucuronide and Pregnanediol-3-Glucuronide Excretion Rates to Navigate the Continuum of Ovarian Activity

The patterns of a woman's normal ovarian activity can take many forms from childhood to menopause. These patterns lie on a continuum ranging from no ovarian activity to a fully fertile ovulatory cycle, but among the other defined patterns are cycles with anovulatory ovarian activity, including luteinized unruptured follicles (LUFs), and ovulatory cycles with deficient or short luteal phases. For any woman, these patterns can occur in any order, and one can merge into the next, without an intervening bleed, or be missed entirely. Consequently, it is not yet possible to predict the pattern of a future cycle, but it is possible to use our knowledge of the continuum to interpret the current cycle, which has clear implications for the management of personal fertility. An individual's position in the continuum can be monitored directly in real time by daily monitoring of ovarian hormone excretion rates, without either calendar-type calculations or reference to population means and standard deviations. The excretion of urinary estrone glucuronide (E1G) gives a direct measure of follicular growth, and the post-ovulatory rise in urinary pregnanediol glucuronide (PdG) following an E1G peak provides good evidence of ovulation. Specific values of the PdG excretion rate can be used to determine whether a cycle is anovulatory with or without a LUF, or is ovulatory and infertile or ovulatory and fertile. These specific values are important signposts for navigating the continuum. For a woman to take advantage of the knowledge of the continuum, the data must be reliable, and their interpretation has to be based on the underlying science and provided in an appropriate form. We discuss the various factors involved in acquiring and providing such information to enable each woman to navigate her own reproductive life.