Ovulation is a funny thing. It can seem pretty straight forward. I mean it happens in the middle of the cycle every month right?!.

Hmm.. maybe not.

It can actually be surprisingly complicated and even a source of anxiety. For example, did you know that every woman’s picture is different and it can even vary between cycles?! It has also become a bit of a minefield to choose a product to track it. From apps, to temperature, to peeing on sticks, to mucus (yep…).

However, we firmly believe that knowledge is empowering. Even more interesting when it comes to ovulation….

Did you also know that Ovulation patterns could be an indication of your own health?

Ok. So, lets take a look at the latest research and tech and help you navigate ovulation. Using the info to learn your own individual picture in the right way for you.

Where to begin?! 

How on earth do you navigate this pretty important function? Important not only for conception, but also as a potential indicator for your health overall. In fact, the latest science is showing it can even be an indicator for specific health conditions. (More to come below).

In order to do this we sat down with the CEO of one of the leading pioneers in research and technology around ovulation Robert Milnes CEO of Fertility Focus. We talk everything from the basics, to what they are seeing more of in their own data and research. Everything from ovulation disruption, miscarriage and most importantly what you can do about this.

Click here for the podcast version. 

As always. It is about using information. Information of your own individual position in an empowering and positive way.

Read on for the highlights from our interview with Robert. Or, click here for the podcast version.

TJ: Ok, so. First thing’s first. Can you give us a little bit of an introduction to ovulation. What do we need to know? 

RM: So we know that 75% of women who struggle to conceive (ie. have been trying for over six months) have some form of ovulatory disturbance. That being said, some women won’t know they have this. So, knowing when you personally ovulate is the first part of trying to understand the process of conception. Particularly if something isn’t happening. There are a number of ways how you can find out.

Knowing both if and when you ovulate in your cycle is key for natural conception. Some women then need support for their cycles and/or ovulation. However, the good news is there are lots of things that can help. Whether that be from dietary changes, lifestyle or medication. The fundamental first step is to not only get a sense of what is happening in the current cycle but also over a period of time. It is unique to you. 

TJ: Talk to us a bit more about ‘ovulatory disturbance’. It seems there is a common misconception that everyone ovulates at the same time roughly? What is the reality? 

Yes. There is a common misconception that everyone has roughly a 26-32 cycle and that you will ovulate in the middle of that cycle. This is where the ‘day 14’ idea for ovulation comes in. In actual fact only 30% ovulate in the middle. The Wilcox paper is particularly important at saying there is no such thing as an ‘ovulatory norm’.

In fact, there are something like 17% of women who will ovulate earlier. Then a considerable amount (up to 60-70%) who ovulate more in the later part of the cycle. Around two thirds of the way through. All things you wouldn’t expect if there was a middle of the month ‘norm’.

The reality is that every woman varies. What we have found is that ovulation is unique to you. It’s almost like a thumb print for each woman. 

Women with irregular cycles will in fact ovulate on a different day in each cycle. Even if you have very regular cycles there will be a degree of variability. It’s actually pretty common and we are building a body of evidence around this.

Seems like a lot of people experiencing ovulation two thirds of the way through their cycle then. Can that be a problem/signal of a problem?

Well yes, it can be. For a couple of reasons. Firstly, if women are led to believe that ovulation happens in the ‘middle’ and at the same time each month. The issue is that is if you then overlay that assumption with our busy lives (ie. we are less likely to be having sex every other day) then you could be focusing trying to conceive at the wrong point. Essentially ‘missing’ the correct time. Lots of couples now try and time conception for ‘the right time’ in the cycle – click here for more. If you simply focus on the middle you may miss the chance if your own ovulation does not fall in the time you assume it does.  

Secondly, late ovulation may be an indication of a problem. Although not necessarily. The most common condition associated with late ovulation is Polycystic Ovaries (PCOS). That being said. It may not be a sign of an issue. It may just be your own individual ‘normal’.

That being said. Is it the case that if you are ovulating very early/very late, there can be an issue with the endometrial lining? So even if you’re timing in the right way implantation can then be an issue?    

Yes, particularly with a very late ovulation. A gynaecologist will look for something called a short luteal phase. That is defined as having 9 days or less between ovulation and the onset of your period. The chances are you have insufficient endometrial development and/or progesterone to sustain an implantation. It is in fact a relatively common cause of miscarriage. 

So, if you get to know your cycle and your own specific pattern of ovulation it can potentially flag up other issues?

Yes. Absolutely. The good news is that if you know, you can get it treated. If you are diagnosed with short luteal phase then you are likely to need clinical intervention. Otherwise it is quite hard to sustain a pregnancy. 

There are now so many ways to work out how you ovulate. It can be confusing. There are apps, pee on a stick, body temperature. What is most accurate and why?

Well when it comes to using temperature to show ovulation there are a few things to know and different ways to measure it. With varying levels of accuracy.

The first thing to know is that Progesterone is released by the ovaries during the process of ovulation. It is this that causes a rise in internal temperature. When you measure internal temperature (also known as ‘core’) we are able to actually see the rise in progesterone that is a direct result of ovulation. You cannot measure this with external temperature monitors (Basal body), nor with skin work temperature devices. Those are both good at pinpointing whether or not you have ovulated. Particularly if you have normal/regular ovulation. However, they cannot see what is happening in this current cycle. 

A bit more on each:

Oral temperature: also know as basal body temperature. This is a single point of temperature taken in the morning upon waking. You then chart this and over time it will give you a picture of how your temperature moves. A temperature rise will be shown after ovulation.

Skin based: there are a couple of devices you can get. One type you measure under the arm/bra strap or you can measure on the wrist. As a single measure external temperature is not as good as oral in telling you the picture in terms of what is going on in the ovaries. The flip side is that instead of a single measurement you get measurement many more times. Algorithms are then used to predict when ovulation will occur in a future cycle. However, these are not useful if you ovulation day then varies in that cycle. The accuracy is around 89%. 

Internal/CBT: has an accuracy of 99% of detecting ovulation. This is what Ovusense measures. Using an internal vaginal sensor. The advantage of this is that you can see the progesterone rise as it is happening. 

So is it the case that the Basal Body/Skin measurement gives an indication of ovulation, but after the point of ovulation rather than capture it it as it happens? Real-time?

Funnily enough, that is the common perception amongst gynaecologists. However, its not quite right. Many will tell you that temperature rises after ovulation. In actual fact, we found that is not correct. It is just that those technologies you’re using to measure that temperature rise are incapable of seeing the rise as its actually happening. You will only see it after it has happened.

The advantage once again of using core body/internal temperature gauges (which is what Ovusense does) is that you effectively see it in ‘real time’. If the skin/oral temperature could indicate it as it is happening you could use that too but unfortunately you are not measuring the direct action of progesterone on the ovaries. Instead they are measuring the body’s subsequent reaction to that.

Also, you’ll know with skin temperature, you can get opposition ie. if your core is hot you will sweat, cooling down the skin. 

How does using temperature to monitor ovulation compare to the more traditional mechanisms like cervical mucus and pee on the stick?

LH Strips (pee on stick) are very good for women with no ovulatory issues. They can only predict the onset of ovulation using the current cycle. However, they cannot confirm for sure ovulation has happened. So, that causes a number of issues as you dont know whether the ‘prediction’ is false. 

For example, if you have PCOS: unfortunately LH tends to peak at a different point within your cycle to when you actually ovulate. So, you dont get an accurate prediction. Companies such as Clearblue are quite open about that. That is on their website for example. Some others will get no positive response. Which suggests that you are not ovulating, but what it is really saying is that you do not have enough of a surge of LH in your urine to cause a positive test to be recorded on a test strip. 

So an LH surge doesn’t necessarily mean ovulation?

In essence when you have PCOS. The four main reproductive hormones in your cycle will not be behaving in a way that is expected.

So, LH tends to peak earlier than ovulation. We know it should peak 24-48hrs before. For example, take a woman with PCOS. Say she has a fairly regular cycle, and say she ovulates day 16. Normally, if she didnt have PCOS you would have a positive strip result day 14. For her, it would be more likely day 7 or 8 because the LH peak is happening earlier because her hormones are out of sync. That is the effect of PCOS not the cause of it. But, it is a well known issue. 

So it could be very misleading if you have PCOS and are peeing on sticks?

Yes. In fact it is very unlikely that you will ovulating early, it is much more likely, if you have PCOS that you ovulate late. 

What about not ovulating at all? Will that show no temperature rise as no progesterone increase happens?

Essentially yes. Although no woman has a ’flat line’ on a temperature chart. It tends to fluctuate naturally  (which is another reason why skin/oral temperature is not fully reliable). It does vary less internally however.

The issue you can get with say PCOS, or other another disturbance that may lead to lack of ovulation is that you simply don’t get the steep rise expected with ovulation.

The good news is that there is one constant. For every woman’s ovulation, when there is progesterone released, the rise will look roughly the same for all women. That is what we have learnt from our research.

What we know is that when ovulation does happen there is around a 0.3-0.4 degree Celsius rise in temperature. You will see this for 3-4 days. It is very rare that a woman who has ovulated doesn’t have that kind of pattern. 

You must see quite a bit of data on people’s cycles? What are some of the trends you are seeing more of? Why do you think that is?

We have talked about late ovulation. That is the most common. That is often PCOS related but it can also be caused by ageing. In fact, it is looking increasingly likely that as you age your cycle in terms of ovulation is going to get later. We are planning to publish more data shortly on this in The American Society of Reproductive medicine.

The data we have actually pulls up some very interesting cycle patterns. Patterns which we believe are indicative of various syndromes. We know that around 50% of people with PCOS go undiagnosed. Simply because they dont fit the normal profile. We think there is a clear temperature cycle and pattern associated with that. We also think we will be able to pick up an increased risk of miscarriage. We think both of these are important for understanding the science of ovulation. We have also applied some mathematical analysis to this. 

Is this coming back to a short luteal phase relating in higher chance of a miscarriage?

This is without a doubt. It is very well established within research. Using core body temperate to confirm the date of ovulation with 99% accuracy is a really good way of understanding what your luteal phase looks like. When you use this method and you see it lasts 9 days or less that is a red flag. 

If I had realised over a couple of cycles, if I was ovulating late/short luteal phase? What would I do with that info?

If you are getting an abnormal and repeating (one cycle isnt really enough info) cycle of this type of pattern then you should speak to a doctor. 

How would a doctor approach treating this? 

Progesterone treatment is most common. However, it depends why you are getting that pattern. If it is because of PCOS. The first thing you want to do is to bring Ovulation more to the middle. You can use supplements like Inositol or drugs like Metformin may be prescribed. For women who don’t have regular periods, a doctor may use medication to bring this on. The bottom line however is that you should never take advice on this from anyone other than your doctor. However, understanding your own body and your cycle is the first step on the road to a successful pregnancy. 

Taking a step back and looking at bigger picture trends. We are getting older when we have kids. You also point out you are seeing more later cycles. Are there any other lifestyle factors coming up in the data you see? 

Generally speaking, the more overweight you are, the greater the chances that you will have cycle disturbance. That is both a cause and effect thing. Obesity will cause disruptions and can lead to PCOS. Even if you have diabetes but you have a normal BMI, then you are likely to get cyclical disturbance. These are fairly well known trends. However, ageing is probably the much bigger demographic change happening in the background. 

You mention a high BMI being an issue. However, what about the reverse? With the trend towards size 0 and very intense exercise. Are you seeing this cause issues? 

A lot of women with PCOS can even be underweight in fact. It is not uncommon. We are embarking on a study around this. Well, specifically around lifestyle: exercise, BMI etc. 

What are some of the things/your focus that you think you can use with this cycle and ovulation based information and technology?

At the moment, we think we have cycle patterns to assist with diagnosis of ovulatory disorder. The key thing is that sooner you understand your cycle pattern, the higher the chance of pregnancy. Why? Because if you know you need treatment, the sooner you’ll be able to get it. Similarly, if you are timing it wrong from a conception perspective you will also benefit from knowledge of your own body.

On top of this, simply being able to reassure yourself that everything is working ‘as it should be’ can be a very powerful tool and can increase conception rates. It is about control and understanding of what is going on with your body that is most important. Everyone is an individual. 

I can absolutely see how in a world of chronic anxiety, knowing that something is working, or not working but you can fix it can be very powerful. What are some of the other things that have surprised you?

Honestly, the most surprising thing to me is the general lack of knowledge of the individuality of each woman’s cycle. For a very long time we have been intuitively acting as all women’s cycles are the same. We are taught that in school. It seems to have been ingrained. That is just not accurate.

Similarly with menopause it has become ingrained that you will roughly hit age 45 and it may start. We need to reverse this to improve conception and treatment. It is absolutely not the case that every woman’s cycle is the same. That shouldn’t be the most enlightening thing but it is so important. 

Why do you think it is that the received wisdom has been wrong? Is it average/cost/resource thing? 

My glib answer to this is that the science was invented by men! But actually, I think we have never really regarded conception in the same way as other medical issues, because it is a natural process. We have therefore accepted that we are going to treat infertility by allowing you to go away and keep trying.

That is known as ‘Expectant Management’. That was fine when the average age of conception was early/mid 20s (15yrs ago it was 25). Back then it was perfectly acceptable to say ‘we will try and find out if you’re able to conceive by going away and trying for a year. Come back if that doesn’t work.’ However now, the average age for conception is 31 and increasing.

At the age of 31 your chance of being infertile are 10-15% higher than at the age of 25. So, Expectant Management is no longer the right way. If you are starting in your 30s and you’re told to wait a year, that is probably time wasted as you could be doing something active about it to increase your chances. 

What about Menopause/early menopause: can measuring your Core Body Temperature flag this up?

Yes there is a well known cycle pattern associated with core temperature. The ‘slow rise‘ is a potential indication of diminished ovarian reserve caused by perimenipause. Something not particularly well known is that there is a big variability as to when menopause happens. Most think that it occurs post 45, but, for some women it happens a lot sooner. This has a big genetic component and can happen in your 20s. Understanding that this is starting to happen is really important and understanding if you need help around this is crucial. It is something you need to get ahead of. 

AMH is another indication of Ovarian Reserve? Is this something separate?

If you were getting a slow rise, I would then always recommend an AMH test, which is relatively new. Doctors just used to just to FSH. However it is not that useful though as it doesn’t really give you a chance to catch it early enough. AMH gives you a chance to see it early enough. This gives you an idea how far along you are. The slow rise is just an indication not a diagnosis of diminished AMH/perimenopause. It simply means you need further investigation. 

One final question: from your perspective. What do you think we can do better when it comes to fertility and having healthy babies?

Well, the most obvious thing is to conceive earlier in our lives, but that may not be realistic! Instead what we can do is to educate ourselves better about what is happening during each cycle. We hope to add to that science. The good news is that we can monitor sooner than we would have done previously. We can catch issues before they really set it.

Interestingly enough we are seeing a higher degree of education in the younger users. There is definitely a greater trend to understanding your body. Particularly within the millennial generation.

So being proactive and education is the key!

Yes, absolutely. 

To get a better sense of your own body using Core Body Temperature check out Ovusense. Click here for more. 

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