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Advanced practice nurses (APNs) have an important role in the initial evaluation of both fertility and infertility and are frequently asked to discuss fertility issues with couples who desire a pregnancy.
The ovarian cycle is a cyclical continuum of events that includes changes in ovarian hormonal secretions, which in turn actively influence the hypothalamic pituitary control (Figure 1) (Khan-Sabir & Carr, 2003). There are two methods usually used to teach women to understand when they are ovulating: prospective methods and retrospective methods. Studies primarily from researchers at the National Institutes of Environmental Health Sciences have provided evidence that there is essentially a 6-day interval of fertility ending with the day of ovulation (Wilcox, Weinberg, & Baird, 1995). Virtually the same procedure for measuring BBT has been followed for decades, except the route could be oral, rectal, or vaginal. In an attempt to increase the accuracy and utility of BBT, a number of computerized devices based on BBT have been developed.
Since the BBT nadir is thought to precede ovulation, it has been proposed that the low temperature could be a useful predictor of ovulation and when couples who want to achieve pregnancy should have intercourse. McCarthy and Rockette (1986) examined over 17,000 natural family planning charts for temperature and cervical mucus patterns. Some providers think that the shift in BBT during a menstrual cycle is more reliable as a confirmatory marker of ovulation than the BBT nadir as a predictor of ovulation.
Wetzels, Hoogland, and de Haam (1982) compared BBT with ultrasound findings for ovulation detection in 47 cycles with hormonal evidence of ovulation. European and American researchers collaborated on a large study to determine days of highest fecundability (Dunson et al., 2001). Over the last 30 years the vast majority of researchers have concluded that BBT is not a reliable marker of ovulation. In answer to the question of whether BBT should be recommended, research would tell us that the BBT chart is of limited usefulness. The lack of expense, objectivity, simplicity, and high acceptability of BBT seem to be common reasons why health-care professionals still recommend BBT charting. Mary Lee Barron is a Family Nurse Practitioner and Assistant Professor and Director, Center for Fertility Education, School of Nursing, Saint Louis University, MO. These are great for sharing the excitement with your friends and family who live far from you.
It is essential, therefore, that APNs understand the most current data regarding ovulation, optimal timing of intercourse in relation to ovulation, and time frames in which couples can expect to conceive. Follicle-stimulating hormone (FSH) is the key stimulant to the growing follicle, which in turn secretes estrogen in the form of estradiol.
With the advent of digital thermometers and the concern over mercury, women using symptothermal methods of natural family planning are now instructed to use an oral digital thermometer immediately after waking in the morning. These rely on the time of the BBT shift in the previous cycle to estimate ovulation in the subsequent cycle. Although no hormonal comparisons were made, criteria for the presumed day of ovulation were defined based on thermal shifting and the peak of cervical mucus. However, research studies over the past 30 years have demonstrated problems with that notion. Volunteers and patients were carefully instructed to measure rectal temperature before getting up each morning.
The estimated day of ovulation for the study was based on the BBT shift; that is, the first day of the BBT rise was considered the day of ovulation. In a study to determine the reliability of the most widely used methods for predicting or confirming ovulation in infertile women, Guermandi et al.
Interrater reliability in interpretation of temperature curves ranges from 25% to 50% depending on the day of the cycle being studied (Guermandi et al., 2001).
It is estimated that approximately 20% of women with infertility fall into the ovulatory dysfunction category (American College of Obstetricians and Gynecologists, 2002). Fehring, Hanson, and Stanford (2001) examined attitudes of 450 certified nurse midwives (CNMs) toward natural family planning methods.
As a method to confirm ovulatory cycles, BBT charting has limited utility because of problems with interpretability.
For many decades, basal body temperature (BBT) charting has been one of the methods discussed with couples to help them establish the presence of ovulatory cycles and to help them time intercourse. Estrogen, as the dominant hormone in the preovulatory phase, stimulates the cervix to soften, dilate, and produce profuse amounts of (estrogenic) mucus capable of supporting viable sperm for 3 to 5 days. Within 1 to 2 days before the LH surge there is a nadir (low point) in BBT (Martinez et al., 1992). The probability of pregnancy decreases by about 50% during this 6-day window when cervical mucus is not observed (Dunson, Sinai, & Colombo, 2001).

Morris, Underwood, and Easterling (1976) examined the temporal relationship between serum LH and the BBT nadir in 27 normal cycling women. Their conclusion was: "The prediction of ovulation solely with the basal body temperature graph is not useful because of the day-to-day variability of temperature readings, cycle variability and the effects of illness, medication, diet and changes in sleeping patterns" (p.
All four of these studies compared clinical and hormonal indices of ovulation with ultrasonographic evidence of ovulation. The ovulation detection rate by ultrasound proved to be considerably higher than by BBT criteria. They found that 82% of the cycles had biphasic temperature shifts and 75% of the cases indicated a BBT nadir, 90% of which were within 2 days of ovulation of the estimated day of ovulation based on urinary evidence of the LH surge. Some would consider this an imprecise way to interpret a BBT chart, as there are others who consider the nadir of BBT to predict the LH surge (Martinez et al., 1992). There are many reasons for this, including the technique of the patient, confounding factors such as alcohol intake or timing of temperature taking, or the woman's physiologic hormonal milieu. Despite their use for decades, BBT charts do not aid in diagnostic decision making about ovulation. For couples that were having difficulty achieving pregnancy most CNMs would recommend either observation of cervical mucus (81%), BBT (79%), or midcycle intercourse (77%).
The biphasic BBT chart may provide other information that may be of use to the APN: duration of the menses (if charted), length of the cycle, length of the follicular and luteal phases, the pattern of the timing of ovulation, and intercourse patterns.
Rather than suggest BBT, APNs might consider recommending a low-technology method such as cervical mucus charting (Bigelow et al., 2004). Temporal relationship between basal body temperature nadir and luteinizing hormone surge in normal women. In view of the fact that now there are more accurate and prospective biologic markers available to predict and detect ovulation, it is relevant to ask whether BBT charting should be recommended. Leuteinizing hormone (LH) allows the final maturation and growth of the dominant follicle, the initiation of ovulation, and the development of the corpus luteum. Examples of prospective methods include the presence of cervical mucus (which at its peak looks like egg white), use of urinary LH detection kits, or the Clearblue Fertility Monitor (a handheld electronic device designed to detect urinary metabolites of the preovulatory estrogen rise and the LH surge) (Bigelow et al., 2004). For over 30 years, this nadir in temperature has been identified as possibly useful in predicting ovulation (Lundy et al., 1974).
Factors that may affect the temperature readings include consumption of alcohol, having had a late night or disturbed night, oversleeping, holidays, travel, time zones, shift work, stress, illness, gynecologic disorders, and medications (Clubb & Knight, 1999). The Babycomp version of the monitor is targeted for women who are trying to conceive a pregnancy. In 22 of the cycles (81%), the LH surge occurred on the same day or within 1 day of the BBT nadir.
The results from all four studies also demonstrated that BBT was not reliable as a predictor of ovulation. The BBT nadir, the coverline-determined temperature shift, and eye-balling of the temperature shift as estimators for the day of ovulation showed a very wide frequency distribution.
Out of 7,288 cycles, approximately 20% of the BBT and mucous secretion data charts did not have enough information to provide an interpretable BBT shift (Dunson et al., 2001). In a study of Missouri physicians who cared for patients with reproductive needs, Stanford, Thurman, and Lemaire (1999) concluded that physicians were more likely to recommend the initial steps of BBT or calendar calculations than monitoring of cervical mucous discharge.
However, because of the limitations of BBT identified over many years of research, advising couples to use BBT to achieve pregnancy is not the most appropriate method for them to identify ovulation. For more accuracy but also more expense, use of the Clearblue Fertility Monitor can be recommended to identify the fertile window to appropriately time intercourse. Fehring is a Professor and Director, Institute for Natural Family Planning, Marquette University College of Nursing, Milwaukee, WI. The relationship between cervical secretions and the daily probabilities of pregnancy: Effectiveness of the two-day algorithm.
Inaccuracy of basal body temperature charts in predicting urinary luteinizing hormone surges.
The purpose of this article, then, is to review the research basis for BBT to help APNs give the most current advice to couples seeking pregnancy. In the postovulatory luteal phase, LH supports luteal function, that is, the secretion of progesterone by the corpus luteum.
Retrospective methods rely on postovulation events, namely the presence of a corpus luteum with progesterone dominance.
The monitor does not give readout of temperature but rather a green (infertility), red (fertility), or yellow (unsure) light. Likewise, Quaglierello and Arny (1985) in a retrospective 60-cycle chart review found BBT to be an inaccurate predictor of the day of the LH surge but did conclude that the periovulatory time could be identified.

In Bauman's study six experienced physicians evaluated BBT charts from menstrual cycles of 98 women. Nurse midwives' knowledge and promotion of lactational amenorrhea and other natural family planning methods for child spacing. Temporal relationship and reliability of the clinical, hormonal, and ultrasonographic indices of ovulation in infertile women. The timing of the "fertile window" in the menstrual cycle: Day specific estimates from a prospective study.
Both selected follicles and luteal cells have a fixed lifespan that determines the length of the menstrual cycle. This increase is thought to be due to the thermogenic effect of pregnanediol, a metabolite of progesterone, which increases after ovulation and is secreted by the corpus luteum.
Lenton, West-on, and Cooke (1977) in a study of normal and infertile women noted that the day of ovulation was predicted in only 34% of the charts (n = 60).
The time of ovulation was estimated from the charts by a consensus of at least five of the evaluators. Mucus observations in the fertile window: A better predictor of conception than timing of intercourse. Day-specific probabilities of clinical pregnancy based on two studies with imperfect measures of ovulation.
Relation between the luteinizing hormone peak, the nadir of the basal body temperature and the cervical mucus score. Basal body temperature as a method of ovulation detection: comparison with ultrasonographical findings.
At the level of the endometrium, estradiol and progesterone are the main regulators of the cyclical transformations and prevent cell death, responsible in part for cyclical shedding during menstruation (Speroff & Fritz, 2004). Assessment of when cervical mucus has ended can also be considered a retrospective method of ovulation (Barron & Daly, 2001).
Guermandi et al., similar to the Hilgers study of 1980, found that the BBT nadir had "a wide variability, ranging from 8 days before to 4 days after ovulation" (p.
Only 22.1% of the 77 cycles that were determined by endocrine profiles to be ovulatory and to have adequate luteal phases demonstrated an interpretable shift.
They found that only 18 of 25 cycles (72%) had a BBT shift, whereas LH kits detected 27 of 29 cycles (93%).
Researchers did not separately examine the use of a urinary LH kit compared with vaginal ultrasound in their cost analysis.
Simple office methods to predict ovulation: The clinical usefulness of a new urine luteinizing hormone kit compared to basal body temperature, cervical mucus and ultrasound.
Progesterone stimulates thickening of the cervical mucus and has a role in the warming of body temperature.
Advising women to use BBT basically alerts them to this small increase in body temperature, indicating that ovulation has occurred. In a retrospective review the thermal nadir coincided with ovulation in 43% of the cycles in fertile women and only 25% of the cycles in infertile women.
Bauman noted the failure of BBT to identify short luteal phases and indicated that BBT patterns are inaccurate in the majority of women and also noted the resistance of healthcare professionals to abandoning the BBT method of confirming ovulation. Daily measurements of urinary LH, FSH, estrone-3-glucuronide, and pregnanediol3-glucuronide and transvaginal ultrasound examination of the ovaries were recorded for 326 cycles of data from 107 normally cycling women (aged 19 to 45). The reliability, acceptability and applications of basal body temperature (BBT) records in the diagnosis and treatment of infertility. Comparison of low-technology and high-technology monitoring of clomiphene citrate ovulation induction. This makes the use of BBT as a method of timing intercourse to achieve pregnancy less than useful. Hilgers and Bailey (1980) in a study of 74 cycles noted a 6-day variability of the nadir of BBT in estimating the time of ovulation in comparison with the serum estrogen:progesterone ratio determination of ovulation. Templeton, Penney, and Lees (1982) compared the BBT nadir and cervical mucus scoring to the LH peak by radioimmunoassay.
The timing of the maximal cervical mucus score was similar to that of the LH peak in all but 7% of assessable cycles (n = 198 cycles). In contrast, the timing of the nadir of the BBT differed widely from that of the LH peak in 45% of cycles with interpretable charts.

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