Are You Really Ovulating? | Luteinized Unruptured Follicle Syndrome (LUFS) (Episode 631)

Full Transcript: Episode 631

Lisa Hendrickson-Jack:

This is the Fertility Friday podcast, episode number 631.

In today’s episode, I am going to be talking about an issue that I think is better known in fertility awareness circles or potentially fertility specialists. It’s not really something I hear people talking about a lot unless it’s within the context of charting and the menstrual cycle. And it’s something called luteinized unruptured follicle syndrome.

I think that this particular situation is a really good example of why charting is important, especially for women who are trying to conceive, especially for practitioners to be aware of it if you’re working with fertility clients, because it’s a really interesting example of how ovulation can be disrupted in the menstrual cycle and you don’t always know about it. And so it shows you, I think, the importance of being aware of the menstrual cycle, being aware of what’s happening, and also being aware of some of the specific challenges that can impair fertility.

The paper that we are going to be going through today is specifically talking about this situation. The titles are always really long and leave a lot to be desired. But basically, this paper is discussing the potential for there being a therapy to actually target this and it’s kind of talking about why — and it’s really interesting because they did study the instance of it, so we get a little bit of additional information as to how common it is, how prevalent it is, and also if it’s something that we can actually identify through charting. Not directly, but I would say indirectly, based on the information of the paper.

What is luteinized unruptured follicle syndrome? If it’s something that you have never heard of before, it is a potential cause of infertility because what’s happening in this situation is that ovulation is potentially appearing to happen. So even if you’re charting your cycle, you’re seeing a temp shift — like it looks like ovulation is happening — but the actual follicle is not rupturing and the egg is not being released.

In this situation, the way that they describe it, they say luteinized unruptured follicle syndrome is a cause of infertility consisting in the unruptured of the dominant follicle after the LH surge. They’re saying the LH surge takes place and progesterone starts to be released, but the egg is not actually released. Obviously pregnancy is not possible if the ovulation process is not happening. It’s a very peculiar event because it actually would be occurring in people who potentially would be thinking that ovulation is happening.

I want to go through some of the key points that really stood out to me that are relevant to our conversation about why this could be such an issue, especially because it’s a lesser known issue.

The first one is that when we look at the research, luteinized unruptured follicle syndrome — from now on I might just say LUFS because it’s a pretty big mouthful — is far more common than most practitioners realize. And when somebody is having this issue, they’re more likely to have a recurrence of it, meaning that it’s not just happening kind of once. If this phenomenon is observed in a woman, then it’s probably recurring. There’s a higher chance that whoever’s experiencing it is experiencing it more frequently.

What they estimate is that in about 10% of natural cycles in fertile women, luteinized unruptured follicle syndrome is occurring. That’s pretty significant — one out of 10 cycles, potentially, even though it appears ovulatory, the egg is not being released.

But what the researchers found was that in an infertile population — and they usually define infertility as trying to conceive for about 12 months without success — 25 to 43% of infertile women are showing evidence of luteinized unruptured follicle syndrome. If you are working with clients who have been struggling to conceive, what the research is telling us is that this phenomenon is actually far more common in infertile populations. And it’s often being missed as a contributing factor because our standard way of dealing with fertility cases doesn’t involve looking at the cycle or having a woman chart and trying to understand what’s going on.

There was a study that looked specifically at infertile women who were undergoing IUI — intrauterine insemination. In the first cycle, about 25% of the women who were undergoing this procedure were found to have this luteinized unruptured follicle situation. In cycle two, almost 80% of those who had experienced it also experienced it in the second cycle. And then almost 90% of those had experienced it by cycle three.

What that means is that the women who had it were much more likely to have it as a continual repeated issue. And I think it is worthwhile saying that in the women who had this unruptured follicle — so they’re showing and appearing to ovulate, if they were charting you would see a temp shift — the actual egg is not being released.

One of the takeaways, even from the fertility awareness perspective — and this is something we teach our practitioners in our FAM program — is that we can identify when ovulation is happening based on charting. We can look at the cervical mucus, we can look at the BBT, we can look at cervical position, and we can look at other secondary signs. But what we can’t confirm is that ovulation is actually happening normally. We can confirm it’s happening, but we can’t confirm that it’s happening normally.

Luteinized unruptured follicle syndrome is a really good example of that because in this situation, there is follicular development and there’s an LH surge. It’s just that the LH surge in this particular person may not be strong enough to actually cause the follicle to rupture and the egg to be released. It has all the appearance of ovulation on the chart, but it’s not necessarily happening.

When you’re working with clients who are struggling with fertility issues and everything seems to be normal, it’s worthwhile having an investigation. I have interviewed various NAPRO technology doctors, doctors trained in the Creighton method, who are trained in this process of actually using the menstrual cycle as a vital sign in an allopathic model. Typically doctors who are trained in that type of modality would actually be having their clients chart. And if they’re noticing that pregnancy isn’t happening, one of the things that they’re going to investigate is ovulation — to find out if it’s happening normally. The way to do that is actually by a series of ultrasounds throughout the cycle so that you can actually observe the follicular development, observe what’s happening after ovulation, so that you can actually see visually with ultrasound if the egg is being released.

Something like this can really only be picked up by a more thorough investigation, and that would typically take place via a series of ultrasounds. The recurrence rate in two to three cycles was reported to be almost 80% and about 90%. The women who were experiencing this were continuing to see this pattern of not releasing the eggs, and that obviously was contributing to their inability to conceive.

One of the interesting findings that this study reported — they were looking at the process of ovulation and they have described it as an inflammatory process. In The Fifth Vital Sign, when I was researching menstruation in chapter two, I did mention that menstruation and ovulation are considered to be these inflammatory processes. The normal unfolding of this process does involve controlled inflammatory responses.

One of the things that I found to be really interesting in the study is that ibuprofen and NSAIDs can directly cause luteinized unruptured follicle syndrome. Because they’ve identified ovulation to be a normal inflammatory process, women who are using NSAIDs probably at a higher rate can potentially induce this unruptured follicle situation. These drugs — NSAIDs, non-steroidal anti-inflammatory drugs to be specific — can actually suppress the inflammatory process that the follicle needs in order to rupture.

Of course, don’t take this to mean that I’m saying never take them. What I’m saying is that the researchers did identify ovulation to be this inflammatory process, and they’re identifying that anti-inflammatory drugs may actually cause this to happen in some situations by suppressing the normal inflammatory process required in order for the follicle to rupture.

I’ve already alluded to this point, but I think it’s an important one. In a luteinized unruptured follicle cycle, the LH surge has happened and progesterone is being released. It’s not that progesterone isn’t being released. The issue is that the follicle is not correctly releasing the egg. Everything is happening except there’s an issue at the follicular level where the egg is not being released.

One of the things that the researchers say is that this issue can only be identified with ultrasound because a serum progesterone does not actually confirm that the follicle ruptured. It confirms what they call luteinization. The luteinizing hormone has an effect on the follicle, which typically then causes the follicle to rupture. But this is a specific issue where luteinization is happening and progesterone is being produced, but there’s an issue at that follicular level where the egg is actually not being released.

This is something that can’t be identified with only a blood draw. Even doing a test to confirm progesterone levels does not confirm that ovulation is happening normally. That is definitely a pretty big takeaway.

Does this mean that charting isn’t useful and isn’t giving us useful information? Absolutely not. One of the challenges is that I don’t know that there’s a reliable specific way on the chart to say this is exactly what’s going on. But understanding this phenomenon, knowing how it works, and knowing that it’s a lot more prevalent in couples struggling with infertility should prompt us to actually investigate more and encourage our clients — when it’s seemingly unexplained, where they’re having these issues and it’s like, what’s going on, we’re not really seeing any signs — to remember that some of these issues can appear to be silent and might require more thorough investigation.

When they did look at the blood levels of women who were showing luteinized unruptured follicle syndrome, there were some differences in hormone production. The LH levels were significantly lower in these LUF cycles. Progesterone was different — it was rising abnormally high from day three, where typically progesterone in ovulatory cycles isn’t rising as high at that specific point.

There are obviously going to be differences in a situation where the follicle is not responding normally to LH and it’s not rupturing as it should and the egg isn’t being released. But these would be very specific and subtle tests that you wouldn’t just get probably with testing one day randomly. A series of tests might be necessary to pick up some of these subtle differences.

Despite all of this, the overall cycle length, the overall luteal phase length and follicular phase length, and even the length of menstruation did not show any significant differences between an ovulatory cycle and a luteinized unruptured follicle cycle. There may have been some subtle differences here and there, but there was nothing consistent enough to actually show us a statistical difference between the two.

I think this is an important reminder for those of you who are teaching charting — there are obviously limitations with charting. But the backbone of charting and understanding how the cycle works and understanding how ovulation works and some of the things that can go wrong and interfere with that process really gives us the foundation to support our clients, even in cases like this where there could be a silent issue. This is a silent issue because it would appear like normal ovulation on the chart. It would even appear like normal ovulation when you look at a blood draw. And if you don’t know about this condition that affects 10% of fertile women and up to 25 or more percent of women who are struggling with fertility, then you wouldn’t necessarily know to look.

What the researchers say are that certain signals could prompt ultrasound, including the unexplained infertility question — when you have apparently ovulatory charts and everything is looking pretty good, sperm quality is looking pretty good, but we’re still not really seeing anything going on. History of endometriosis, because the instance of luteinized unruptured follicle actually reaches an estimated 73% in estimated populations. The most common place that you will find an endometrioma is on the ovary. And so it does make sense that endometriosis could interfere with the normal ovulatory process.

There are certain additional triggers that would indicate that we should be looking deeper. But ultimately, I wanted to share this paper with you today, especially for those of you who may not be familiar with this topic. If you can think of someone who would benefit from hearing more about this, feel free to share this podcast episode. I’d love to hear what you think — we’ll be talking about it on social media, so feel free to find me over at Fertility Friday and share what you think about luteinized unruptured follicle syndrome.

I hope you have a wonderful week — whenever you’re tuning into the show. And of course, as always, until next time, be well and happy charting.