Contradictions in the cycle research between practice and doctrine
Institute of natural conception regulation (INER) Prof.Dr.med.Rötzer eV.
The present study is based on the author’s experience of 50 years with over 300,000 archived cycle charts from about 7,000 women. Drawing on this experience he attempts to shed light on certain opinions encountered in conventional gynecological textbooks and manuals, where the female cycle is forced into a rigid stereotype (e.g., 28 ± 3 days with ovulation "mid-cycle"). Cycle chart data can, in the following situations, provide a significant necessary corrective to avoid erroneous decisions about what procedures to recommend when treating a patient, and can provide additional information about the patient’s condition:
- Infertility (still unsuccessful in attempts to conceive).
- Irregular cycles, oligomenorrhea, polymenorrhea.
- Correct prediction of due date, using one’s own personal cycle data to identify the date of conception, thus avoiding the problematic situation (still encountered) of induced births artificially premature in cases of "conception late in the cycle" in a long cycle.
- Cycle-appropriate* hormone determination.
- Cycle-appropriate* administration of progesterone.
- Recognizing a long-term hyperestrogenism as a potential source of endometrial carcinoma.
Textbooks showing unrealistic waking-temperature curves (to display a supposedly "necessary" temperature jump of several tenths of a degree Celsius) and incomplete instructions for correct taking of the waking temperature, have as a consequence many "irregular" temperature patterns, uninterpretable by the misguided rules or erratic because of poor temperature-taking technique. And because of that many reject temperature taking as having any significance. The present paper, on the contrary, will demonstrate that self-observation of the cervical mucus combined with taking the waking temperature almost always leads to interpretable results, and is an indispensable first step toward analysis of the cycle in one’s medical practice and for identifying appropriate therapeutic measures.
* The term "cycle-appropriate" needs to be understood precisely. We wish to emphasize by the term "cycle-appropriate" that any proposed procedure match the unfolding of the observed data in the patient’s personal cycle pattern as shown on her charts. Elsewhere in the literature we find a very different usage for the term. For instance one generally reads of a "cycle-appropriate administration of progestins during the 16th to 25th day of the cycle" e.g. [42: p.28]. This is appropriate for a 28-day cycle, but it is not appropriate in many cycles - not "cycle-appropriate" - and can be associated with negative consequences, such as, for instance, continuous bleeding or increased cycle irregularities.
In March 1951, the author of these lines began to look for ways whether and how a woman could observe and distinguish the different stages of her menstrual cycle. For the years 1944 and 1945 there were three English-language works [2,13,47], which gave the relevant information for the technique to measure the temperature, namely to take the measurement immediately on waking. Therefore, from the beginning of our own consulting services the necessary temperature measurement was called "waking temperature" .
The in the medical literature used term "basal temperature" demands from the woman often barely accomplished conditions, such as measuring daily at the same time, at least six hours of sleep, etc. The term "waking temperature" indicates that the temperature is to be measured immediately after waking up as the first action. An unvarying time of measurement is not necessary; it is also negligible whether the night's sleep was disturbed or whether the sleep in the corresponding night was even shorter than six hours. More detailed and practically relevant instructions on the measuring of the temperature and a critical analysis of the problems associated with the term "basal temperature" can be found at Rötzer [38,39].
From the very beginning of our instructions for observing the cycle the introspection of the cervical mucus, which is increasingly produced in the pre-ovulatory phase, has been taught. The observation of cervical mucus at this stage provides a sign of fertility for women and allows the determination of the personal fertile days. In Rötzer [38,39] is described in detail what signs can be considered as a sign of fertility.
About the importance of preovulatory occurring liquefied cervical mucus for enabling a concept there already existed an extensive literature in German, English and French in 1951 (Knaus, 1953) , (Rötzer, 1968) . Occasionally one could find a note in the respective literature that some women themselves could observe the external secretion of the cervical mucus.
Interestingly, questions about the meaning of a temporarily occurring "slimy secretion" in connection with the temperature increase were asked in the own consulting services.
After appropriate instruction more and more women were able to observe the temporary increased secretion of cervical mucus and also to differentiate within the cervical mucus. It soon turned out that practically almost all women can be led to this observation. The first relevant figures have been published by Rötzer 1968 . In a five-nations-study by the World Health Organization (WHO, 1981) , the best results for observing the cervical mucus have been reported from India: 99.5 percent of Indian women were able to observe the cervical mucus and evaluate this accordingly after a first instruction.
"In the own work, it was mainly a question of whether a procedure could be developed that makes a reliable regulation of conception possible. Buxton and Engle  reported in 1950 that in a number of cases in surgery unruptured mature follicles – and not necessarily a corpus luteum - in the ovary could be found on the day of a significant temperature increase. This meant that in certain cases ovulation could occur in the second higher measurement - or even later.
From the very beginning of their own work it was therefore clear to Buxton and Engle  that at least three higher measurements have to been waited in order to assume an infertile phase.
This assumption is in accordance to the 1959 by Holt  indicated and downright ingenious rule for interpretation of the waking temperature: One search for three higher measurements that are higher than the six previous measurements. According to Holt it was only necessary that each of the three measurements were higher at least 0.1 ° C than the highest measurement of the preceding six lower measurements. According to Holt, one was in the state of the high temperature level with the presence of the third higher measurement in which the infertile period can be assumed. At this point, the remark is permitted that the book of the Dutchman Holt appeared in German translation in a medical publishing house in Vienna. However, this book wasn’t considered and the rule according to Holt wasn’t recognized in its importance. However, with the rule according to Holt - as with the temperature measurement at all – it isn’t possible to determine the "day of ovulation”. This isn’t necessary for the purpose of conception regulation as it’s about the determination of the beginning and end of the fertile days.
Due to own experience resulted in the course of several years, the additional requirement arose that the three higher measurements:
1. must occur after the last day with the best cervical mucus (Rötzer, 1968) 
2. must achieve at least 0.2 ° C temperature difference from the highest of six deeper measurements for the third higher measuring (Rötzer, 1979, p.35) . It is included therein, that the temperature may slowly rise prior to the third higher measurement. Even in such a cycle, a woman can get pregnant.
With the above stated rules, the beginning of those days, who have so far always proven to be absolutely infertile, can be determined in the high temperature level. About this form of the first true sympto-thermal method writes Hoffmann (1996, p.256) : "This method goes back to the Austrians Rötzer, who has described it in 1968  for the first time". In Raith et al. (1999, p.9)  it is pointed out that "in 1965 the Austrian doctor Rötzer published the world's first sympto-thermal method with a differentiated evaluation of the temperature and in dependency of the observation of cervical mucus"; In 1965 , this was a guide for couples. In Raith et al.  - a relevant standard work in this field - there are also valuable tools for self-observation of cervical mucus, which is for women with previously unfulfilled desire for children of utmost importance. All in Raith et al.  specified rules for interpretation of the temperature and the majority of the symbols used in the cycle records are taken from the works of Rötzer [35,36,37]; Deviating from Rötzer is the fact that the interpretation of cervical mucus and temperature is carried out separately, but both procedures usually come to the same conclusion.
When studying literature it stands out how much presence the 28-day cycle with ovulation in the middle of the cycle ("mid-cyclical") has and only a few days of deviations from it are as seen as "normal". However, if one saw tens of thousands of cycles, then it becomes clear that there are cycles of longer or shorter duration, in which the signs of fertility aren’t observed "mid-cyclical" and in these days - in long cycles late in the cycle and, in very short cycles unusually early in the cycle - repeatedly pregnancies have occurred. From the current literature it is apparent that mostly women with "regular” 28 day-cycle’s length are used to explore the cycle process. In such an environment, the processes surrounding ovulation happens naturally "mid-cyclical". However, this leads to a not quite true picture of the everyday and quite normal cycle courses which are different from the preconceived idea. The consequence of this is a not always proper proceeding during the diagnosis with consequent incorrect results and often a not targeted therapy. The described procedures aren’t adapted to the personal course of the cycle. They aren’t "cycle suited" in the true sense of the word; on this it will be discussed separately.
With previously unfulfilled desire for children as well as with irregular or long cycles, a proper cycle observation is required for our advisory services. Very few women know where the fertile days are to be found in the cycle, particularly as these aren't very often located "mid-cyclical". It is surprising how often the desired pregnancy occurs only after determining the personal fertile days. During this cycle observation wel also investigate in our consulting services if there is a general illness, which can lead to menstrual disorders. So it may come necessary that the advice must be given to determine the level of prolactin, androgens and thyroid hormones for example.
If in a long cycle the pregnancy occurs late in the cycle, this late conception date is also the starting point for calculating the date of delivery. Already in 1946, Tompkins  harshly criticized the usual calculation of the birth date, starting from the day of the last menstrual period. When conception occurred late in the cycle, he came due to the curves of the waking temperature to a theoretical and still to be regarded as normal gestational age of 266 days. The women, wo cooperates with us, have repeatedly clashes on this topic with her gynecologist, who still wants to determine the date by Naegele; the envisaged additional correction in long cycles doesn’t seem to work. So we see unfortunately still artificial premature births. Due to these negative experiences, a number of women avoided this conflict by putting the date of the last menstrual period 14 days before the date of conception set by themselves. Then, the calculation according to Naegele came to the same result as our calculation due to the conception date.
For a correct determination of the conception date due to cycle observation not only the course of the waking temperature is crucial, but also the introspection of the cervical mucus is particularly important. A young colleague who worked a year at a clinic in England during the course of her education as a gynecologist - just before the new millennium - had a controversial dialogue with her boss because of our represented determination of the birth date due to the conception date. This inexplicable fact that nowadays you still have to defend the determination of the birth date due to the cycle recording is occurring not only in German speaking countries; the author of this article was able to discover the same phenomenon also in his frequent visits to the US.
Learning to perceive the estrogen-related increased cervical mucus as a sign of fertile days can have a positive impact in a broader sense in the life of a woman. For a long-lasting estrogen surplus the woman can observe prolonged phases of secretion of cervical mucus which sometimes aren’t followed by a high temperature level. With such prolonged phases of secretion of cervical mucus also heavy bleeding may be connected. In this way an observation of prolonged hyperestrogenism, which may in the further consequence lead to endometrial cancer, is accessible for the woman. This enables the treatment with progesterone for these women. Our consulting services are striving to lead such irregular cycles with prolonged phases of secretion of cervical mucus to a regulation, even for women without children desire. For this purpose we have developed a step by step approach, which is described in detail in Rötzer (1999) .
A normal high temperature level can be observed in the majority of cases where cycles lasts significantly longer than 28 days after the late observed signs of fertility. In our opinion, such a cycle course shouldn’t immediately be considered as a "cycle disorder" or "rule pace disorder" in the sense of a treatment-requiring "Oligomenorrhoea". Even if a long biphasic cycle should have a short high temperature level, we generally wait some time before giving an advice.
If you can watch the long cycle for several months after an enlightening conversation, it may, so to speak, come by itself to a regulation and shortening of the cycle. Ober  already wrote in 1952 in his work "waking temperature and ovarian function" (S.361): "One often makes the surprising finding that a fixed cycle is triggered itself during measuring the temperature". Ober  advices that the temperature is best to be measured in the time of waking up, in which "fluctuations of the measuring time to 1 to 2 hours at 6-9 o’Clock isn’t significant according to experience.” In the ambulance of the clinic about 10% of patients provided " from a lack of insight or insufficient interest useless measurements.” He states further: "When we let such women re-measure in the clinic, we always got useful curves. There are investigators who say that under 1184 cycles only 3% couldn’t be utilized". This is also our experience, as well as the experience of a number of other authors, who belonged in 1966 to a scientific group of the World Health Organization and whose results were published in 1967 . In this commitee was also Döring, which stated this rule of interpretation [7: p.20]. However, it is "vital that the patients are memorably explained how to carry out the measurement" as Ober  outlines in detail by citing other necessary information.
Prior to Ober Tietze  indicated already in 1948, based on numerous own observations, the advantages of a continuous measurement of the " Morning temperature” and cited the "waking temperature" by Barton and Wiesner . Tietze makes at the beginning of his work the remarkable statement: "It is incomprehensible that such a long-known fact as the ability to track the female cycle through the course of the morning temperature wasn’t declared long time ago as a secure diagnostic method."
As it will be shown later, this is still not done in the desirable extent, mainly due to misleading information. Our cooperating women are over and over affected by the fact that the cycle records are barely accepted by the majority of colleagues. This is somewhat understandable, since both in the study as well as in training only in a few places a comprehensive way of observing and recording the female cycle according to Holt  is taught. In our members' meetings that take place every year in a different country of the German-speaking world, the women talk about their sometimes painful experiences in the gynecological practice.
As part of such a meeting, an open discussion with doctors could be very fertile and break down many misunderstandings. Such joint discussions could also clarify in what form and to what extent a more intensive gynecological training would be necessary. For the individual woman, it is relatively easy to learn the correct interpretation of her own cycles. However, a proper interpretation of the various cycle records of other women requires a lot of additional knowledge and a great experience. This is often underestimated. Only those who have participated in our intensive training, this can be gauged correctly. Participants are always amazed as how extensive and time-consuming this training is.
It must be positively noted that the currently available textbooks and handbooks on gynecology inform in an excellent manner about the results of recent research on the theory of the female cycle and gynecological endocrinology. There are depictions at a high scientific level. In assessing various cycle processes and in various diagnostic and therapeutic measures, however, some important needs of the practice are obviously not seen. Following quotes - which could be extended for every single question for each textbook - demonstrates how much these common ideas relating to the 28-day cycle doesn’t meet the practice. Similarly, it seems necessary to expose statements that aren’t scientifically correct and which thereby could make the understanding of cycle records impossible
The undermentioned "Classification of menstrual disorders through the menstrual pattern" can be found repeatedly at various parts in the relevant works, for example, [8: p.72] [24: S.554]:
- Oligomenorrhea > 32 days, or: more than 30-to 35-day intervals
- Polymenorrhoea < 24 days "
It is inappropriate to explain these " tempo anomalies" as a "menstrual disorder” without additional differentiation, as this immediately leads to therapeutic trials. It is tried to apply therapy repeatedly without further clarification, for example: "If it is only desired to regulate the cycle estrogen - progestin - combined preparations or cyclic progestins are used. If pregnancy is desired, ovarian stimulation treatment is indicated" [6: p.46]. Also in the abstract (p.56) - As well as in many other places in literature - the literature does not address the first necessary step of a personal cycle observation, but as a basis for further action the so-called Kaltenbach scheme is being applied, which in our opinion offers only a rough and very shallow orientation; it wouldn’t be inappropriate to classify this schema as obsolete.
Again and again, the 28-day cycle plays a special role. "The normal interval between bleeding is 28 days "[11: p.34]. "The menstrual cycle usually lasts 28 days, in which a variation of ± 3 days is being regarded as regular. In the normal cycle, ovulation takes place on the 12th-14th cycle day. The duration of the corpus luteum phase with 13-14 days is more stable than the follicular phase "[42: p.44]. Regarding the luteal phase, it should be noted that the results of the research carried out by Knaus [20,21,22] and Ogino [28,29] with the assumption of the duration of a normal luteal phase of about 12 to 16 days have been proven correct. In 1957, Rauscher made for a collective of 77 women who want children following statement : "The ovulation time is during a period which starts 17 days before menstruation and ends 9½ days before." He added that in in the previous cycles of those women who became pregnant later, the intervals in question were 12 to 16 days. Maybe an extension of the luteal phase to 11 to 17 days (Landgren et al., 1980)  covers the entire range of the interval that is consistent with the assumption of a fertile cycle.
The view on the possible fluctuation of a normal and fertile cycle course can also be disturbed, for example, if a rigid scheme is specified for the determination of progesterone and not the cycle-just scheme in our sense:
"Progesterone: Standard value: >20 ng / ml
(Serum sample obtained at 23. cycle day, corresponding to 8 days after ovulation, the day of the peak stage of the corpus luteum in a normal cycle) [43, S.341].
The following page 342 begins with a per se true cautionary note:
"Cave: false-negative value in Oligomenorrhoea with normal luteal phase."
This cautionary note is obviously mostly skipped or might seem meaningless, since the description on the previously page claims with the nature of its formulation general-validity and really expresses that only one cycle of about 28 days in length is to be regarded as normal and an Oligomenorrhoea would a priori need treatment anyway. Again and again in our advisory services we get the message from the women that the diagnosis "monophasic" or "anovulatory" cycle has been stated when there was no progesterone on the 25th day; the corresponding documents are in our archive. Not only in existence of a desire for children a number of therapeutic measures were taken, which have to be regarded as unnecessary in the majority of such cases. This especially when the additional observation of cycles revealed that the signs of fertility were not "mid-cyclical" but with an underlying long cycle they were later in the cycle followed by an increase of the waking temperature with normal long high position. We informed those women with such a situation that the therapeutic measures were initially not necessary, but a proper cycle observation for some time with the corresponding behavior when desiring a child would be important.
Determinations of progesterone to evaluate the luteal phase should only be carried out in compliance with observing the waking temperature when the high temperature level is given, even if this - as would be expected in long cycles - should be late in the cycle. Only in this case we can, in our opinion, say that the hormone determination was done "cycle just ". The therapeutic approach could be viewed as "cycle-just" if, for example according to Goerke et al [10: p. 501], the progesterone-substitution would start on the 3rd hyperthermic day. It could also be viewed as “cycle-just” according to Diedrich (1998, p.84)  if “the start of the progesterone-release is 3 days after LH-Peak" However, in another article in the same year nearly the same team of authors wrote. "The progesterone application can start 3 days after the mid-cyclic LH-rise” [5: p.216]. Also in this context, the remark is permitted that in a normal cycle the LH-rise is not necessarily "mid-cyclical" .
We understand with the term „cycle-just" an approach that is based on the personal history of the female cycle and for diagnosis and therapy the appropriate phase of the cycle is waited for even with very long cycles. When in the literature the phrase "cycle-just administration of a progestogen from 16 to 25th cycle day" is mentioned [42: p.28] [40: p.225] [49: p.255], this illustrates, how much a 28-day cycle as the only normal cycle is assumed. For many cycles this just quoted administration of a progestogen is not cycle-just in the genuine sense of the word and this can lead to permanent bleeding or subsequent increased cycle irregularities. This may be a reason why some colleagues are opposed to a progestin therapy as worse results are to be expected when the administration of progestogen is fixed to certain cycle days. Behind this there are also not proper information in the package inserts of progestogen compounds, in which, for example, a polymenorrhoea is administered e.g. from day 14 to 25 of the cycle; However, this isn’t for many cycle courses "cycle- just".
A cycle-just progestin therapy may be based on the course of the waking temperature and may be started at the third higher measurement; or rather this should better begin according to our experience after the estrogen-specific phase of the observable cervical mucus. Then the endometrium is stimulated according to estrogen and - at best - 12 days of administering progesterone may cause secretory transformation and subsequent bleeding; withdrawal bleeding must always be expected in such an approach. For long-lasting phases of observable cervical mucus (signs of hyperestrogenism) a different approach has been developed –this will be skipped here. Under a cycle-just progestin therapy in the true sense of the word we could observe good results in irregular cycles. Since we do not perform therapy in our counseling services, we are sometimes in a not very pleasant situation. If a woman akss if she should take the recommended progestin from day 14 to 25, but this is not appropriate due to her cycle record, we try to make an agreement with the attending physician. We provide a leaflet in which a cycle-just therapy in our sense is explained. In the leaflet, the recipe for progesterone for vaginal application is mentioned, for example as u in fig. al. [8: p.22], and the possibility of taking progesterone in micronized form (Germany: Utrogest®, Austria and Switzerland: Utrogestan®). In most cases an agreement with the colleagues can be made.
"If in textbooks and handbooks, the temperature measurement is mentioned which is used for cycle observation, usable instructions for correct measuring of the waking temperature are quite always missing. Also, the description of the temperature course doesn’t correspond generally to the reality, as for example the requirement of a temperature rise of several tenths of a degree or its occurring within certain cycle days [8: S.129f, p.177.]:
"Measurement of waking temperature, if possible at the same time and under similar conditions (e.g. lying after a certain period of rest) ." - "A daily body temperature determination (morning, if possible at the same time before getting up) is required …"
"Normal is a peri-ovulatory temperature rise of at least 0.3-0.5 °C within 48 hours ..
Evidence of pathological processes are:
- step-shaped rise: corpus luteum insufficiency (CLI);
- Temperature rise after 16. Cycle day: …".
"The through ovulation and luteal phase induced temperature rise(0.5-1.0 ° C) is used to determine the ideal time of conception."
"For the detection of a disturbed ovarian function the following is relevant: … a temperature rise before the 12th-13th and after the16th-17th cycle day " [24: S.554].
However, the occurrence of pregnancy with staircase-rise is repeatedly observed. A temperature rise before the 12th and after the 16th cycle day followed by normal high temperature level mustn’t initially be classified as pathological. There are pregnancies that result from a intercourse from 4th to 6th cycle day, with an increase in temperature on day 11 and earlier; about the case of late in the cycle occurring pregnancies in long cycles has already been spoken.
A temperature rise in the extent described above is hardly ever present in practice, but it is described in almost all textbooks and handbooks as a necessary normal course, sometimes called as "mid-cyclical" increase, for example [6: p.35, p.62, p.92] [10: S.479, S.517] [10: p.32] [12: p.72] [15: p.29] [18: p.117] [19: p.32] [30: p.62, p.84] [40: S.454] [41: p.30] [42: p.38, p.119] [43: p.133] [44: p.38] [49: p.210].If supplementary temperature curves are depicted, these have to be regarded almost always as artificial curves with an exaggerated strong and steep temperature rise. If such criteria are taken to scale, the temperature curves submitted by women must mostly appear irregular and non-evaluable, or the temperature measurement is then regarded as largely useless. By following our instructions and our application according to Holt’s rules  only few temperature curves are considered as not evaluable.
Again and again, there is the statement that the temperature measurement is used to distinguish between an ovulatory and an anovulatory cycle and that the temperature is rising after ovulation [6: p.35, p.92] [12: p.72] [15: p 29] [30: p.84] [40: S.454] [43: p.133] [44: p.38] First, it should be pointed out that a biphasic cycle is not evidence that an ovulation has taken place. Therefore, an ovulatory cycle can’t be determined in this way. Moreover it is to state that the waking temperature can rise before ovulation, which is described as early as 1950 in the work of Buxton and Engle . Rauscher (1954, 1958) [32,34] has this to say: "The increase in temperature can occur within a period ranging from some days before ovulation to 4, in extreme cases even up to 6 days after ovulation" This is not just a theoretical question, but it also serves for the understanding of the so-called "premature temperature rise" (Rötzer, 1979) [37,38,39]; an explanation for this lies in the obligatory luteinization of granulosa cells of the mature follicle. The fact that the temperature can rise before the ovulation, is also described in other works [1,9,14,25]. An example of an ovulation in the second higher temperature measurement (in 7 -11% of the studied cases) can be found in Raith et al. (1999, p.106, p.113) . The always-to-find information that the temperature rises after ovulation makes it difficult to understand how a pregnancy in the third higher temperature measurement and even later (personal observation) may occur, when the end of the secretion of cervical mucus isn’t taken into account. A reliable interpretation of the temperature curve is only possible in conjunction with the observation of cervical mucus. This can’t be explained in more detail here. In Rötzer [38,39] as well as Raith et al.  and in the Guidelines based on it , the details can be found.
In this context, attention is drawn to another widespread misconception. Women receive repeatedly information from the medical world that the lowest point ("Nadir") before the rise in temperature is the day of ovulation. Two days later conception is no longer expected. This has already led to startling pregnancies. It should first be noted that a distinctive low point before a steep rise is rare. Morris et al. (1976)  set in 27 women the lowest point of the temperature before the rise in relation to the LH-rise from which a time-bound relationship with the day of ovulation can be assumed. Within this small number of women there was a variation of the day with the LH-rise ranging from 3 days before to 2 days after Nadir; which gives at least 6 possible days of ovulation. Templeton et al. (1982)  found in a similar study compared to the Nadir 8 possible days of ovulation in 198 cycles. Wetzel et al. (1982)  determined the day of ovulation using ultrasound and hormone determination. In 34 cycles a variation up to 10 days compared to the Nadir have been resulted, whereat the day of ovulation could be found up to 6 days after Nadir. "
We are bound to thank especially those colleagues who took part in our intensive training in Germany, in Austria, in Switzerland, in Italy and in Poland or educated themselves personally. As a good example of a positive cooperation subsequent solution has proven itself: In the ambulance, a space is provided in which a trained counselor - usually in the evening - can give a consultation. The ambulance is relieved, especially as a comprehensive cycle monitoring and evaluation can consume a lot of time. Moreover, the then available cycle records are a good basis for the diagnosis and any necessary treatment.
There is no doubt an agreement that in medical practice the concern for the welfare of women seeking advice has to come first. The modern woman is very interested in all matters having to do with her health, and inevitably receives much relevant information from television and all kinds of print media, which then comes up in the medical consultation. As physicians, we should take good arguments of women seriously and not rush to make a superficial judgment. Thus, the above-mentioned experience of unnecessary friction between too little about the cycle happening in the woman informed doctors and with their personal cycle familiar women have led the author of these lines to write a with detailed references supplemented monograph that attempts to offer corrections and extended information for both sides(Rötzer, 1999) . At the heart of this book is the personal cycle of the woman, from the pre-puberty to menopause. There, it is dealt with the normal cycle, the cycle of girls and young women, the proceeding when desiring a child, records after birth, the cycle in menopause, irregular cycle, the cycle after stopping the "pill". Due to the current literature-knowledge of the author this monograph is likely the first to publish records from a girl before the onset of menarche. It may also be appropriate to note that for those girls who early observe her cycle processes, a biphasic cycle with sign of fertility and with sufficient high temperature level seems to occur in this early stage. Corresponding examples are given in the monograph.
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Address of the author:
"Sensational news" about multiple ovulations
a response of Prof. Dr. Rötzer
A-4840 Vöcklabruck, 10.01.2004 "
From about July 2003, it frequently came to “sensational news" that in the course of a menstrual cycle more than one ovulation occurred and this in different phases of the cycle. Therefore, the textbooks have to be rewritten and natural conception regulation is no longer possible. It was referred to Angela R. Baerwald et al. who published a scientific work of a University Women's Hospital in Canada in the prestigious medical journal "Fertility and Sterility, Vol.80, No.1, July 2003 pp.116-122".
To the above mentioned hasty conclusions necessary clarifications should be given to our INER members.
It has long been known that that group of follicles, which later emerges to the mature follicles, can be detected several months before ovulation in the ovary. There a growth of the follicles in successive waves occurs. It is also known for some time that in the luteal phase of the cycle preceding the ovulation can be seen already more grown up follicles, but none of them reaches the usual size of a mature follicle. So far, the comments of the Canadian accord with our current knowledge. The from the examining scientists as new classified observation that in the cycle in which the ovulation occurs, the growth of the follicles can be done in two or three waves, is only a confirmation of the observation made by us many years ago that in long cycles two or more phases of S may occur before ovulation. In the textbooks, however this remained unnoticed.
The Canadian study doesn’t describe observed and actual ovulation outside the estrogen-specific ovulatory phase, especially not in the luteal phase.
In the Canadian study there is only the speculative assumption that ovulation could take place in the luteal phase developing follicles in the luteal phase, if a stronger and steeper LH rise leads to rupture of a follicle. It should be noted:
- It can only come to the necessary LH rise, when a steeply rising and very high level of estrogen (estrogen peak) triggers an LH rise. Such a high estrogen levels is never given in the luteal phase.
- In addition, the necessary LH rise in the luteal phase can’t take place because the progesterone formed by the corpus luteum does not allow this in this phase. In practice, neither a such strong and steep LH rise neither an ovulation in the luteal phase has been observed, and this has never been described in the world literature.
The result of Canada's study was misinterpreted mainly of journalists and thus, an erroneous view was trumpeted in the world. Unfortunately even medical journals adopted this agency report without critical examination.
Overall, it is clear that the basis of the natural conception regulation remains untouched and is unwavering:
Outside the determinable potentially fertile days, there is no ovulation.
Prof.Dr.med.Josef Rötzer, A-4840 Vöcklabruck, 10.01.2004
Address of the author: