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Table of contents



A "yellow" light indicates the need for another test strip. In practice, Persona is recognized as effective for adequately detecting both the fertile period and the infertile period 57, 58, 59, When surrounded by layers of granulosa cells, the primary follicles become 0. A preantral follicle takes about 25 days to reach antrum, when it measures roughly 0.

The follicle destined to ovulate leaves the preantral reserve three cycles before reaching preovulatory size. Antral follicles from two to five mm in diameter have little sensitivity to gonadotropin stimulation.

When the cycle begins, each ovary with normal characteristics has a similar aspect in terms of number; approximately eight follicles above three mm in average diameter. In follicles under 12 mm, it is valid to measure two diameters and to average them. If they are over 12 mm, three diameters can be measured.

Ovulatory follicles are much rounder than atresic follicles and can be distinguished easily on the basis of average follicular diameter, which is an appropriate term for referring to the measurements of a follicle and for entering those measurements on follicular growth curves This term refers to follicular growth under the influence of gonadotropins and can be defined as the onset of growth in a cohort of follicles.

Each woman has an individual FSH threshold, above which follicular recruitment occurs. The largest number of recruited follicles usually is produced between days three and eight of the cycle and, during this period, they grow at a rate of 0. During this period, it is possible to spot one to five follicles measuring four to eight mm The follicle that will ovulate is selected from among the recruited follicles.


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In natural selection cycles, the follicle destined to ovulate usually is selected towards days six and seven of the cycle. There may be other larger-sized follicles that are not selected for ovulation, and low FSH levels are usually what prompt the selection 11, 12, and When a follicle takes over or governs the ovarian cycle, it provokes the withdrawal of the follicles that accompany it. This occurs by about the ninth day of the cycle and the mean diameter is usually 10 mm The dominant follicle becomes spherical in shape, with a smooth inner surface, and the average echogenicity increases more quickly, at a rate of approximately 1.

The follicles under mm become irregular and atresic. This phenomenon is more pronounced in the dominant ovary than in the contralateral one. The increase in estrogen levels becomes obvious and occurs parallel to follicular growth. The dominant follicle is in charge of the major production of estradiol. In turn, at the endometrial level, the influence of estrogen, such as growth of the endometrial line and the presence of the typical three-layered echographic pattern of the periovulatory phase, can be seen 11, Ultrasonic Signs of Maturity: Acceleration in follicular growth is an evident sign of follicular maturity and one that is easy to verify.

Therefore, when a follicle reaches approximately 20 mm in size, it can be considered mature. The ovary is larger in volume, approximately 12 ml, at the expense of the preovulatory follicle. Generally speaking, a follicle roughly 19 to 20 mm in size will ovulate in hours, on average The cumulus oophors can be observed 36 hours prior to ovulation, and it may occasionally be detected as an eccentrically located, echogenic, 1 mm internal mural protusion.

Occasionally, a double contour is evident. It usually appears from six to 10 hours after ovulation and occurs when the theca splits from the granulosa cell Appears hours after the urinary LH surge. Ultrasonic Signs of Ovulation: There are currently a number of ultrasonic indicators on which to base an ultrasonic diagnosis of ovulation. The first, when it can be documented, is the disappearance of a previously observed follicle or when its reduction in size, with flattening, is documented.

There is no unanimous consensus on the release time. It can occur quickly, in one minute, or slowly during the course of an hour. According to Bajo Arenas, this is the most reliable sign of ovulation Nevertheless, one cannot rule out the possibility that release may have occurred, but the egg remains trapped inside the follicle. A second ultrasonic sign is when the walls appear irregular and there are multiple echoes within the follicle. A third sign is the presence of fluid at the bottom of the Douglas pouch, and a fourth is the presence of a wave of luteal conversion.

Usually, it is not necessary to assess the corpus luteum in a spontaneous and normal cycle. However, cases of luteinized unruptured follicle syndrome LUF can be documented on the basis of the absence of a wave of luteal conversion The estimated day of ovulation has been used to determine, retrospectively, the change from an infertile period to a fertile state. This method makes it possible to define the fertile window. It can be used in clinical practice and to detect the fertile period by means of the different methods documented already.

Although the role of cervical mucus is well known, it currently is not used widely to identify the days when there is a high probability of conception and the days when fertility is poor 40, In fact, many physicians now recommend ovulation-detection kits. However, the changes observed in cervical mucus at the vulva also can be used to identify the threshold of the fertile window and the end of the fertile period This method has a well-established biological justification, seeing as estrogenic-dependent cervical mucus increases about 5—6 days prior to the day of ovulation Most of the studies that compare the fertile window to cervical mucus to identify the fertile period detect a longer interval with cervical mucus, compared to the classical tools used by the American Society for Reproductive Medicine Adlecreutz compared this interval to cervical mucus and found the cervical mucus overestimates the actual length of the sixday fertile period by an additional four days, on average.

In his study, the fertile window was In this case, the length of the fertile period was 6. In others studies, the changes in the pattern throughout the cycle, both in quantity and type of cervical mucus, have been identified by observing the discharge of this mucus in the vagina 43, 48, Estrogen-type mucus can be used not only as a marker of fertile days, but also to predict non-fertile secretion based on the absence of sufficient levels of estrogen-type mucus There are various classifications of cervical mucus at the vulva.

Scarpa proposes a four-point scale to classify vulvar secretion and to learn to identify estrogen-type mucus, which is has the best conductivity for sperm survival and transport.

This method has the advantage of being non-invasive, and it is easy to implement with a minimal amount of training. There are several ways to classify cervical mucus. The most traditional method is the one described by Billings, which involves taking a cervical mucus sample at the vulva, then charting and interpreting it on a graph of the infertile or fertile characteristics.

Other observation methods are the classifications described by Hilgers and Fehrning, which are based on the Billings clinical method involving sensation, appearance and consistency of cervical mucus. However, the subjective nature of the test could be the critical point in this method 66, If the threshold theory of ovulation works well, the biomarker measurements possibly could indicate follicular development is occurring.

In reality, there is no device to confirm this event in real time. Perhaps the more technical approach would be monitoring by means of a daily ultrasound examination. However, this is possible only in clinical practice. ClearPlan One Step and similar monitors might be useful for this purpose, but probably in combination with some other clinical test.

The correlation between plasma and urinary sex hormone measurements from day six prior to ovulation up until day one after ovulation is well documented. The starting point to detect the onset of the fertile period inside the fertile window has been defined as detection of the beginning of the surge in oestroneglucuronide and the end point, as the second consecutive day at peak LH. This conclusion is based on normal cycles 24, However, a good correlation also has been observed between the signals of the start and end of the fertile period in cycles of sub-fertile women with regular menstrual periods with no specific pathology and without hormone therapy These clinical signs can be diagnosed through external signals, and these measurements can be used, in turn, to detect the window of fertility in the menstrual cycle of women with regular menstrual cycles, because the fertile window has a normal variability 24, 28, In women with normal spontaneous menstrual cycles, the FSH threshold level is probably constant.

For this to be the case, a pull of antral follicles sensitive to the FSH threshold is needed if self-regulation in the hyphotalamic hypophysis-gonadal axis is to occur effectively and the necessary physiological changes in LH, estradiol, and progesterone hormones are to take place.

However, it is important to remember that bleeding of gynecological origin can halt the normal course of the ovulation process and the regular menstrual pattern. There are different causes that can alter this situation, the most frequent being stress, perimenopause, poliquistic ovary syndrome PCOS , hypothyroidism, hyperprolactinemia or treatments with gonadotropin-releasing hormone GnRH preparations, which can alter normal follicular development because of their long half-life.

These are the most frequent cause of irregularities that interrupt the normal menstrual cycle. However, any other change in the regularity of the days of menstrual bleeding should be examined to rule out other causes of gynecological origin, such as the possibility of ovarian tumors, luteal phase pathology, or any other obstetric reason for irregular bleeding.

A clinical diagnosis requires a simple, organic and functional evaluation, which now is available to most women. According to what has been said, at length, about the process of normal follicular development, FSH concentration during the early follicular phase is of crucial importance. The surge of FSH levels in plasma above a specific threshold will trigger the entry of follicles into the rapid growth phase. And, the period of time during which the concentration of FSH is above the threshold level will determine the number of follicles that reach their final stage of maturation.

It is essential that FSH levels quickly fall below the threshold, if follicular stimulation is to be limited to a single follicle. However, in normal menstrual cycles without pathology, even if the amount of FSH is reduced, some follicles that have been recruited already may continue to grow, despite the decline in FSH concentration, but ultimately only one follicle with achieve dominance. Therefore, the concentration of FSH in plasma may be the most important factor in identifying the hormonal change in the fertile window and in detecting the trigger points of the fertile and infertile periods.

To prove this theory, the variations in estradiol concentration have been tested in a number of studies in order to confirm the threshold hypothesis works well throughout the individual cycle 71, The more traditional devices to monitor this process in clinical practice are the ones that use highly sensitive hormone test kits that are easy to apply. The temporal relationship between a positive signal from a kit that predicts when ovulation will be possible and the rupture of the follicle has been studied in detail by Collins, The time of a positive reading for follicular rupture ranged from 24 to 48 hrs.

These results coincide perfectly with the outcome of the WHO studies 26, The advent of new technology such as specific hormone tests, serial measurements of estrogens, progesterone metabolites and the LH hormone, plus the new methods currently under investigation may be of help to eventually do a better job of diagnosing the fertile window in women 73, 74, 75, It is now possible to combine the signals, registration and calculation of fertility signs to improve prediction and detection of the fertile window. Combining resources could be interesting in terms of improving how the fertile window is approached.

INTRODUCTION

An individualized tactic to detect the fertile window also can be useful in some cases, in combination or with a selection of existing methods and markers Medicine currently counts on subjective and objective examinations so as to diagnose the highest and lowest fertility point. In addition, it is likely to keep track of the biological fertility factors which may eventually provide vital and reliable information regarding menstrual cycle.

Follow -up examinations might come in useful for NaproTechnology RNF and also for some other focus groups interested in dealing with current theoretical resources stem from updated medical literature. The authors wish to thank all the volunteers who participated in the preparation of this manuscript. Outcomes from treatment of infertility with Natural Procreative Technology in an Irish general practice. J Am Board Fam Med ; Speroff L, Fritz MA.

The physiological basis of the fertile period. Int J Gynecol Obstet. Pharmacokinetics of follicle- stimulating hormone: On the isolation and characterization of the alpha and beta subunits of human pituitary folliclestimulating hormone. Rathnam P, Saxena BB. Primary aminoacid sequence of follicle- stimulating hormone from human pituitary glands. Effects of estradiol phenobarbitone and LHRH upon the isoelectric focusing profile of pituitary follicle-stimulating hormone in an ovariectomized hamster.

Male and female forms of human follicle-stimulating hormone in plasma. J Clin Endocrinol Metab. Dynamics of follicular growth in the human: A model from preliminary results. Pituitary control of ovarian function-concepts derived from gonadotropin therapy. The importance of the FSH concentration in initiating follicular growth in polycystic ovary-like disease. Ovarian responses in Macaques to pulsatile infusion of follicle-stimulating hormone FSH and luteinizing hormone: Increased sensitivity of the maturing follicle to FSH.

Prediction of ovulation by urinary hormone measurements with the home use ClearPlan Fertility Monitor: Comparison with transvaginal ultrasound scans and plasma hormone measurements. Hum Reprod ; 15 Barret JC, Marshall J. The risk of conception on different days of the menstrual cycle. Schwartz D, Macdonald P. Fecundability, coital frequency and the viability of the ova.

Basal body temperature, ovulation and the risk of conception, with special reference to the lifetimes of sperm and egg.

Sexualidad, amor y bioética : reflexioó teológica

A prospective multicentre trial of the ovulation method of natural family planning. Characteristics of the menstrual cycle and of the fertile phase. Cumulative pregnancy rates in patients with apparently normal fertility and fertility-focused intercourse. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Engl J Med. Papanicolaou The sexual cycle in the human female as revealed by vaginal smear. American Journal of Anatomy. Hospital Virgen del Camino.

Day-specific probabilities of clinical pregnancy based on two studies with imperfect measures of ovulation. Hum Reprod ; 4: Fehring RJ, Schneider M. Variability in the hormonally estimated fertile phase of the menstrual cycle. Fertil Steril ; 90 4: Hormonal indices of ovulation and the fertile period. Task force on methods for the determination of the fertile period.

Temporal relationships between indices of fertile period. Fertil Steril ; Prediction of the potentially fertile period by urinary hormone measure ments using a new home-use monitor: Comparison with laboratory hormone analyses. Human Reproduction ; 16 8: The measurement of urinary steroid glucuronides as indices of the fertile period in women. J Steroid Biochem ; 6: Variability in the Phases of the Menstrual Cycle. Ultrastructure of the human periovulatory cervical mucus. Journal of Electron Microscopy ; 54 5: Bases y Aplicaciones de la fertilidad humana. Indicadores de la fertilidad.

Its physiological role and clinical significance. Adv Exp Med Biol. Functions and physical properties of mucus in the female genital tract. Br Med Bull ; Some characteristic changes in the consistency of the uterine secretion. Cornell University Medical College. Sterility in Male-Female and its Treatment. Micro-NMR in high permanent magnetic fields. Scand ; 45, Suppl 2: The functional structure of human cervical mucus. Acta Obstet Gynecol Scand ; The biophysical aspects of cervical mucus.

Jordan JA, Singer A, editors. The biophysical properties of the cervicalvaginal secretions. Natural Family Planning ; 7, 1: Cervicovaginal fluid changes to detect ovulation accurately. American Journal of Obstetrics and Gynecology ; A new diagnostic aid for natural family planning. The Response was examined according to the procedures of the Congregation, which, finding it to be unsatisfactory, decided to offer Father Vidal another opportunity to clarify his position on the points at issue.

A new set of questions was submitted for the approval of the Ordinary Session of the Congregation on January 20, , which also decided to grant Father Vidal an additional three month period in which to make his response, as indicated by the Regulations. This manner of proceeding and the text of the above-mentioned questions were approved by the Holy Father in the Audience granted to the Cardinal Prefect on February 5, The new documentation with an accompanying letter were presented to his Superior General in the course of a meeting at the Congregation on June 7, In addition, while manifesting the sincere hope that Father Vidal would understand the offer of this new opportunity as an invitation to a deeper reflection, for his sake and that of the Church in whose name he carries out his service of teaching theology, it was decided that his responses should be prepared personally, in an unambiguous and succinct form, and should arrive at the Congregation for the Doctrine of the Faith before September 30, Informed of this decision, Father Vidal gave assurances through his Superior General that he would comply with the requests made by the Congregation.

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This second Response was then submitted to the judgment of the Congregation, in accordance with the Regulations for Doctrinal Examination. On November 10, , the Ordinary Session of the Congregation, on the basis of all the phases of the examination and the entire documentation, concluded the exceptional procedure.

The Congregation noted with satisfaction that the author had shown himself willing to correct the ambiguities in his writings on heterologous artificial procreation, therapeutic and eugenic abortion, and abortion legislation, and that he had stated his adherence to the teaching of the Magisterium on the doctrinal points at issue, though without substantial or concrete modification of the other doctrinal points mentioned in the Contestatio.

In light of this situation, the Congregation judged it necessary to prepare a Notification, which would be presented to Father Vidal in a meeting aimed at obtaining explicit recognition of the errors and ambiguities found, and at verifying, in keeping with the principles recognized by the author, his commitment to revise his books in the manner decided by the Congregation. Moreover, the text of the Notification, incorporating the results of the meeting and approved in Ordinary Session by the Congregation, would subsequently be published. These decisions were confirmed by the Holy Father at the Audience granted to the Secretary of the Congregation on November 12, The above-mentioned meeting with the author took place on June 2, After the formal presentation of the Notification, and a cordial and productive conversation regarding the doctrinal questions and the procedural aspects of the case, Father Vidal accepted the doctrinal judgment formulated by the Congregation for the Doctrine of the Faith, as well as the formal obligation to revise his writings according to the instructions given.

The text of the present Notification, including these conditions, was sent through the Superior General to Father Vidal, who manifested his acceptance by affixing his signature. This resolution is not meant as a judgment on the person of the author, on his intentions, on the totality of his work, or on his ministry as a theologian, but solely on the works examined. Moral de Actitudes is composed of three volumes. The first is devoted to fundamental moral theology. It also seeks to moderate positions considered to be extreme through a consideration of the data supplied by the human sciences and by contemporary philosophical currents.

The author expresses more than once the determinative approach of Moral de actitudes: Therefore, Moral de Actitudes does not stress sufficiently the ascending vertical dimension of Christian moral life. And the great Christian themes, such as redemption, the Cross, grace, the theological virtues, prayer, the beatitudes, the resurrection, judgment, and eternal life, are hardly mentioned and exert almost no influence on his presentation of moral teachings.

Consideration must be given, finally, to the tendency to make use of a methodology of the conflict of values or of goods in the study of various ethical problems, as well as to the role played by references to the ontic or pre-moral level. On a practical level, he does not accept the traditional doctrine on intrinsically evil actions and on the absolute value of the norms that prohibit such actions. The author maintains that contraceptive methods which intervene after fertilization and before implantation, are not abortifacient. The author holds that the doctrine of the Church on homosexuality possesses a certain coherence, but does not enjoy an adequate biblical foundation 28 and suffers from significant conditioning 29 and ambiguities.

El aborto en América Latina y El Caribe

With regard to responsible parenthood, the author states that none of the present methods of birth control is good in every respect. On homologous in vitro fertilization, the author distances himself from the teaching of the Church. Moral de Actitudes also contains ambiguous judgments on other specific moral problems, for example, on married couples having recourse to artificial insemination with the sperm of a donor, 50 on heterologous in vitro fertilization 51 , and on abortion.

The author rightly affirms the overall immorality of abortion; however, his position on therapeutic abortion is ambiguous. His statements on eugenic abortion are similarly ambiguous. The Congregation notes with satisfaction the steps already taken by the author and his willingness to follow the documents of the Magisterium, and trusts that his collaboration with the Doctrinal Commission of the Spanish Episcopal Conference will result in a text suitable for the formation of students in moral theology.

With this Notification, the Congregation also wishes to encourage moral theologians to pursue the task of renewing moral theology, in particular through deeper study of fundamental moral theology and through precise use of the theological-moral methodology, in keeping with the teaching of the Encyclical Veritatis splendor and with a true sense of their responsibility to the Church.