the one where LUFS is all you need

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Jan 17

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So, you’re trying to get pregnant (I imagine my body might say to me).

I also know - continues some particularly clever and conniving part of my body; a demonic ovary, perhaps - that you have scientific training. That you’re conditioned to look for patterns among symptoms, to thrive on charts that make sense, to spend hours on end looking for clues suggesting a logical framework where there really isn’t one.

Lovely - continues my fiendish left fallopian tube. I know just the thing to make you perfectly insane. What if we - gestures to entire reproductive system - were to work really hard to ensure that you experience an entirely convincing symphony of symptoms that makes it 100% clear that everything is going right - work overtime, in fact, bend over backwards to make it perfectly apparent that everything’s cool - while, in fact, masking the fact that the one thing required to make a pregnancy happen just - inexplicably - isn’t happening?

Welcome to the backstage mechanizations of the mind-bending drama that is LUFS.

Let’s break it down. Beginning with the basics:

What is LUFS?

LUFS stands for Loudness Units Full Scale, and it’s an integral part of how the music industry is currently scaling to ensure customers are wowed by the way albums and soundtracks are mixed without breaking everyone’s eardrums. It’s apparently the next big thing; as AudioDraft.com puts it: all you need is LUFS.

Wait. (And DAMN, I’m mad I didn’t come up with that.)

In the significantly less snazzy infertility world, LUFS stands for Luteinized Unruptured Follicle Syndrome. Vocabulary time!

Follicle is just a fancy word for the little ovarian pod that houses an egg prior to ovulation/fertilization/destiny.
In order for ovulation to happen, at some point, the follicle must rupture. Or break. The pod has to release the egg.

So, so far we’ve got a Syndrome in which the Follicle doesn’t Rupture. Cool.

Luteinizing Hormone (or LH) influences the way that a woman’s ovaries work. In the first part of a woman’s cycle, it stimulates the ovaries to produce estrogen. In the middle of the cycle, LH levels abruptly roller-coaster to the sky - and that dramatic change is what causes the aforementioned follicle to rupture. In the second half of the cycle, LH manages the way that the broken follicle heals, produces hormones of its own, and ultimately vanishes.

Ever used an ovulation predictor kit? Those tests seek that surge of LH that should just precede ovulation. It can happen at any time - which is why some women use ovulation predictor tests twice a day - and, generally speaking, is a reliable indicator that ovulation is about to successfully occur within maybe 36 hours.

Except, of course, when it isn’t.

why doesn’t a follicle rupture? WTF?

Why, Tear-resistant Follicle? WHY? [SOBS]

Let’s talk for a second about how ovulation normally happens. If you’re cycling regularly, it’s like 99.999999% the case that you’re ovulating. LUFS, or trapped egg syndrome, is a relatively rare phenomenon.

Ovulation Mythbusting Fact Time!

Ovulation is a multi-step process that takes place over time. It isn’t a boom, EXPLOSION, egg poings out of follicle, one minute there, next minute WOMB-there-it-is (sorry) situation.

Over the days prior to ovulation, your ovaries get exposed to different chemicals and enzymes - active substances - that weaken the walls of your follicle, making it much more likely that it’ll break at the right time. That way, when LH (which I’m now visualizing as, like, some kind of hammer) comes around, the follicle is primed to break.

AFTER normal successful rupturing and ovulation, the follicle no longer has an egg in it. The follicle then shrinks in on itself and starts to dissolve away, so as to no longer take up room in a woman’s ovary - which, remember, gets to go through this whole production every month.

BUT! Before it does, the follicle transforms into something called the corpus luteum, a little hormone-producing factory. The corpus luteum makes progesterone, a hormone that is very, very important for the second half of a woman’s cycle and early fetal development, if fertilization/implantation has occurred.

Why is this important? IN THE MAJORITY OF CASES, when women want to figure out if they’ve ovulated or not, they look for signs that they have a lot of progesterone. This makes sense. Progesterone should only come from the follicle after it’s ruptured and released its egg.

It’d be really weird and rare to have a lot of progesterone swimming around in your system if, like, the egg was still in the follicle and the follicle didn’t undergo its transformation process.

Yep. Bet that never happens. [THROWS HANDS UP IN AIR]

In some circumstances, the follicle will see that the towering hammer of LH is on its way and decide, hey, NOT TODAY.

The stubborn follicle will withstand LH’s rupturing force - perhaps it wasn’t sufficiently weakened pre-ovulation, perhaps there’s just not enough LH to persuade it to break, scientists are still looking for other reasons because this just doesn’t happen that often, ahem - and shrink down into itself and become the corpus luteum with your bonny wee egg trapped inside.

It’s a horror movie happening monthly in your ovaries and it’s as insidious as hell - because your corpus luteum goes on its merry way, making progesterone for your body, telling all the world that duh, ovulation happened.

This is problematic because a) most people assume that progesterone = ovulation happened, and b) it’s pretty hard to confirm ovulation if you need to look for non-progesterone-related evidence. Pretty much the only way to really, truly confirm ovulation is to a) realize that you’re pregnant, duh or b) watch it happening on a serial progression of ultrasounds, which, $$$$$.

Which is why most people just assume progesterone = ovulation.

Which, again, is almost definitely the case for the vast majority of women.

It’s just not the case for me.

luteinized unruptured follicle syndrome and symptoms

If you’ve been hanging around here for a bit, you might have endured several rants from me already about my completely nonsensical symptoms.

I have PCOS, but I’m (relatively) lean and cycle boringly regularly.

My basal body temperature rises mid-cycle like clockwork, but we have pretty concrete evidence that my ovaries are stacked with unruptured follicles - a sign that I’m not ovulating. (Concrete evidence = a picture of it.)

Those two things should not exist at the same time.

LUFS first entered our cinematic universe when our Napro mentioned it at the end of one of our consults - I’d asked why on earth my temperature was rising if it didn’t seem I was ovulating. I ran home and overloaded Google’s servers with searches, and happened upon this article featuring Anna Saucier’s LUFS diagnosis. I read it and was like, these are my people.

If you’re wondering if you have LUFS - and remember, this is rare, BUT it does happen - common symptoms may include:

Low progesterone
Uncommon forms of PCOS (for example, instead of insulin-resistant PCOS, androgen-excess PCOS or adrenal PCOS)
Unexplained infertility
Silent endometriosis
General confusion and hysteria.

The only way to concretely diagnose LUFS is with a serial progression of vaginal ultrasounds - essentially, to track ovulation not happening.

It’s also important to note that LUFS may or may not happen each month. Women may have follicles of varying levels of stubbornness; women may produce slightly more or less LH each month - or whatever the underlying (mysterious, personal) mechanisms for a LUF may be. As this is the case, being diagnosed with LUFS does not mean that you’ll never get pregnant.

However, if you LUF every other cycle, or something like that, it’s obviously gonna take twice as long as it would normally take, as it’s impossible to get pregnant in an essentially anovulatory cycle.

treatment options for Luteinized Unruptured Follicle Syndrome

Fortunately or unfortunately, the treatment for LUFS is simple.

Even though it’s mysterious and mind-numbing and weird (I look like I’m definitely ovulating; I’m not; my body is literally gaslighting me; lovely), at the end of the day, if you have LUFS, the problem is simple. You’re not ovulating. LUFS is therefore considered a form of ovarian dysfunction or failure in terms of prognosis/treatment.

The answer? Drugs to make you ovulate. One 2015 study showed that letrozole (your Femara) is more effective than clomiphene (your Clomid) for helping women with LUFS ovulate - almost doubly so. However, every woman’s body responds to these drugs differently. Some doctors also recommend an ovulation trigger shot, usually an HCG injectable, to really make sure that ovulation happens. (For me, we’re going with Femara rn, and we’re saving injectables for later, as a logical course of escalation.)

However, that same study showed that, unfortunately, treatment doesn’t always work. Almost 200 women entered that study, 98 received Clomid and 98 Femara. 41 of the Femara patients got pregnant within the year. That’s better than none.

That’s still less than half.

As I wrote in a previous article: LUFS - you can lead a horse to water, but you may still not ovulate anyway. (Or there could be something else wrong with the horse. Or the water. How does anyone get pregnant??? Don’t answer that.)

One team has established a protocol for seeing if acupuncture can positively affect LUFS, but that’s currently underway, so, no info yet.

luteinized Unruptured Follicle Syndrome and NSAIDs

One theory floating around the internet concerns one possible cause of LUFS - a potential connection between a LUF cycle and NSAIDs, or non-steroidal anti-inflammatory drugs (your ibuprofen, for example). One theory goes that NSAIDs MAY have some effect on the substances that work to weaken your follicle walls.

Basically, NSAIDs MAY stop those substances from doing their thing, resulting in a stronger follicle when the Hammer of LH swings round.

According to this theory, using NSAIDs MAY, in this case, increase the likelihood of an unruptured follicle and a trapped egg and a necessarily infertile cycle. The connection’s tenuous and would likely require really really high levels of NSAID use, but, like, it’s potentially there. Just a thought.

(For me, I’ve used ibuprofen maybe once a month in the past, and - as acupuncture’s gotten rid of my period pain - haven’t really done so in a long time.)

our plan for getting pregnant with luteinized unruptured follicle syndrome (LUFS)

2021: Our year of playing Trapped Egg Roulette, basically. What fun! We talked about our 2021 Infertility Battle Plan at the end of 2020, but for those just joining the party, here’s a brief summary of our situation:

Every month, early in my cycle, I take letrozole to let one of my follicles know that its lease is up in two weeks.
I track (likely, hopeful) ovulation via cervical fluid, ovulation predictor kits, and basal body temperature shifts.
We still don’t know that I’m ovulating, but we’re hoping that the chances are better - and, as aforementioned, the only way to be 1000000% sure would be to do the really expensive ultrasounds each/every month, which, no.
Once I’ve confirmed (likely, hopeful) ovulation, I start taking progesterone supplements to help give any potential pregnancy its best shot.
We’ll consider a trigger shot after just-letrozole doesn’t seem to work, if that’s the case.
We’ll consider options for sussing out silent endo (much) later, if that’s the case. (That would require surgery, which, for many reasons, we’re not planning on pursuing in the immediate future.)
I take Metformin to manage PCOS (current solution, not long-term).
I eat relatively healthily and move my body often.
We cross our fingers and do other things and try not to let infertility fester in our brains and distract ourselves with our jobs, working on our home, and games/mindless TV. (Has anyone else watched WandaVision? SHARE YOUR THEORIES BELOW I’M DYING I LOVE IT SO MUCH NO SPOILERS PLEASE.)

And there you go. Stay tuned.

While Ted and I may feel trapped in the seemingly-endless cycle of infertility, it’s my eggs - the stuff and substance that could potentially end up becoming the third member of our little family - that keep getting actually trapped. And that’s no fun. For any of us.

But! Something good has come of this discovery, of course. We’ve realized something about ourselves and this whole process that, perhaps, we’ve always known: Project Waterbear is - first and foremost - a LUFS story.

[Exits, giggling, followed by bear.]