If you’ve ever found yourself stuck in a frustrating cycle of bacterial vaginosis (BV) that just won’t shift, you’re not alone. For many women, BV becomes a revolving door of symptoms and unfortunately with a lack of understanding around the drivers to this condition and inaccurate testing, recurrent infection is extremely common. There is something that may be contributing to your issues that you haven't yet thought of! Recent research is shedding light on an important factor that is very commonly missed: your partner’s reproductive microbiome may be silently influencing yours. This 2022 study discussing the role of the reproductive microbiome for fertility health, quite clearly maps out the impact: “Unprotected sexual intercourse creates a bacterial exchange between partners, and in addition, each partner can influence the microbiota composition of partner's reproductive health tracts” (Koedooder et al., 2022). If BV keeps coming back, it's time to consider not just your treatment, but the shared microbial environment between you and your partner. Vaginal Microbiome 101: Why Balance Matters for Recurring BV The vaginal microbiome is best described as a low-diversity ecosystem typically dominated (in a healthy state) by a single Lactobacillus  species. That dominant bacterium keeps the pH acidic and suppresses other microbes. When this dominance is lost (dysbiosis), anaerobes or fungal species can overgrow, raising the risk of bacterial vaginosis, yeast infections, and greater susceptibility to STIs. Many factors can tip this balance. Changes in hormone levels throughout the menstrual cycle, personal hygiene practices, diet and lifestyle and medications such as antibiotics or the contraceptive pill are common examples. In addition, the transfer of microbes between partners during intimate contact can significantly affect vaginal health. The Microbial Exchange Between Partners Sexual partners share more than intimacy, they share microbiomes. Whether in heterosexual or same-sex relationships, the reproductive microbiota can shift through unprotected intercourse. That means one partner’s bacterial landscape can directly influence the other’s, sometimes in ways that make treatment for vaginal dysbiosis frustratingly ineffective. So, when only one person is treated, it’s a bit like patching a leak without checking the rest of the plumbing. What a Partner-Inclusive Approach Looks Like Shifting our lens from “treating a woman’s infection” to “addressing a couple’s shared microbiome” opens up more effective pathways for care: Testing Both Partners - Assessing microbiota from both individuals can identify patterns that might otherwise go unnoticed, like a male partner carrying BV-associated bacteria that reintroduce imbalance after treatment. Treating in Tandem - Simultaneous treatment (e.g. antibiotics, probiotics, or lifestyle shifts) reduces reinfection risks and creates space for long-term microbiome restoration. Preventative Conversations - Encouraging partners to talk about sexual health, microbiome balance, and the impact of behaviours like condom use, hygiene, and even diet fosters a proactive approach to wellbeing, not just reaction to symptoms. The Hidden Consequences: Endometriosis, Infertility & Recurrent Pregnancy Loss The impact of vaginal dysbiosis has much broader implications for reproductive health. Particularly for women. Overgrowth of certain microbes and a lack of beneficial lactobacillus species has been shown to lead the way to a pro-inflammatory environment. Setting the stage for an increased risk in conditions like endometriosis, infertility and recurrent pregnancy loss. Endometriosis:  A positive correlation exists between vaginal microecology dysbiosis and endometriosis, notably with intermediate BV (Wang et al., 2024). Recurrent Pregnancy Loss (RPL):  BV has also been shown to be significantly associated with spontaneous abortion in a large meta-analysis including over 20,000 women (Haahr et al., 2016). Assessment of the vaginal microbiome in addressing all aspects of women's menstrual and fertility health is an essential consideration. Vaginal Microbiome Testing: Gram Stain, PCR, and NGS Explained When it comes to vaginal health, there are a few ways your microbiome can be tested, some more beneficial than others. Here’s a quick look at the main methods: 1. Gram-Stained Vaginal Smear (Hay/Ison) This is the test most people are familiar with.Your GP takes a vaginal swab, sends it to the lab, and technicians stain it so bacteria are visible under a microscope.They then grade what they see using the Hay/Ison criteria, which helps diagnose bacterial vaginosis (BV) or assess your overall flora balance. It’s quick, inexpensive, and great for spotting obvious infections, but it only gives a broad overview of what’s happening. In short:  It shows whether Lactobacillus  (the “good” bacteria) are dominant or if other bacteria have taken over, but it doesn’t tell you exactly which species are present. 2. PCR Test PCR looks for the DNA of specific microbes in your sample. It’s mostly used to check for STIs or targeted bacteria. It looks for the genetic material (DNA or RNA) of specific pathogens (for example, Chlamydia trachomatis , Neisseria gonorrhoeae , Trichomonas vaginalis , or Mycoplasma genitalium ). PCR gives species-level information but is usually used for infections, not general microbiome screening on the NHS. 3. Next-Generation Sequencing (NGS) NGS is a more advanced, DNA-based test. Instead of looking at bacteria under a microscope, it reads the genetic code of all the microbes in your sample. This means it can identify hundreds of bacterial species, including ones that can’t be seen or cultured in a standard lab test. NGS can also detect subtle shifts in your microbiome, changes that may not cause symptoms yet but could affect fertility, pregnancy outcomes, or vaginal health over time. It’s the test researchers often use to explore conditions like endometriosis and recurrent pregnancy loss, where microbial balance may play a role. This is the preferred test for Functional Medicine practitioners based on its specificity and reliability. Side-by-Side Comparison of Vaginal Microbiome Tests Feature Gram-Stained Smear (Hay/Ison) PCR Test Next-Generation Sequencing (NGS) Used by NHS? Yes - standard for BV Yes - mainly for STIs No -research/private only Method Microscopy DNA amplification Whole-genome or 16S rRNA sequencing What it detects Bacterial morphotypes (Lactobacillus vs BV bacteria) Specific microbial DNA (targeted) Full microbial community profile Level of detail Low Moderate (species-specific if targeted) Very high (species-level + abundance) Common uses Diagnose BV, assess flora Detect STIs, specific BV/STI panels Research, fertility, chronic dysbiosis Speed Hours Hours–1 day Days–weeks Cost Low Moderate High Availability Routine GP/sexual health clinics NHS for STIs, private for microbiome Specialist labs/private clinics What About Testing for Men? So we’ve established the testing options for women, but the point of this blog is about shared microbes between partners. So how do we go about testing men? Testing can be done with a swab from the urethra, penis, or foreskin. This is similar to the Gram-stained smear used in women, but it’s less commonly performed in men. It only shows broad bacterial groups and can’t identify specific species. A PCR test  can also be performed and is the most commonly used test for detecting viruses or STIs in men. PCR detects DNA from specific bacteria, such as Chlamydia , Gonorrhoea , or Mycoplasma . The sample is usually a swab, but it can sometimes be done with a first-catch urine sample. PCR is very accurate for targeted infections, but it doesn’t provide a full picture of the microbiome - it only tests for known pathogens. Next-Generation Sequencing (NGS)  can analyse the entire male genital microbiome, including bacteria, viruses, and fungi. It’s mainly used in research or private fertility clinics. Pros:  Very detailed; can detect subtle microbial imbalances that may affect fertility. Cons:  Expensive, slower, and not routine in NHS clinics. NGS can also be performed on semen to look at the bacteria and other microbes in a man’s reproductive system. A semen sample is collected in a sterile container, and the DNA of all microbes is analysed. This gives a detailed picture of the microbial community and can help fertility specialists understand possible links between microbes and sperm health or unexplained infertility. NGS doesn’t test sperm directly, and it’s not a routine NHS test, it’s mainly used in private clinics or research studies. Because of its specificity and accuracy, NGS is the preferred test by Functional Medicine practitioners. It helps identify potential drivers of male factor infertility and inflammatory microbes that may negatively impact sperm quality. Importantly, it’s also the best way to address dysbiosis that may be shared between partners, which can create a cycle of reinfection and impact both reproductive microbiomes. When recurring BV is an issue both partners must be tested. A Call for More Inclusive, Evidence-Based Care It’s time to evolve how we approach vaginal health. The one-sided treatment model doesn't reflect the science or the lived experiences of so many women dealing with persistent, recurrent BV. A shared microbiome requires a shared strategy, one that includes both partners in the conversation, the testing, and the treatment plan. How Can I Do This? When it comes to addressing recurrent BV, I always test both my clients and their partners - this is a private Next-Generation Sequencing (NGS) test that you can do from the comfort of your home. If needed, I work alongside medical treatment and provide guidance on how to access it. While antibiotics can be helpful, using them alone often leads to reinfection. That’s why a comprehensive approach is better, one that focuses on nutrients and herbs to help break down microbial biofilms, making bacteria more susceptible to antibiotics, while also implementing long-term strategies to rebuild a healthy vaginal pH, support Lactobacillus species, and address other contributing factors such as hormonal balance, gut health, and immune system support. If you would like to break the cycle of recurrent BV and take control of your vaginal and reproductive health, book a consultation to explore testing options for you and your partner, and discover a personalised plan to restore balance, prevent reinfections, and support long-term wellness. References Koedooder, R., Singer, M., Schoenmakers, S., Savelkoul, P. H. M., Morré, S. A., de Jonge, J. D., & Broekmans, F. J. (2022). The role of the reproductive tract microbiome in reproductive health: A review. Frontiers in Cellular and Infection Microbiology, 12 , 909853. https://doi.org/10.3389/fcimb.2022.909853 Wang, X., Xu, X., Zhang, X., et al. (2024). Association between vaginal microbiota dysbiosis and endometriosis: A cross-sectional study. PLOS ONE, 19 (8), e0306780. https://doi.org/10.1371/journal.pone.0306780 Haahr, T., Ersbøll, A. S., Karlsen, M. A., et al. (2016). Bacterial vaginosis and spontaneous abortion: A meta-analysis. Journal of Human Reproductive Sciences, 9 (4), 221–228. https://doi.org/10.4103/0970-9371.188050

When it comes to assessing hormone levels, a blood test is a great place to start. It’s an inexpensive test and, if timed properly, can be a really useful tool. Although inexpensive, I wouldn’t say it’s non-invasive, especially if you’re anything like me and not a huge fan of needles or the sight of your own blood. Yes, I know, how can a women’s health specialist be squeamish about blood? Don’t worry, it’s only my own blood that makes me go all wobbly at the knees. Don’t ask me why- it’s a thing… and it’s not uncommon. It’s for this reason that it really gets my goat when women come into my clinic with blood test results from their GP, only for me to find out they were done on the wrong day of their cycle. It’s a huge waste of time, and of course, an unnecessary visit for a dreaded blood test. Testing hormones at the wrong time can lead to inaccurate results, making them difficult to interpret. To get the most reliable insights, it’s essential to know when  and how  to test your hormones properly. In this guide, we’ll cover the best timing for key hormone tests, preparation tips, and common pitfalls to avoid, so your results are both accurate and actionable. Why Timing Matters in Hormone Blood Testing Hormones fluctuate naturally throughout the day and across your menstrual cycle. Many follow a diurnal rhythm, meaning their levels rise and fall depending on the time of day. Others vary dramatically based on your cycle phase. For example, reproductive hormones like FSH, LH, and Oestradiol are best tested at the start of your cycle, while Progesterone needs to be tested after ovulation. Testing at the wrong time can produce misleading results, potentially leading to misdiagnosis or ineffective treatment plans. That’s why correct timing, alongside proper preparation, is important for reliable hormone testing. General Guidelines for Hormone Testing Test in the Morning, Fasted For most hormones, testing first thing in the morning while fasted (no food or drink except water) provides the most consistent baseline. Avoid eating, drinking coffee, exercising, or sexual activity on the morning of your test, as these can affect hormone levels. For adrenal hormones like Cortisol and Prolactin, it’s also best to avoid these activities the night before. These hormone testing guidelines are important for both men and women. While men don’t need to consider monthly cycle timing, their hormones do follow a diurnal rhythm, meaning levels fluctuate throughout the day. For this reason, men should also aim to test their hormones early in the morning, ideally between 6–9 AM, to capture the most accurate baseline. Key Hormones and When to Test Them FSH, LH, and Oestradiol These hormones provide important information about ovarian function  and menstrual cycle health and are essential for sperm production in men. When to test:  Day 2 or 3  of your menstrual cycle. Note:  Day 1 is the first full day of bleeding (spotting does not count) FSH and LH  follow a diurnal, pulsatile pattern, which is why it’s essential to test them first thing in the morning  to capture accurate baseline levels. These hormones provide valuable insight into the function of the Hypothalamic-Pituitary-Ovarian (HPO) axis , helping us understand how well the early part of your cycle is functioning in preparation for ovulation. FSH and LH work closely with Oestrogen and Progesterone , influencing their production and regulation. Oestradiol , a form of estrogen, can also be tested in the luteal phase, alongside Progesterone. Its levels not only reflect ovulatory function but also give us a window into endometrial health, since oestrogen is responsible for thickening the uterine lining during the follicular phase. As with all hormones, we’re looking for a balance, not too high or too low . There’s a hormonal "sweet spot," and interpreting oestrogen levels in isolation won’t give the full picture. It’s crucial to assess them in context , particularly alongside progesterone, to gain a more accurate understanding of overall cycle health. Progesterone Often tested to confirm ovulation  and evaluate luteal phase function , also very important for embryo implantation and pregnancy. When to test:   7 days after ovulation - this is when this hormone should peak. Since cycle lengths vary, it’s important to track your ovulation  first (using basal body temperature, ovulation kits, and cervical mucus monitoring) to time this test correctly. Important:  Many doctors order a “Day 21 Progesterone” test routinely, but this timing is only accurate for women with a textbook 28-day cycle who have ovulated on day 14 - ovulation timing will vary from women to women. Personalised timing is essential for reliable results. Testing progesterone at the start of the menstrual cycle is useless as progesterone is produced after ovulation from the corpus luteum (a glandular structure formed from the ruptured follicle where the egg is released). P4:E2 Ratio (Progesterone to Oestradiol) Testing both Progesterone  and Oestradiol  7 days after ovulation can help detect issues like luteal phase deficiency, Oestrogen excess  or hormonal imbalances common in perimenopause. Prolactin Prolactin is a hormone involved in reproductive health and can affect menstrual cycles and fertility if elevated. When to test:   Cycle day 2 or 3 or peak luteal phase so 7 days after ovulation . Timing and Preparation:  Prolactin levels can be influenced by stress, physical activity, and sexual activity. For accurate results, test first thing in the morning, fasted , and avoid exercise, sexual activity, and caffeine  the night before and the morning of your test. Thyroid Hormones: TSH, Free T4, and Free T3 Your thyroid plays a central role in regulating metabolism, energy levels, and overall hormonal balance, but its influence doesn’t stop there. It also impacts heart rate, bone health, circulation, and has a significant effect on both physical and mental wellbeing. What’s more, thyroid function is closely interconnected with other hormones, and can be particularly sensitive to prolonged periods of stress. When to test:  Any day of the month Preparation:  Avoid biotin supplements or multivitamins  for at least 5 days prior, as biotin can interfere with thyroid test results. Testosterone, DHEA, and Cortisol These hormones play a key role in energy, stress response, libido, and overall vitality. Testosterone is essential for both sexes, supporting ovulation in women and sperm production and quality in men. DHEA and Cortisol are adrenal hormones, and while they’re often misunderstood, they’re vital to health. DHEA is actually a precursor to our sex hormones, while Cortisol, despite its bad reputation, is critical for survival, influencing everything from metabolism to immune function and blood pressure regulation. When to test:  Any day of the month but if you are testing a full hormone profile I find it best to do them at the same as this makes it easier to interpret - plus less blood tests for you. Timing:   First thing in the morning, fasted  (6–9 AM) Preparation:  Avoid coffee, physical exercise, and sexual activity  the night before and morning of your test, as these can spike hormone levels and affect accuracy. SHBG SHBG (Sex Hormone Binding Globulin)  is a protein produced by the liver. Think of it as the big sister  of your hormones, its job is to bind to hormones like estrogen and testosterone, carrying them through the bloodstream and keeping their levels in check by rendering them inactive when necessary. I like to include SHBG in hormone blood panels because it offers valuable insight into hormone bioavailability, that is, how much hormone is actually free and active in the body. It can also flag potential issues with blood sugar regulation , adding another layer of depth to your overall hormonal picture. When to test:  Cycle day 2 or 3 or peak luteal phase, 7 days after ovulation. Preparing for Your Hormone Blood Test: Tips to Ensure Accuracy Avoid supplements  that can interfere with results (like biotin) for 5-7 days before testing unless prescribed by your doctor. Avoid sexual activity, exercise, and caffeine  the night before and morning of your test. Track your menstrual cycle carefully to schedule tests like FSH, LH, Oestradiol, and Progesterone on the correct days. Final Thoughts: Accurate Hormone Testing Empowers Better Health Decisions When testing your hormones, timing is everything. By scheduling your tests according to your cycle and following preparation guidelines, you ensure your results reflect your true hormonal status. Accurate data allows healthcare providers to make informed recommendations tailored to your unique needs, whether you're managing fertility, balancing hormones, or navigating perimenopause. As part of my investigation process I will often recommend a comprehensive blood test . If you would like support deciding on the right blood tests for your needs, ascertaining when in your cycle you need to do these tests and clinical interpretation of the results please get in touch .

This might surprise you, but your period is not  the main event of your menstrual cycle. Yes, managing your monthlies takes some attention (especially if you suffer during this time), but it's actually ovulation that determines if, when,  and how  your period shows up - and it's a far more complex process than most people realise. Ovulation occurs when one of your ovaries releases an egg. Women of reproductive age should ovulate every month, but a lot needs to go right for that to happen. It actually takes around 100 days for an egg to fully mature - so the one you release this month began its journey more than three months ago. During that time, you have the opportunity to either support or potentially disrupt the development of the egg and its chances of being released successfully. What Is Anovulation? Anovulation or lack of ovulation, is surprisingly common and can happen for various reasons. The intricate hormonal symphony that controls ovulation is highly sensitive to disruption. So, depending on what’s going on in your life or with your health, you might occasionally skip ovulation. That’s normal from time to time , but when it happens regularly, things can start to go haywire, and not just for your periods. Chronic anovulation will affect your overall health and well-being, too. Why Do We Need to Ovulate? The obvious reason is, of course, to get pregnant. But even if you're not trying to conceive, ovulation brings with it a whole host of other benefits: To maintain a healthy and regular menstrual cycle - Ovulation is key to cycle regularity. Without it, cycles can become erratic or disappear altogether. Irregular menstrual cycles come with a whole host of unwanted symptoms. To produce the hormone progesterone in the luteal phase (the second half of your cycle) - If you don’t ovulate, you won't make Progesterone. This hormone is important for mood stability, sleep quality, and has a calming effect, reducing anxiety. It's important for inflammation control, pregnancy, and reduces heavy periods. We also need Progesterone to make Testosterone. Metabolic health - Ovulation and the associated hormonal fluctuations of oestrogen and progesterone support insulin sensitivity and regulate metabolism and appetite. Bone health - Both oestrogen and progesterone help protect against bone loss and support bone density.  Cardiovascular health - Ovulatory cycles are linked to better heart health, with women having a longer reproductive lifespan and regular ovulatory cycles having a reduced risk of heart disease. Brain health - The production of hormones like oestrogen and progesterone at ovulation also support mood, memory, and cognitive function. Libido - Ovulation usually boosts libido - your body’s way of encouraging reproduction, but also a sign of hormonal harmony. Why Tracking Ovulation Matters Understanding your menstrual cycle and knowing when you ovulate can help you avoid pregnancy or  pinpoint your fertile window when trying to conceive (TTC). But it’s important to track it the right way. Cycle tracking apps are popular, but most of them calculate ovulation based on the average menstrual cycle length. This method isn’t reliable because your ovulation can’t be confirmed just by knowing when your period starts. A Quick Overview of the Menstrual Cycle The menstrual cycle can be broken down into four main phases: Follicular Phase  – before ovulation Ovulatory Phase  – ovulation itself Luteal Phase  – after ovulation Menstrual Phase  – your period For this post, I’m going to focus on the follicular  and luteal  phases, since the other two are wrapped up within these. The Follicular Phase  The follicular phase begins on day one of your period  and lasts until ovulation. This phase is the final stage of follicular development, as these follicles have a much longer lifespan and take 100 days to mature in total.  During this time, your ovaries respond to a pituitary hormone called FSH (follicle-stimulating hormone)  by producing follicles - small fluid-filled sacs. As these follicles grow, one becomes dominant. This is the follicle that will release an egg during ovulation, and it also becomes the primary source of oestrogen (Estradiol)  production. Oestrogen is the queen bee  of hormones. When it’s produced at healthy levels it boosts serotonin and dopamine production, making you feel pretty fabulous. It thickens the uterine lining and stimulates the production of fertile cervical mucus . It also increases libido in the lead-up to ovulation. Clever, right? The dominant hormone at your most fertile time makes you feel sexier and  creates nature’s ultimate lube. Just before ovulation, oestrogen peaks. In the presence of rising levels of oestrogen, FSH triggers a surge in another pituitary hormone— LH (luteinizing hormone) . LH surges around 24–36 hours before ovulation , triggering the release of the egg. Once this happens, oestrogen drops, and you transition into the luteal phase . The length of your follicular phase can vary, lasting anything from 7 to 21 days.  The Luteal Phase After the egg is released, the leftover follicle on your ovary becomes a temporary structure called the corpus luteum . This glandular structure now starts producing progesterone . Progesterone brings a more calming vibe compared to oestrogen. You might feel less energetic, less social,  more inclined to slow down, and your appetite may increase. Sex drive takes a back seat, and your cervical mucus will shift, becoming thicker and less watery, maybe even disappearing altogether. Progesterone supports the uterine lining, making it nutrient-rich and ready to welcome a fertilised egg. It also plays a critical role in embryo implantation  and will continue to support early pregnancy until the placenta  takes over hormone production. If no fertilised egg implants, both oestrogen and progesterone levels will drop around 10–14 days after ovulation . This hormonal decline triggers the shedding of the uterine lining- aka your period. And then the whole cycle starts again. The Luteal phase should last from 10-14 days. If any longer than this, you may not have ovulated. If shorter, you may have still ovulated, but this will be classed as a short luteal phase and you won't make enough progesterone - this can impact fertility and also menstrual health.  Can I Still Have a Period If I Don’t Ovulate? Yes - but it's technically not a true period. What you may experience is a breakthrough bleed , where the endometrial lining sheds without ovulation. This is what's happening when taking the combined oral contraceptive pill (COCP) , as this prevents ovulation but still allows for a withdrawal bleed during the pill-free days. Why Might I Not Be Ovulating? Ovulation relies on a delicate hormonal balance. Disruptions to this system can be caused by: Stress Low or high body weight Blood sugar imbalances Inflammation or illness Disordered eating Medications Sleep disruption, shift work, or travel And of course, pregnancy These factors can delay or prevent ovulation altogether, especially if they're ongoing. How do I know when I am ovulating and which tests to use? A combination of methods is often most effective. Here are several ways to track your fertile window  and confirm if you're ovulating: 1. Ovulation Predictor Kits (OPKs) These test for a rise in luteinizing hormone (LH)  in urine, which peaks 24–36 hours before ovulation. However, they need to be timed well and are less reliable for women with PCOS , as LH may be persistently elevated. Tip:  Watch for fertile signs like cervical mucus before beginning OPK testing and then use these tests daily until you see a clear change of colour or smiley face (depending on the brand) on the test strip indicator confirming the day of ovulation. 2. Basal Body Temperature (BBT) Charting Your BBT  increases after ovulation due to a rise in progesterone . Using a BBT thermometer: Take your temperature first thing each morning (before moving or getting up). Track it daily from day 1 of your cycle . This is the first day of your period with full blood flow (spotting doesn't count). A temperature shift mid-cycle suggests ovulation has occurred. You should see a biphasic pattern with a rise in temperature of around 0.2C in the 3 days following ovulation. This rise in temperature should remain consistent for around 10 days. Note:  Illness, alcohol, or irregular sleep can affect readings. Apps or wearable devices can help automate the process. 3. Fertility Awareness Method (FAM) FAM combines BBT tracking  with cervical mucus observation  and sometimes cervical position checks . Fertile mucus  is clear, slippery, and egg-white-like - your body’s natural sign that ovulation is near. Cervical position may also rise and soften around ovulation. Fertile mucus is capable of keeping sperm in a prime position for up to 5 days. With this in mind, you are most fertile on the days leading up to ovulation, when this mucus is present, on the day of ovulation, and for 1-2 days following ovulation. This equates to around 6 days in total. When learned correctly and with practice, FAM is highly effective.   This method is not for everyone, as tracking your BBT can be stressful, particularly if you are TTC.  4. Hormone Blood Testing To confirm ovulation via blood work,  progesterone levels need to be tested  7 days after suspected ovulation  (Ovulation + 7). You will need to use a combination of the above methods to time this right.  For deeper insights, I always test FSH, LH, and oestrogen between days 2–3 of your cycle . This helps identify issues with the start of your cycle that could be impacting your ovulation.  In perimenopause or PCOS, hormone testing can be trickier - it's best to work with a fertility-awareness practitioner or fertility nutritionist  to support you with this.  Tip: Day 21 progesterone test - most GPs, when testing progesterone, will standardly do this on day 21 of your menstrual cycle. This is only accurate if you are having a textbook 28-day cycle and ovulating on day 14. As we know cycle length and time of ovulation can vary. 5. Follicle Monitoring Scans Ultrasound scans can confirm ovulation by visualising the developing and released follicle. This method is used in clinical settings - ideal during fertility treatment or when investigating irregular cycles , but not practical for monthly self-monitoring. What’s the Best Way to Track Ovulation? If budget allows, wearable digital devices that monitor temperature (like Oura Ring or Tempdrop ) offer convenient and accurate ovulation tracking. Otherwise, the best method is a combined approach : Observe cervical mucus to pinpoint your fertile window (remember this is around 6 days) Use OPKs  at the onset of your fertile window  (when fertile mucus is noticeable) to identify the day of ovulation. Confirm ovulation with BBT  and/or blood tests . Working with a practitioner to help you with it is generally needed in the early stages. If your cycles are irregular or absent , ovulation may be infrequent or missing. You should always consult with your GP if you are experiencing symptoms of anovulation in order to rule out any conditions that may require medical treatment. Also don't forget to consider a potential pregnancy. If you would like nutritional support with optimising your ovulation and your menstrual cycles please get in touch. References: Wang, Y.X., Arvizu, M., Rich-Edwards, J.W., Stuart, J.J., Manson, J.E., Missmer, S.A., Pan, A. and Chavarro, J.E., 2020.  Menstrual cycle regularity and length across the reproductive lifespan and risk of premature mortality: prospective cohort study. BMJ , 371, p.m3464. Available at:  https://pubmed.ncbi.nlm.nih.gov/32998909/  [Accessed 9 May 2025]. Briden, L., 2017.   Period Repair Manual: Natural Treatment for Better Hormones and Better Periods . 2nd ed. GreenPeak Publishing.​ Reed, B.G. and Carr, B.R., 2018.  The normal menstrual cycle and the control of ovulation. In: K.R. Feingold, S.F. Ahmed, B. Anawalt, et al., eds. Endotext  [online]. South Dartmouth (MA): MDText.com , Inc. Available at:  https://www.ncbi.nlm.nih.gov/books/NBK279054/  [Accessed 9 May 2025].​ Femometer, n.d. 5 Basic Things You Should Know about BBT Charting . [online] Femometer. Available at:  https://www.femometer.com/Blog/5-Basic-Things-You-Should-Know-about-BBT-Charting  [Accessed 9 May 2025].

OK, so let me set the scene: You and your partner have been trying to conceive for a while. Your GP has asked you to do a semen analysis. You follow through, and you’re told everything looks normal. Great news, right? Well, yes - but what does ‘normal’ actually mean? And does this test tell you everything you need to know? What Is a Semen Analysis or Sperm Test? A semen analysis is a test that evaluates the health and viability of a man's sperm. It's an important first step in assessing male fertility and can help identify potential issues that might affect conception. Some things to consider about the reference ranges in a semen analysis: Reference values may vary slightly between labs, but the values I've provided below are defined by the W.H.O. (2021), Sixth Edition of the W.H.O . Manual for Human Semen Analysis (a bit of a mouthful, sorry). For this post, I am referring to these values as ‘normal’ rather than healthy, let me explain why: These values represent the lowest acceptable range  for natural conception; anything below these ranges suggests that IVF/ICSI is indicated. The values in a semen analysis have been taken from the lowest 5th percentile of fertile men. These reference ranges show the cut-off for the levels that suggest you should be able to conceive naturally. Ideally, you would want to exceed these ‘normal’ values for optimal fertility. Understanding Your Semen Analysis If you've recently had a semen analysis, you might be staring at a page full of numbers and unfamiliar terms. What does it all mean? I’ll break down the key markers and help you understand their meaning. Key Markers in a Semen Analysis Marker Description Normal Reference Range Volume of Ejaculate Measures the amount of semen produced. > 1.4 ml pH Measures the acidity or alkalinity of the semen. 7.2 – 8.0 Sperm Concentration Measures the number of sperm per milliliter of semen. > 16 million/ml Total Sperm Number Total number of sperm in the entire ejaculate. > 39 million Motility Percentage of sperm that are moving. Total motility should be high, with a portion showing progressive (forward) movement. Total: > 42%; Progressive: > 30% Morphology Assesses the shape of the sperm. Indicates the percentage of sperm with a normal form. Does not assess quality or DNA damage. > 4% normal forms Agglutination and Aggregation Refers to sperm clumping. Presence may indicate inflammation, infection, or prior surgery, and can interfere with analysis of concentration and motility. Ideally none; presence may be clinically relevant Sperm Antibodies The presence of antibodies against sperm may impact fertility. Ideally undetectable Why These Markers Matter Each of these markers plays a role in the health and function of your sperm. Low sperm count (concentration) can reduce the number of sperm capable of reaching and fertilising an egg. In more severe cases, this may impact success even with Assisted Reproductive Technology (ART). Poor motility affects the sperm's ability to swim toward the egg. Natural conception relies on sperm moving efficiently through the female reproductive tract, so poor or sluggish movement can significantly reduce the chance of fertilisation. Abnormally low or high pH levels in semen can impact sperm survival and motility. While this may seem like a minor detail, pH imbalances can indicate underlying issues such as infection or inflammation. Poor morphology reflects how many sperm are structurally normal. While this doesn’t directly measure DNA quality, it can be a marker of how well sperm were produced and whether they’re functionally capable of reaching and fertilising an egg. Agglutination and aggregation , where sperm clump together, may result from infection, inflammation, or immune reactions, particularly when paired with the presence of sperm antibodies . These antibodies, often produced after infection, injury, or surgery, can impair motility and function. Semen pH and sperm antibodies are two markers that are often overlooked or dismissed in conventional medical assessments unless they’re significantly abnormal.  However, from a functional medicine standpoint, even subtle changes in pH or the presence of low-level antibodies can be clinically relevant. These findings may point toward underlying issues such as chronic infection, inflammation, or immune disregulation. In these cases, further investigation is warranted, such as blood tests to assess hormone profiles or a semen culture to rule out infection, especially if conception is proving difficult despite ‘normal’ semen parameters. Where Things Can Get Complicated Semen analysis on its own should not be relied on to rule out male factor infertility or suboptimal sperm quality. Your semen analysis results could all come back within the normal range, but as this doesn’t give the full picture, you could still have trouble conceiving. A key limitation of the semen analysis is how the results are often interpreted in clinical settings . There’s a common misconception, both among patients and sometimes even among clinicians that if a result is just above  the normal threshold, everything is fine. In reality, these reference ranges represent the lowest 5th percentile of fertile men . So if your results are sitting right on the edge or slightly above the cut-off, this does not necessarily mean your sperm are "super sperm", it just means you're not in the lowest-performing group. It’s a low bar, not an optimal one. For example, a sperm concentration of 17 million/ml technically meets the reference range, but it's only barely above the cut-off of 16 million/ml. In functional terms, this may still present challenges with natural conception, especially when paired with suboptimal motility or morphology. Medical assessments that overlook this nuance risk missing underlying issues that could delay or prevent pregnancy. Furthermore, semen analysis does not evaluate key aspects of sperm function, such as DNA integrity, oxidative stress levels, or the presence of subclinical inflammation or infection. These limitations mean that a “normal” semen analysis result does not rule out male factor infertility. A DNA fragmentation test, which assesses the integrity of your sperm’s DNA, is a reliable marker of sperm quality. This test gives further insight into your ability to conceive both naturally and via IVF/ICSI ( Agarwal et al., 2021 ). If a DNA fragmentation test shows a high level of DNA damage to the sperm, this may warrant further investigation with your GP or fertility consultant. Certain medical conditions, infections, injuries, nutrition, and lifestyle can all have an impact on the quality of your sperm. The Takeaway It's important to understand that male factor infertility could present as the sole factor, or as a contributing factor, in up to 50% of infertility cases . As such, we should be ensuring that male fertility is included as a standard part of the investigation process ( Krausz, 2015 ). A semen analysis is a good starting point, but it doesn’t provide all the information needed to assess male fertility health. You may need to test hormone levels to ensure adequate testicular function, assess the seminal microbiome or do a semen culture to identify potential infections, and measure specific nutrient levels required for sperm health. Optimal fertility requires optimal overall health!  Any health issues contributing to systemic inflammation will affect your sperm quality. Any improvements to your health in the lead-up to conception will not only be beneficial for your fertility but also the health of your future child. Disclaimer This blog post is for informational purposes only and should not be considered medical advice. Always consult with a healthcare professional for any health concerns or before making any decisions related to your health or treatment. Interpretation of these results should always be done in consultation with a healthcare professional or fertility clinician. References Agarwal, A., Tadros, N. N., & Sharma, R. (2021). Evaluation of sperm DNA damage by TUNEL assay and its correlation with sperm parameters and outcomes in infertile men. Basic and Clinical Andrology, 31 (1), 1–10. https://doi.org/10.1186/s12610-021-00117-1 Krausz, C. (2015). Male infertility: Pathogenesis and clinical diagnosis. Best Practice & Research Clinical Endocrinology & Metabolism, 29 (3), 271–285. https://doi.org/10.1016/j.beem.2014.08.002

Have you been referred for IVF without fully understanding why you are unable to conceive?  I understand; time is of the essence, and you don’t want to miss the window of opportunity, but what if there were a way you could improve your chances of conception before heading down the Assisted Reproductive Therapy (ART) route?  I’ve been working with couples to support their fertility health for the last seven years, meeting them at various stages of their journey. The majority come to me after having already gone through fertility treatment, sometimes multiple rounds, without success.  Almost every couple I see at this point has had clinical tests that merely scratch the surface. They've been given no reason as to why they are struggling to conceive and are often feeling very lost as to where to turn next.  What are the success rates of IVF?  Infertility affects around 1 in 7 couples in the UK. A significant number of these couples will either be referred for, or will choose to undergo Assisted Reproductive Therapy (ART). Thanks to advances in fertility treatment, success rates for IVF and ICSI are higher than ever before. However, the national average remains around 31%, with the highest pregnancy rates at 41%, seen in women aged 18 to 34. Source: HFEA How much does IVF Cost? Eligibility for NHS-funded fertility treatment is strict, and varies depending on your local Integrated Care Board (ICB), but age and body weight are often primary factors. The cost of private treatment also varies, typically starting at around £2,500 per cycle at the lower end of the scale, however, this doesn’t cover all your treatment. Additional medical investigations, medications, and consultations all need to be added, and depending on your clinic of choice, the total can end up being closer to £10,000. This is the kind of figure I often hear from clients in my clinic, and a primary reason as to why they are looking for alternative support. My IVF Story  Sophie Skardon, Nutritional and Herbal Therapist specialising in Reproductive health. My own experience with IVF was relatively straightforward. I was fortunate to have some inside knowledge, having qualified as a Nutritional Therapist two years prior, and was well-versed in research and preparation before undergoing any kind of medical procedure. My partner at the time had been previously diagnosed with suboptimal fertility and was upfront about the likelihood of needing medical assistance to conceive. We’d been in a relationship for six years, not actively trying to conceive but also not using contraception. It became clear that natural conception wasn’t happening, and we reached a point where we were ready to take it seriously. I wasn’t willing to begin fertility treatment without a dedicated preconception period for both of us. I had already been preparing my body for some time, and my partner agreed to a three-month detox. This included eliminating alcohol, adopting a supplement routine, and making major dietary changes. The results were remarkable. By the time of our egg collection, his sperm count had significantly improved, along with motility and morphology. So much so that ICSI was no longer required. Out of the eight eggs collected, four fertilised, and one developed into a viable blastocyst suitable for freezing. And guess what? We were successful! At my seven-week scan, a strong heartbeat was already visible and we went on to have a healthy little baby boy. I know how fortunate we were, and after working with many couples, I truly appreciate just how rare this outcome is.  "It was my own experience that lead to me where I am today and my passion for helping others on this journey" The Most Common Scenario My experience with fertility treatment is rarely a shared one, and this is partially because very few people know what goes into prepping their body for IVF; and why would they? Preconception advice is seldom given, and when it is, it’s generally lacking in depth.  By the time couples have come to me, they’ve often been through the wringer. They’ve spent 12–24 months trying to conceive, sometimes enduring multiple failed rounds of IVF. They’ve had minimal fertility investigations, are exhausted from endless hospital visits, and are emotionally drained by the heartbreak and financial strain. Does this sound familiar?  It shouldn’t have to be this way! IVF can be a powerful tool, but it shouldn’t be the first  step. If only every couple referred for fertility treatment were offered proper preconception care, comprehensive testing, and evidence-based guidance to optimise their health beforehand. Imagine how much time, energy and disappointment this could save! The basic concept of assisted reproductive technology (ART) is to bypass some of the hurdles to natural conception. This can be incredibly helpful for multiple reasons, but there are a many things IVF and ICSI can’t do. Before embarking on your first or next round of treatment, consider the following factors in order to maximise your chances to success.   These are the things I wish all couples knew before starting IVF IVF and ICSI treatment can control your cycle, collect multiple oocytes (eggs), and make life a whole lot easier for sperm to get to those eggs, but it can’t do the following:  Improve Egg Quality  - Egg quality is influenced by a number of factors; including age, hormones, lifestyle, stress, inflammation, and nutritional status. Some gynaecological conditions can also impact egg quality; PCOS and Endometriosis, for instance. It take 100 days for an egg to fully mature, this is a critical time for chromosomal development. Supporting your health during this time has been shown to positively impact egg quality. Sperm Quality  - IVF can't improve this and so optimising sperm parameters before treatment is essential. Spermatogenesis (sperm production) takes from 72-76 days, implementing positive nutrition and lifestyle changes during this time can enhance the quality of the genetic material within sperm cells and improve your chances of fertilisation and a successful pregnancy. Genetics  -  Genetic mutations or chromosomal abnormalities can affect fertility outcomes and miscarriage risk. These aren't commonly explored in standard IVF workups. In some cases this needs to be investigated. The Reproductive Microbiome  - A healthy vaginal, seminal and gut microbiome supports implantation and early pregnancy. Imbalances can contribute to inflammation or infection, which may impact sperm and egg quality and also increase the risk of miscarriage. IVF doesn’t help to address this. Nutrient Levels  – Fertility clinics very rarely test nutrient levels.  Folate, Vitamin D, Iron, and B12 are vital for egg and sperm health, ovulation, hormone balance, and embryo development. A simple blood test can identify nutrient deficiencies and give you an opportunity to fix this prior to pregnancy. Miscarriage Risk  – Fertility treatment can provide hormonal support to prevent this, but miscarriage is often multifactorial. Some of the things I have already mentioned, i.e, microbiome health, genetics, and sperm and egg quality, also need to be addressed to reduce the risk of miscarriage. Thyroid Health - Thyroid hormone imbalance and the presence of Thyroid Antibodies has been shown to affect pregnancy outcomes. A full thyroid panel should be included in a comprehensive blood test to rule this out. So what's the solution?  Get started on this journey well before IVF is even suggested. OK, so you might not get access to all the tests you want on the NHS unless you’ve been trying to conceive (TTC) for over 12 months, but you can still take matters into your own hands. If you’re not conceiving after 6 months of trying, I’d suggest working with a fertility adviser or fertility nutritionist who can help identify what might be getting in the way. Assessing your nutrient intake, addressing lifestyle and stress factors, and gaining insight into your cycle and ovulation patterns are all great starting points. Private testing is also an option. While sometimes costly, it can highlight areas that need support and, in some cases, lead to a fertility strategy that doesn’t involve medical treatment. Remember IVF can’t fix egg or sperm quality. That’s why it’s so important to optimise your health beforehand  to improve your chances of success. Reproductive health doesn’t exist in isolation; it's intricately linked to every system in your body. Focusing on your overall health in the four months prior to conception has been shown to positively influence egg and sperm quality, improve pregnancy outcomes, and even benefit your child’s health throughout their lifetime. Source: Fertility and Sterility, 2022 . 4 month is also the ideal window for addressing hormonal imbalances and supporting a healthy reproductive microbiome. You may still need medical intervention, but here’s the thing: whether you’re eligible for NHS treatment or paying privately, you’ll want to do everything you can to give yourself the best chance the first time around . If you’d like to find out more about how I can help you investigate your fertility and prime your body for a healthy pregnancy, please get in touch. Sophie Skardon, Registered Nutritional and Herbal Therapist specialising in reproductive health.