Author: Alan S. Berkeley, MD

All couples who want to have a child know that you can only conceive a child on the day of ovulation. Gynecologists say that ovulation occurs in the female body from about 12 to 16 days of the cycle. However, due to some reasons (stress, climate change, hormonal failures, etc.), ovulation may shift for several days, and occur at the beginning of the cycle, or at the end of the cycle. In addition, the time of follicle development may differ not only in several different women, but even in the same one — in different cycles. This is confirmed by the planning moms themselves, who determine ovulation by tests over several cycles. So how do you determine the right day for conception, how do ovulation tests work? Now we will talk about this in detail.

How ovulation tests work

Each menstrual cycle, a woman Matures one, two or more follicles in the ovaries. As the follicle Matures, female hormones called estrogens are produced in the cells of the follicle. The larger the follicle becomes, the more estrogen its cells produce. The high content of estrogen stimulates a sharp increase in the content of luteinizing hormone, which causes the egg to literally break through the ovarian wall within one to two days after a sharp rise in its level. When the level of these estrogens reaches a level that will be sufficient for ovulation, luteinizing hormone (abbreviated as LH) is released. A small amount of LH is always present in the urine, but 24-36 hours before ovulation (the release of an egg from the ovary), its concentration increases sharply.

To fertilize an egg, sperm must enter the female body at about the same time as the egg leaves the follicle. It may seem that this is easy to achieve, but we must remember that the egg after leaving the follicle lives for only 24 hours, and the sperm remain able to fertilize it for 3-4 days, less often a week. Thus, sex should occur at the appropriate time, i.e. at ovulation, if the couple is planning to conceive. Without tests, this can sometimes be difficult to achieve.

What day should I start testing?

This day depends on the duration of the menstrual cycle. The first day of the cycle is considered the day when menstruation began. Cycle length — the number of days that have passed from the first day of the last menstruation to the first day of the next. If you have a constant cycle, it is better to start doing tests 17 days before the start of the next menstruation. For example, if your normal cycle length is 34 days, then you should start testing from day 18.

If the normal length of your cycle is 28 days, then you should start testing on the 11th day. If your cycle duration is different, select the shortest cycle for the last 6 months and use its duration to calculate the day when to start testing. To start testing, it is not superfluous to visit an ultrasound, after which, after making sure that the follicle has reached 18-20 mm, you can start testing every day. For convenience, ovulation tests are not sold in a single version, but in the amount of 5, 7 or 10 pieces. For accurate results, it is better to use tests 2 times a day (morning and evening).

When is the best time to use an ovulation test?

The best time for testing is from 10 am to 8 PM, this is the time when LH is produced, so you should stick to this time of the test. At the same time, you should refrain from urinating for at least 3 hours before the test. Avoid excessive fluid intake before starting testing, as this may lead to a decrease in the concentration of LH in the urine and reduce the reliability of the result.

How to perform an ovulation test correctly?

If you are using a digital ovulation test, remove it from the packaging, remove the cap, and place the tip of the test strip in the device module, following the arrows. If everything is done correctly, you will hear a click, and a ready indicator will appear on the test.

It is not recommended to perform the test until it lights up. Collect the urine in a jar and immerse the absorbent end of the test in the urine for 15 seconds. Place the receiver on a flat, dry, clean horizontal surface. Wait 4-5 minutes. The ready symbol will start flashing on the device, and you can see the result on the display in a few minutes.

If you use a test strip, then you need to open the bag, get the strip and lower it into a pre-prepared container with urine. The test strip should be lowered for 10-20 seconds to the specified “Max” mark. Next, the test strip should be placed on a flat surface. The result should be evaluated at room temperature in 5 minutes, but not later than 10 minutes after the start of the procedure. The test strip is only used for one-time use.

Digital ovulation test results

To determine the exact result, compare the color intensity (lighter or darker) of the test strip with the control strip. The digital ovulation test is convenient for recognizing the result, which can be one of three and is indicated on the screen.

An empty circle indicates that there is no LH release yet, or its presence is insignificant and you need to continue monitoring the surge using tests.

Smiley-indicates the highest PH value. The cell is already on its way or about to be released. Sexual acts can be safely planned for this and the next day.

The results of the test strips for ovulation

First, it is important to determine which line on the test is the control line and which is the test line. The control card always appears, regardless of the presence of ovulation, it shows that the test is correct and the test was performed correctly. The test line (second) indicates the presence of LH in the urine.

Look at the test, if there is a second pale bar — the test is negative, the release of LH has not yet occurred, and testing needs to continue. If, after testing correctly for several days, you have not found the second bright stripe, then the cycle is anovulatory. There are several reasons for this: stressful situations, sudden climate change, the use of powerful medications, the postpartum period, breast-feeding, premenopause, active physical activity, etc.

A positive test is a bright stripe the same as the control one or even brighter. A positive test means that you will ovulate within 24-36 hours.

The most appropriate time for conception begins from the moment when You have determined that the release of LH has already occurred. In this case, the release of LH occurred on the 15th day of the cycle and if sexual intercourse occurs in the next two days, the chance of getting pregnant will be maximum. Once you have determined that the release of LH has already occurred, there is no need to continue testing, the tests will start to fade.

Today we publish the continuation of the article “Signs and symptoms of ovulation, feelings of a woman”, the first part can be read here

The feeling after ovulation

Some women, especially those who use the calendar method of pregnancy prevention, are interested in symptoms after ovulation. This is how women calculate “safe” days for unwanted pregnancies. These signs are very unusual and may coincide with the early symptoms of pregnancy:

Vaginal discharge

As soon as the egg is released from the main follicle and dies (its life span is 24, maximum 48 hours), the discharge from the genital tract also changes. Vaginal whites lose their transparency, become milky, possibly interspersed with small lumps, sticky and poorly drawn.

Pains

Within one to two days after ovulation, discomfort and minor pain in the lower abdomen disappear.

Libido

Gradually, sexual desire also fades, since now it makes no sense for spermatozoa to meet with an egg, it has already died.

Basal temperature

If the basal temperature is significantly higher than 37 degrees at the moment of rupture of the Graaf vesicle, then after ovulation it decreases by several tenths of a degree, although it remains above the 37 degree mark. This sign is unreliable, since even with conception, the basal temperature will be above the 37-degree mark. The only difference is that by the end of the second phase (before the start of menstruation), the temperature will drop to 37 degrees or lower.

Acne

On the eve and at the time of ovulation, hormonal changes occur in the body, which affects the condition of the skin of the face – acne appears. Once ovulation is complete, the rash gradually disappears.

Ultrasound data

Ultrasound allows you to identify the dominant follicle that has fallen due to the rupture, a small amount of fluid in the post-uterine space, and later the yellow body that is forming. Ultrasound data are most significant in the case of dynamic research (maturation of follicles, determination of the dominant follicle and its subsequent rupture).

Calendar method for determining ovulation

Ovulation is the release of a Mature egg from the ovary. The egg Matures during the menstrual cycle, which is necessary for the preparation of the uterus and the maturation of the egg, the result of which is ovulation. To determine ovulation using the calendar method, you need to know your menstrual cycle for the last few months. Knowing the cycle, you can calculate its length, i.e. the period from the beginning of one month to the beginning of the next. From the total duration of the cycle, 14 days are subtracted. So, if the cycle is 28 days, then subtracting 14 days, we get the 14th day of the cycle, in which the egg can be released from the ovary. For conception during the week before and after ovulation, the couple is recommended to have an active sexual life, preferably with breaks of 1-2 days, in order to have time to Mature the sperm. As already calculated above, the release of a Mature egg occurs somewhere in the middle of the menstrual cycle.

However, every woman may have ovulation shifts a few days later, this may be due to infectious pathologies of the reproductive system; excessive physical exertion; stress and hormonal disorders.

Among the causes of early ovulation, the following can be distinguished: disorders in the balance of estrogen and progesterone hormone; disorders in the adrenal cortex; colds and flu diseases, etc. Such factors may well trigger the onset of early ovulation. In addition, each cause can affect other systems of the female body. Therefore, to avoid this, it is recommended to avoid such factors that may affect ovulation and, as a result, the bearing of a child in the future. Premature ovulation is dangerous if it repeatedly occurs in the female body, in this case, the reasons lie in hormonal failures and other various abnormalities, a woman may need gynecological intervention. In addition, it is possible that pregnancy will not occur for a long time, if only the couple focuses on the middle of the cycle. Or, on the contrary, the onset of an unwanted pregnancy, if the woman is not protected at the beginning of the cycle, again using the calendar method. Over the course of a woman’s life, ovulatory shifts in different directions are periodically observed, so there may be a late release of the egg.

The reasons for late ovulation lie in the following: hormonal disorders in the body; lack of weight, because lack of adipose tissue negatively affects the production of estrogen, provoking a delay in maturation and exit of the female cell; taking emergency contraceptives in the past; gynecological pathologies, infections and lack of menstruation, are also characteristic companions of late egg release. To restore the cycle, a woman needs to undergo a full examination, after which appropriate treatment is prescribed.

After accurate compliance with all medical recommendations, ovulatory processes are normalized, the cycle is restored and a long-awaited pregnancy occurs.

Determination of ovulation by basal body temperature

Basal temperature measurements are performed in the morning, however, it is not advisable to get out of bed before measuring, so prepare a thermometer in the evening. To measure the temperature, you can use both a simple mercury thermometer and an electronic one. Carefully insert the thermometer into the rectum and hold it there for five to seven minutes. Record the measured temperature in the table every day, except for days when a woman has her period. After taking measurements throughout the cycle, you need to build a graph. To build a table, you can specify the days of temperature measurement on the top, and on the left, specify the possible BTT on these days. At the junction of the lines, put points that are connected by a straight line.

On days when there is a sharp increase in body temperature, after its rapid decrease, and ovulation occurs. This jump is explained by the fact that during ovulation, the hormone progesterone is actively produced, which affects the thermoregulation center in the brain. It is its increase that leads to fluctuations in BTT, which increases sharply after the release of a Mature egg. If you notice strong, atypical changes in temperature, or it does not change at all, you need to see a doctor to find the cause, which may be due to estrogen deficiency or other factors. It is easy to create a basal temperature chart using special applications that are placed on some women’s websites or in applications.

This method is available, but not 100% reliable, because there is not always time to measure the temperature, you can also just forget about the measurement, missed days can significantly change the picture and schedule of building the BTT

In addition, factors such as medication, sexual intercourse, climate change, stress, etc. can affect the usual and normal schedule for building BTT. Therefore, for greater confidence in determining day X, an ovulation test that is sold at any pharmacy can help.

For the early onset of pregnancy, it is important to know and be able to determine the days when ovulation occurs, since the conception of a child occurs on such days. This article will describe how to determine the onset of ovulation.

Ovulation is the process of leaving a Mature and fertilized egg from the ovary. The menstrual cycle of a woman is so arranged that in its first phase there is maturation of follicles and eggs in them (normally it is one or two eggs), which at the time of ovulation come out and are ready for fertilization. With the help of the fallopian tube, they enter the uterine cavity, where they merge with the spermatozoa. If this does not happen, then the egg dies, and the second phase of the cycle will help to remove it and prepare the uterine cavity and endometrium for the next attempt.

For the early onset of pregnancy, it is important to know and be able to determine the days when ovulation occurs, since the conception of a child occurs on such days.

The egg Matures during the menstrual cycle, which is necessary for the preparation of the uterus and the maturation of the egg, the result of which is ovulation. To determine ovulation using the calendar method, you need to know your menstrual cycle for the last few months. Knowing the cycle, you can calculate its length, i.e. the interval from the beginning of one month to the beginning of the next.

14 days are subtracted from the total duration of the cycle. So, if the cycle is 28 days, then taking away 14 days, we get 14 days of the cycle, in which the egg can exit the ovary. For conception within a week before ovulation and after it, the couple is recommended to have an active sexual life, preferably with breaks of 1-2 days, in order to have time to Mature the spermatozoa. As already calculated above, the release of a Mature egg occurs somewhere in the middle of the menstrual cycle.

Ovulation is the only day when you can get pregnant, without it, the onset of pregnancy is impossible. This is a very fast phase, which ends immediately after the release of a Mature egg from the follicle.

The ovulation cycle is usually divided into several periods: preovulation, ovulation itself, and postovulation. Nature created man so that he could have at least a day to conceive before or after ovulation. Why so? all because if the onset of pregnancy was possible only during ovulation, then there would be much more problems with infertility, and thanks to some life of the egg after ovulation, this period increases, which makes it possible for couples to fertilize and reproduce. In all women who are of reproductive age, there is a fertile period, which implies the time of pregnancy. This time falls on the ovulation itself and 3 days before and 2 days after it. This period is associated with the life of a sperm that lives in a woman’s body for up to five days.

Ovulation in women of childbearing age occurs periodically (every 21-35 days). The frequency of ovulation is regulated by neurohumoral mechanisms, mainly gonadotropins of the anterior pituitary and ovarian follicular hormone. Ovulation is facilitated by the accumulation of follicular fluid and thinning of ovarian tissue located above the protruding pole of the follicle. The constant ovulation rhythm for each woman undergoes changes within 3 months after abortion, within a year after delivery, and after 40 years, when the body is preparing for the pre-menopausal period. Ovulation stops with the onset of pregnancy and after the extinction of menstrual function. Setting the ovulation period is important when choosing the most effective time for fertilization, artificial insemination, and in vitro fertilization.

Signs of ovulation

To determine the day of ovulation, knowledge of its signs will help, for which it is necessary to treat your body with great attention. Of course, ovulation can not always be suspected, because its manifestations are very subjective and sometimes go unnoticed by a woman. But the changes in the hormonal background that occur every month allow you to “calculate” and remember the sensations during ovulation and compare them with the new ones.

Subjective signs

The subjective signs of ovulation are those that a woman feels and only she can tell about. Another name for subjective signs is sensations:

Abdominal pains

One of the first signs of ovulation is considered to be pain in the lower abdomen. On the eve of the rupture of the follicle, a woman may feel, but not necessarily, a slight tingling in the lower abdomen, often on the right or left. This indicates a maximally enlarged and strained dominant follicle that is about to burst. After its rupture, a small wound of several millimeters remains on the ovary shell, which also bothers the woman. This is manifested by minor aching or pulling pains or discomfort in the lower abdomen. Such sensations disappear after a couple of days, but if the pain has not passed or is so acute that it violates the usual lifestyle, you should consult a doctor (ovarian apoplexy is possible).

Mammary glands

There may be soreness or hypersensitivity in the mammary glands, which is associated with hormonal restructuring. FSH production stops and LH synthesis begins, which is reflected in the breast. It is swollen and rough and becomes very sensitive to touch.

Libido

Another characteristic subjective sign of approaching and coming ovulation is an increase in libido (sexual desire), which is also due to hormonal changes. It is so predetermined by nature that it ensures the continuation of the genus – once the egg is ready for fertilization, it means that you need to strengthen your sexual desire to increase the probability of sexual contact and subsequent pregnancy.

Aggravation of sensations

On the eve and during ovulation, a woman notes an aggravation of all sensations (increased sensitivity to odors, changes in color perception and taste), which is also explained by hormonal changes. Emotional lability and sudden mood changes (from irritability to fun, from tears to laughter) are not excluded.

Objective sign

Cervix uteri

During the gynecological examination in the ovulatory phase, the doctor may note that the cervix has softened somewhat, the cervical canal has opened slightly, and the neck itself has lifted up.

Oedemata

Swelling of the limbs, most often the legs, indicates a change in the production of FSH to the production of LH and is visible not only to the woman herself, but also to her relatives and the doctor.

Excreta

When ovulation changes its character and vaginal discharge. If in the first phase of the cycle a woman does not notice spots on her underwear, which is associated with a thick plug that clogs the cervical canal and prevents infectious agents from entering the uterine cavity, then in the ovulatory stage, the discharge changes. The mucus in the cervical canal is liquefied and becomes viscous and viscous, which is necessary to facilitate the penetration of spermatozoa into the uterine cavity. In appearance, the neck mucus resembles egg white, stretches up to 7-10 cm and leaves noticeable spots on the underwear.

Basal temperature

This symptom can only be detected by a woman who regularly keeps a schedule of basal temperature. On the eve of ovulation, there is a slight (0.1-0.2 degrees) decrease in temperature, and during the rupture of the follicle and after the temperature rises and remains above 37 degrees.

What does ovulation feel like?

What does a woman feel during ovulation? Every woman who carefully monitors her female health can clearly tell the time when ovulation is approaching and when it occurs. Among the signs that indicate the approach of ovulation, highlight the nature of the discharge – they become thick, abundant and transparent. Additional symptoms include:

• discomfort in the lower abdomen
• breast swelling, mild soreness
• an increase in basal temperature, if its schedule is determined by a woman
• sexual desire reaches its maximum

Fortunately, the severity of clinical symptoms of ovulation in most women is so minimal that they do not attach importance to them. Others also note during this period of pain in the lower abdomen on one side, which indicates which ovary ovulated, heaviness in the lower back, which independently disappear after a short period of time. And only a small percentage of women note a pronounced pain symptom that forces them to seek medical help.

We have discussed how to determine ovulation by feeling a little, but it is important to remember that not all women observe such symptoms and this does not allow us to talk about the lack of ovulation in them, because their pain threshold is so high that they level these feelings. You can reliably confirm the presence of ovulation only by measuring basal temperature, conducting ovulation tests, or using ultrasound, which determines the observation of the growth of follicles and the exit from the dominant egg, as well as a sharp change in vaginal secretions allows you to judge the onset or approach of ovulation.

The duration of ovulation

Every woman who plans to give birth to a child should know how many days ovulation lasts in women and by what methods it can be calculated. Ovulation itself involves the release of an egg, ready for fertilization, from the dominant follicle, which breaks under the influence of hormones and in its place a yellow body is formed.

How many days is ovulation in women and how to determine it? All women are interested in this issue at the stage of pregnancy planning, especially if the process of fertilization does not occur for a long time. Everyone knows that pregnancy requires ovulation, and the time of its onset falls in the middle of the menstrual cycle. But, unfortunately, not every woman has a regular menstrual cycle, which allows you to determine its time of onset. Almost every woman who is of reproductive age can become pregnant in the middle of the menstrual cycle for several days. To calculate the time of ovulation you need to use several methods:

• the standard method is that after two weeks from the first day of menstruation, the probability of ovulation increases, but this is not for everyone. This method works if the menstrual cycle lasts 28 days. If the cycle is longer, then the onset of ovulation occurs later.
• measurement of basal temperature from the first day of the cycle in compliance with all the requirements, because during ovulation in the body there is a hormonal adjustment, which is characterized by an increase in temperature on the graph and indirectly indicates ovulation. This method can be judged after several months of observation. The onset of the upcoming ovulation can be judged by a sharp decrease in temperature due to hormonal imbalance and its subsequent increase above 37 degrees
• ovulatory tests make it possible to study ovulation for several days, which is very important when planning a pregnancy

Ovulation lasts on average from 16 to 32 hours, but this is the time of the fertile window, that is, the time when it is possible to fertilize the egg and the onset of pregnancy. The release of a Mature egg itself lasts from a few minutes to a dozen minutes, which was noticed during IVF.

To determine how long ovulation lasts in women, you can use its characteristic signs: increased libido, swelling and swelling of the mammary glands, discomfort in the lower abdomen and lower back, more on the one hand, abundant mucous discharge, sometimes with streaks of blood.

How long ovulation takes depends on the lifetime of the germ cells. A Mature egg that has emerged from the follicle can be fertilized within one or two days, which is always individual. Therefore, if a woman has symptoms of ovulation on one day, then the next two days may also be the onset of ovulation, as well as sexual intercourse three days before it often leads to the onset of pregnancy, because the sperm lives about three days.

How many days is ovulation — each woman can determine by clinical symptoms, and if the vaginal discharge disappears or becomes too thick, pain and swelling of the mammary glands disappear, then we can say that it has passed, and the probability of pregnancy is not.

The period of ovulation in women can fluctuate with inflammatory processes in the reproductive system, with eating disorders, significant physical and mental loads, with severe stress and nervous shocks, with a sharp change in climatic conditions of residence, as well as with active sexual life.

Do not forget that the body can have both early ovulation and late ovulation. Early ovulation is characterized by its early onset and is associated with frequent sexual acts, significant physical activity, strict diets, as well as the presence of diseases that can affect the hormonal background of a woman. Sometimes ovulation comes late, which can also be determined using the tests and techniques that we discussed a little earlier. Due to the presence of ovulation and the regularity of the menstrual cycle, it is possible to indirectly judge a woman’s reproductive age, her probability of pregnancy and gestation. Many women, knowing when they are ovulating, plan a pregnancy or carefully protect themselves from it. The absence of ovulation for 2 or 3 cycles indicates a violation of reproductive health and requires medical attention to correct the hormonal background.

To be continued…

Increasingly, women are turning to a gynecologist with problems with conception. But medicine does not stand still, it is constantly developing, so the desired pregnancy can occur after treatment with special drugs that stimulate ovulation.

Reasons for lack of ovulation

Most often, the inability to get pregnant is associated with the lack of ovulation as such or with its incorrect course. There may be several reasons for this:

• Diseases of the pelvic organs of an infectious and inflammatory nature (chronic salpingoophoritis, polycystic ovaries, cysts, etc.).
• Too small a woman’s weight is usually less than 48 kg, in which there is insufficient production of sex hormones, which leads to a lack of ovulation and amenorrhea.
• Hormonal changes in the body against the background of stress, excessive weight (when the body mass index is more than 25), certain diseases of the thyroid gland (Hypo – or hyperthyroidism), etc.
• Long-term use of oral contraceptives. In this case, the body stops producing hormones on its own, and it sometimes takes several months to fully restore this ability.
• Excessive physical activity can also negatively affect ovulation, especially if it is associated with taking synthetic sports nutrition supplements. These drugs have a very negative effect on the female reproductive system.

In what cases do I need stimulation and when it is not carried out

Ovulation stimulation is possible when a couple cannot conceive a child for a year. If the age of a woman is 35+, this period can be reduced to six months. In any case, a thorough diagnosis (preferably of both partners) is necessary to identify the true causes of infertility and make a decision about stimulation. In particular, the following diagnostic tests are carried out:

• Collection of the patient’s medical history, which takes into account her age, the presence/absence of abortions and pregnancies, miscarriages, chronic diseases, carrying an intrauterine device, etc.
• The patency of the fallopian tubes is checked. Non-operative and operative methods are used for this purpose. The first include metrosalpingography (x-ray examination). A variation is ultrasonic metrosalpingography, when using a contrast agent and ultrasound equipment to check the patency of pipes. These methods are not universal and have their disadvantages, such as the harmfulness of radiation and possible errors in the result. For more accurate diagnostics, laparoscopy is used-an operative study, but it gives the most reliable results.
• The usual ultrasound examination, which can show possible inflammatory processes, polycystic, various neoplasms and other pathologies of the female reproductive system.
• In some cases, ovulatory failures may occur due to hormonal disorders, so it is mandatory to donate blood to determine the amount of female sex hormones. At the same time, it is recommended to conduct research on the activity of the thyroid gland, since this organ has a direct impact on female fertility.
• The partner’s spermogram should also be performed, since sometimes the reason for the absence of pregnancy can be insufficient mobility and viability of spermatozoa.
• Test the compatibility of the partners. If the results are unfavorable, the doctor may suggest artificial insemination.

It should be noted that contraindications to stimulation are inflammatory diseases of the uterus and (or) ovaries, tubes, adjacent organs and systems (urinary tract, gastrointestinal tract), hormonal fluctuations, the onset of menopause or pre-climatic period.

After diagnostic measures and in the absence of absolute contraindications, the gynecologist decides to prescribe drugs that stimulate ovulation.

Methods of ovulation stimulation

Ovulation stimulation is impossible without taking vitamin complexes and useful trace elements. True female” vitamins include E, A, B (folic acid is required), and C. additionally, vitamin D is recommended, especially for women living in areas where Sunny days are rare.

Vitamin A helps follicle maturation and regulates the amount of cervical fluid. B vitamins are recommended to be taken both at the planning stage of pregnancy and during it, as they not only prolong the luteal phase of the cycle, promote endometrial growth and egg maturation, but also during pregnancy eliminate toxicosis, prevent miscarriages and help healthy fetal development. Vitamin E stimulates the maturation of the yellow body, “supports” ovulation itself and increases the production of progesterone, which is especially useful when this hormone is insufficient. Vitamin C helps normalize the hormonal background, and also serves as a means to prevent the development of DNA abnormalities in the future fetus. Also, when preparing for pregnancy, it is advisable to monitor the sufficient intake of polyunsaturated omega-3 fatty acids in the body. They are most concentrated in oily fish, synthetic fish oil, and Flaxseed and olive oils. Drugs containing selenium, zinc, and iron are also used to stimulate ovulation.

All these methods of restoring ovulatory function are effective. However, you can’t use them at random. A doctor’s consultation is necessary, as well as an extensive and comprehensive diagnosis of both partners.