Also see fact sheets
on specific area(s) of interest
The fertile period
When is “day 1”?
How much menstrual bleeding is normal?
Irregular bleeding, when to seek help
Late ovulation
Late ovulation, luteal phase defect
Initiating an evaluation
Where to start?
Endometriosis?
When IVF
IUI or IVF
History of hypothyroidism & infertility
Family history
Exercise
Clomiphene
Infertility after abortion
Clomiphene challenge test
Cervical dysplasia
Increased prolactin, Parlodel
Thyroid replacement
Why measure FSH
Testing egg reserves
“Normal” FSH levels
PCOS & lifestyle
PCOS & ovarian drilling
Male infertility
Breastfeeding
PCOS, planning for the next pregnancy
Question: When is a woman most
fertile?
Comment: In a 28-day cycle the maximum
fertility is day 12-14. Ovulation that occurs later than day
16 had a less chance of establishing a pregnancy and a greater
chance of miscarriage. Intercourse is less successful after
ovulation has occurred. The time of ovulation can be better
predicted with the use of an ovulation predictor kit available
through pharmacies. Follow the instructions. Often this is
not necessary. If the menstrual cycle length is between 26-32
days, intercourse, 3 times during the fertile period, days
11-16, is all that is needed. If the cycle length is over
32 or less than 26 days it is possible that there is a problem
with ovulation and medical intervention may help. sst
Question: What is considered the first
day of a menstrual cycle? Mine always is
a few days of brown, before it turns red. Is it the first
day of brown or the first day of red? No body seems to have
an answer for this.
Comment: You are right. Nobody has the
answer for this and it is amazing how often the question is
asked. I once performed a study that examined hormonal levels
in relation to day of bleeding in the last days of the menstrual
cycle. There was little correlation. Some women bled when
the levels of estrogen were quite high and other waited until
they had fallen to very low levels. One way of calculating
day 1 is to start with the assumption that ovulation occurs
12-14 days before a period. Sometimes a basal body temperature
tracking can help in this calculation. The greatest problem
usually comes in knowing when to start fertility therapy.
Clinics vary in their definition of day 1. Some use the first
day of heavy bleeding. At my clinic we consider day 1 as the
first day of any spotting, but then if we give clomiphene,
we do not start before day 5. This really may be day 2, 3
or 4 for some. Often the day 1 will become more predictable
after therapy. sst
Question: My husband and I have recently
started trying to have a baby. I am concerned about infertility
because I have a history of ovarian cysts. I have never been
given a clear answer on whether this will be a problem in
trying to conceive. Also I have pretty short periods (4-5
days), and I was wondering if this meant anything.
Comment: There is a wide normal range.
We are much more concerned by long heavy menses than short
ones. We are usually more concerned about the length of time
between menses than the number of day of flow. Most women
t do not bleed for over 7 days, or have heavy flow for over
3-4 with several days of light flow or spotting. Very light
flow may indicate lack of ovulation. Very heavy or prolonged
flow may signal anatomic problems such as fibroids or polyps,
which are best evaluated by ultrasound scan Most causes of
abnormal bleeding in reproductive age women are hormonally
related. Most visits to gynecologists are concerned in changes
in menstruation. problems are seen as a change in pattern.
Ovarian cysts can be a sign the ovary is not working (ovulating)
properly. The first step is to determine whether ovulation
is occurring. Good first steps are basal body temperature
tracking and ovulation prediction kits. After this, it is
probably best to have a consultation with a fertility specialist.
Mild ovulatory defects are often easy to fix. sst
Question: How do I know if my periods
are “normal”? How abnormal or irregular must they
be before I see a doctor?
Comment: The average menstrual cycle
length is between 28 and 29 days. The statistical range of
normal is from 26-35 days. Variation outside these limits
is abnormal and may have health consequences. If periods are
very infrequent, a physician consultation is clearly needed
and a diagnosis warranted. For those desiring fertility, if
menses are over 35 or under 26 days, there is an excellent
chance that ovulation is not occurring. This does not means
that pregnancy cannot occur even with very erratic bleeding;
rather, the possibility of conception is much less and the
likelihood of miscarriage is increased. If periods are not
regular, basal body temperature charting or use of ovulation
detection kit (LH surge testing) is a waste of time and money.
It can be assumed that there is an ovarian disorder and intervention
warranted. If there is a desire for fertility, clomiphene
is usually first line treatment. If there are no immediate
plans for pregnancy, oral contraceptives are often the best
option. The non-contraceptive benefits of the "pill"
often far outweigh the side effects and risks. Still, there
is no single therapy that is right for all. Even if one therapy
seems theoretically to be a great choice, it may fail miserably.
The second option for regulation is the periodic use of a
progestin such as Provera (medroxyprogesterone acetate), Aygestin
(norethindrone) or progesterone. sst
Question: Any idea what is going on
here? I had fairly regular cycles of 32-34 days. I charted
temperature for one cycle just before starting to try conceiving
(IUI) and it looked picture perfect. I even had the small
temperature dip before ovulation. Then, the next cycle, when
I was going to try I had a 52-day cycle with no ovulation.
Then, this cycle, I am on day 23 with no ovulation so far
(am using OPKs and temperature) but I have had lots of clear
egg white cervical mucus for over 12 days so far. Any ideas?
Comment: The average cycle length is
28-29 days. The farther one deviates from the norm the greater
the likelihood of poor egg quality, lack of ovulation. Delayed
ovulation is also associated with an increased risk of miscarriage.
The rate of infertility is very high when cycles are over
35 days and I do not even recommend testing for ovulation,
just progressing with therapy. At 32-34 days you may be somewhat
borderline for normal ovarian function. Then too, there could
be other problems such as male and anatomic factors. Still
my first thought with the above scenario is that there is
an ovarian/ovulation problem. sst
Question: I have been using the basal
thermometer for temperature monitoring this cycle and have
discovered (along with charting all baby making encounters
for the past 5 months and cervical mucus) that I am not ovulating
until cycle day 19. However my period begins on day 27 or
28. Am I looking at a luteal phase defect and if I am, what
is my first choice of treatment? I am almost 38 and do not
want to just try for another year after trying for almost
6 now. Could the problem be in the first half of the cycle
if signs point to the fact that I am ovulating or is it more
likely that the problem is just too short of a luteal phase
and therefore implantation is unlikely?
Comment: I do not believe in the luteal
phase defect as such. I believe that most defects of the luteal
phase are in fact defects on the follicular phase. This may
seem to be splitting hairs, but it puts the emphasis back
on the developing follicle and egg and not the resulting corpus
luteum and progesterone production. Good luteal phases follow
good follicular phases. Conversely, if ovulation is delayed,
the luteal phase is often inadequate. Yes, I think that implantation
is less likely because I believe egg quality is decreased.
Depending on a more complete history, you might be a candidate
for clomiphene therapy. Hopefully it would promote a timelier
ovulation. The good news is that a late ovulation is better
than no ovulation and you might need just a little help to
push you over the top. sst
Question: I am a 27-year-old female
who has been trying for almost five years to conceive. When
we first tried, I got pregnant immediately. Unfortunately,
I miscarried after eight weeks. I had a D&C and then had
one shot of Depo-Provera thinking we would wait. After the
one shot we decided to try again. We tried consistently over
the years with no luck. As a result of the shot I did not
have a period for a year and a half. I was told this was normal
and one of the side effects. When I did begin my periods again
they came every 28 days like clockwork. Last year I had an
HSG that was normal. My partner does have two children of
his own, so we believe he is fine. We are both healthy, normal
weight, and limit alcohol and no smoking. Is this a reason
why we are not conceiving or did it have to do with the miscarriage,
D&C, or Provera? I would greatly appreciate any information
you could provide before we jump into any expensive tests
or treatments.
Comment: Your question encompasses the
entire field of infertility diagnosis and management and is
very difficult to answer briefly. I am not a big fan of Depo-Provera
for the reasons stated above. Most individuals with previously
normal ovarian function will resume normal menstruation within
the first six months after a single injection. The chance
that the D&C has caused adhesions in the uterus is slim,
but not impossible. We must look for a single cause that would
combine the miscarriage, prolonged time to resume menstruation
and your present infertility into a unified problem. This
is probably ovarian dysfunction and anovulation. In terms
of a general approach to infertility, I view investigation
and therapy in compartments: 1) ovulation/egg, 2) sperm, and
3) pelvic anatomy (tubes and uterus). The most common reason
not to conceive is disordered ovulation. Ovulation is suggested
with the clinical findings of cycle length not less than 26
or more than 35 days, mid-cycle pain and mucus changes. Ovulation
is further substantiated with and use of basal body temperature
tracking, ovulation detection kits, and blood tests for progesterone
7-8 days after ovulation. If ovulation is not occurring then
use of clomiphene citrate is probably in order. No more than
six cycles should ever be used and most pregnancies are achieved
in 4 or less. Before clomiphene is given an ultrasound scan
should be performed to make sure there are no easily identified
pelvic abnormalities. Many suggest monitoring follicular development
by mid-cycle vaginal ultrasound. In the initial stages of
an investigation a semen analysis should be performed. We
usually do this in conjunction with an insemination procedure
at the time of ovulation. If ovulation is occurring and the
semen parameters are normal, a laparoscopy and hysteroscopy
to evaluate pelvic anatomy is probably in order. The will
exclude problems such as scar tissue in the uterus and pelvis
as well as endometriosis. sst
Question: My husband and I have recently
started trying to have a baby. I am concerned about infertility
because I have a history of ovarian cysts. I have never been
given a clear answer on whether this will be a problem in
trying to conceive. Also I have pretty short periods (4-5
days), and I was wondering if this meant anything.
Comment: We are much more concerned
by long heavy menses than short ones. We are usually more
concerned about the length of time between menses than the
number of day of flow. Ovarian cysts can be a sign that the
ovary is not working (ovulating) properly. The first step
is to determine whether ovulation is occurring. Good first
steps are basal body temperature tracking and ovulation prediction
kits. After this, it is probably best to have a consultation
with a fertility specialist. Mild ovulatory defects are often
easy to fix. sst
Question: I have been trying to conceive
for two years now and recently I read an article about dysmenorrhea.
I feel that I have some signs of this, like painful periods
that bring me to tears. I also read that it can cause infertility.
How true is this? Should I discuss this with my doctor before
getting fertility tests done?
Comment: The two signs/symptoms of endometriosis
are pain and inability to conceive. You seem to have both.
Menses associated with changes in bowel pattern/intestinal
pain and/or painful intercourse are two more symptoms of endometriosis.
Individuals who have endometriosis often have family members
with endometriosis, have longer heavier menses with shorter
menstrual cycles and have not used oral contraceptives. About
30% of infertile women have endometriosis. Endometriosis may
be suspected by history, and further supported by pelvic exam
and/or ultrasound showing an endometriotic cyst. The diagnosis
can be made only by surgical evaluation. This is most often
at the time of a laparoscopy. A laparoscopy may be indicated
solely on the basis of pain. If a laparoscopy is performed,
I suggest choosing a surgeon experienced in the diagnosis
and treatment of endometriosis and one prepared to treat the
abnormal findings at the time of surgery. The vast majority
of the cases of endometriosis can be treated by laparoscopy.
A video or detailed photographic record should be made for
further reference. It is also useful to have a hysteroscopy
at the same time to exclude uterine problems as a cause of
infertility and pain. In women of childbearing age, I always
suggest the tubes should be tested to ensure that they are
open (chromotubation). Whether to have a laparoscopy in your
particular case requires a detailed discussion between yourself
and your physician. sst
Question: What type of treatment should
I be researching? Since January we have done 3 cycles of gonadotropins,
IUI and progesterone supplements. I had a positive hCG on
July 11th but had a miscarriage on July 17th. Now I want to
try IVF but my doctor thinks that since I got pregnant using
IUI that IVF is not the way for us to go. He wants to continue
with IUI but I'm not sure I want to. We were diagnosed with
sub-fertility. The quality of my eggs as well as that of my
husband’s sperm were not what they should be so we were
put on meds and sperm washing combined with IUI. I really
want to do what will give me better chances though. My doctor
doesn’t feel that IVF will give me better chances and
feels that instead it may be worse for me because the surgery
involved could cause more complications
Comments:
I believe there may be several reasons for your doctor's viewpoint.
First, he/she may believe that more gonadotropin/IUI therapy
is truly the best way for you to become pregnant. He/she may
believe that the success rate of IVF, for you, does not warrant
the cost of the IVF-ET procedures. Finally, he/she may not
have easy access to an IVF program. I usually advise no more
than 3 gonadotropin stimulation cycles. In cases of advanced
age, tubal disease, or combined male factor, we may proceed
to IVF after one or two gonadotropin cycles. IVF-ET is useful
for both diagnostic and therapeutic purposes. It is sometimes
better to proceed to this therapy that bypasses the largest
numbers of fertility barriers than to risk money, time, and
failure. In the final analysis, it is an economic and efficiency
issue. I consider your case to be somewhat on the borderline
on indications for IVF, at present. Easily, I could recommend
another cycle of ovarian stimulation. This is especially true,
if you are under age 35 and if the cost of the procedures
is reimbursed under your insurance plan. Again, your age and
the degree of semen abnormality are important. Because of
your recent pregnancy, your chances of eventual success are
better than if a pregnancy had not been established. sst
Question: What type of treatment should
I be researching? Since January we have done 3 cycles of gonadotropins,
IUI and progesterone supplements. I had a positive hCG on
July 11th but had a miscarriage on July 17th. Now I want to
try IVF but my doctor thinks that since I got pregnant using
IUI that IVF is not the way for us to go. He wants to continue
with IUI but I'm not sure I want to. We were diagnosed with
sub-fertility. The quality of my eggs as well as that of my
husband’s sperm were not what they should be so we were
put on meds and sperm washing combined with IUI. I really
want to do what will give me better chances though. My doctor
doesn’t feel that IVF will give me better chances and
feels that instead it may be worse for me because the surgery
involved could cause more complications
Comments:
I believe there may be several reasons for your doctor's viewpoint.
First, he/she may believe that more gonadotropin/IUI therapy
is truly the best way for you to become pregnant. He/she may
believe that the success rate of IVF, for you, does not warrant
the cost of the IVF-ET procedures. Finally, he/she may not
have easy access to an IVF program. I usually advise no more
than 3 gonadotropin stimulation cycles. In cases of advanced
age, tubal disease, or combined male factor, we may proceed
to IVF after one or two gonadotropin cycles. IVF-ET is useful
for both diagnostic and therapeutic purposes. It is sometimes
better to proceed to this therapy that bypasses the largest
numbers of fertility barriers than to risk money, time, and
failure. In the final analysis, it is an economic and efficiency
issue. I consider your case to be somewhat on the borderline
on indications for IVF, at present. Easily, I could recommend
another cycle of ovarian stimulation. This is especially true,
if you are under age 35 and if the cost of the procedures
is reimbursed under your insurance plan. Again, your age and
the degree of semen abnormality are important. Because of
your recent pregnancy, your chances of eventual success are
better than if a pregnancy had not been established. Don't
get discouraged! sst
Question: I am 25 years old. I had a
salpingo-oophorectomy at age 15 due to torsion of an ovarian
cyst. Now I have been trying to conceive for a year. Meanwhile,
I was diagnosed with borderline hypothyroidism and treated
with 50 micrograms Levoxyl. My TSH is normal now, but I am
still not pregnant. My periods are very regular, five days
in length every 28 days, and I ovulate regularly on day 14.
I am due on next cycle for a hysterosalpingogram. What could
be the cause of infertility in my case? Is it my one ovary?
Or hypothyroidism? Or what else? My husband's test results
were normal.
Comment: If the TSH is normal, periods
regular and temperature charts /ovulation detection kits suggest
ovulation, then there should be concern about anatomic factors.
There could be tubal blockage, which often is seen during
a hysterosalpingogram (HSG), or it may be due to scar tissue
from the previous surgery that may only be revealed by a laparoscopy.
sst
Question: I am 25 years old, 5ft.4in,
140lbs, and I consider myself healthy. I conceived my child
without fertility drugs, but it took over 4 years, and happened
after I gave up! Now I’m trying for #2 with no luck.
This time I am charting basal body temperature, cervical mucous,
using ovulation predictor kit, and Clomid. I am not ovulating
on 100 mg. I have no egg white cervical mucous. I have an
LH-surge but no temperature rise. My mother had trouble conceiving.
It took her 5 years for #1, 3yrs for #2. Then after that she
had one almost every year until there were 9 of us. It took
my two sisters 3 and 8 years to get pregnant and it took me
4. Why are we all infertile? Is this a coincidence? Or could
this be hereditary? My cousins do not seem to have problems
so what is wrong with us?
Comment: Sounds like it runs in the family.
Patterns of ovarian function are often hereditary and may
"come down" on either the mom’s or dad's side.
The most common type of ovulatory dysfunction is associated
with polycystic ovaries and is definitely family related.
You should try to learn more about PCOS, but you do not seem
to be the “classic” case. With your previous pregnancy
and family history think that problems with ovulation and/or
egg quality is much more likely than anatomical or structural
changes. I am assuming the your partner’s count satisfactory.
If clomiphene is not successful, you may need to progress
to injectable fertility drugs, or IVF. sst
Question: I am a 34 year old female
with 9 year old fraternal twins. We used Clomid and estrogen
therapy for one month to conceive the girls with continued
progesterone support until 8 weeks gestation. My husband and
I have now been on Clomid 50mg for three months with day 14-28
progesterone support. Our concern is that with this attempt
at pregnancy, I am doing exercise in the excess of 25-35 miles
of running per week. What are your thoughts on estrogen replacement
therapy in addition to clomiphene/progesterone therapy? .
My OB/Gyn doesn't seem concerned with the exercise factor,
but I am concerned that it may be hampering our efforts.
Comment: First, I don't believe that
additional estrogen therapy is of benefit in clomiphene therapy
and there is no scientific data to support its use. However,
I am a big believer in repeating what works and no harm is
being done with estrogen use. I would not start the progesterone
until after ovulation, maybe day 15-16. Its early use can
inhibit ovulation. While commonly used, even in my practice,
it has not been conclusively shown to be effective. Regarding
the exercise, an interesting presentation at an Endocrine
Society meeting showed that exercise itself did not alter
menstrual function but caloric intake did. Are you eating
enough to support normal ovarian function? I reduce all of
my infertility patients to fewer than 20 miles a week and
limit aggressive exercise. Your body is not smart enough to
distinguish your good health, from a situation that may have
occurred a thousand years ago as you were trying to cross
the desert running from hunger or attach, rather than for
pleasure. There is a belief that any body stress whether from
exams, work, or exercise can lead to ovulatory dysfunction
and infertility. sst
Question: I started infertility treatment
in April. I am 36 years old and have no children. In April,
my doctor prescribed Clomid (50 mg). I did Clomid for April
and May and in June my doctor increased the dose to 100 mg.
For the past two months I produced six mature follicles, but
the endometrial lining was too thin. This month, my doctor
prescribed gonadotropins and the lining definitely increased,
but I did not produce any follicles. I'm a little concerned
about this!
My doctor said that she is going to
increase the gonadotropins next month. This is my concern
- since with one dose I did not produce any follicles, why
would I produce any with an increased dose? The Clomid allowed
me to produce follicles and the gonadotropin increased my
lining - so my question is can a person take Clomid and gonadotropins
at the same time?
Comment: Use of clomiphene (Serophene,
Clomid) producers a much higher ovulation rate than pregnancy
rate. Clomiphene is an "anti-estrogen" and as such,
inhibits endometrial development and reduces cervical mucus
production. We always hope that the positive benefit of promoting
follicle development and ovulation is greater than the negative
effect on the uterus. While a good drug, it is not perfect.
Many patients with a poor response to clomiphene do better
with gonadotropin injections A few patients that have a good
response on clomiphene do poorly with gonadotropin injections.
In these special cases, I believe that the resultant follicles
or eggs may be abnormal or unhealthy - at least for that single
stimulation cycle. Patients that don't respond to higher doses
of gonadotropin stimulation (3 or 4 ampules nightly for 6-10
nights) have a particularly poor prognosis for fertility,
regardless of their response to clomiphene. Some patients,
especially older patients, or patients with reduced oocyte/follicle
stores, may respond equally well to either clomiphene or injections
of gonadotropins. In your case, it sounds like you were using
the minimal gonadotropin dose and it just wasn't enough. We
sometimes start with one ampule in patients that have had
good clomiphene response to avoid excessive ovarian stimulation
and the risk of multiple pregnancies. I agree with the present
plan of increased amount of gonadotropin. sst
Question: I had an abortion when I was
16, and I am now 24. I have been trying to get pregnant, but
can't. Could it be because of the abortion? I was not sure
how this would effect me. Please help me. Thank you very much.
Comment: It is very unlikely that the
abortion has caused you to be infertile. The risk of infertility
after abortion may be increased if there was a problem with
infection after the procedure. I first would look at whether
you are ovulating and have a semen analysis performed on your
husband.
There could be problems of tubal disease, or adhesions in
the uterus. After the easy stuff has been tried, it may be
reasonable to have a laparoscopy and hysteroscopy. Regardless,
at age 24 your chances should be really quite good for a pregnancy.
sst
Question: I got the news a couple of
days ago that I passed the Clomid challenge test. I was going
to have an IUI done yesterday but it was canceled due to the
fact that my lining was only 2. I had a failed IVF this past
spring. My reproductive endocrinologist is saying I have poor
egg reserve but tests continue to show I have good egg reserve.
How can you thicken your lining?
Comment: Clomiphene can have a very
negative effect on the uterine lining. It is thought that
is why the ovulation rate with clomiphene is much higher than
the pregnancy rate. It sounds as if you are receiving mixed
messages. If you "passed" the CCCT, that usually
indicates that you are a candidate for either IVF and/or gonadotropin
injections. The uterus is not usually one of the criteria
of the CCCT. If there was a marginal response to your last
IVF stimulation this may be a better predictor of ovarian
reserve than the CCCT. Sometimes it may be a subjective feeling
by your RE that your ovarian reserve is low. If your day 3
FSH is over 10 this single factor alone is a poor prognostic
factor. sst
Question: Can dysplasia affect your
fertility, especially after being treated with cryosurgery?
Comment: Generally cryosurgery will have
no effect on fertility. Deeper biopsy or destruction of the
glands of the cervical canal can affect fertility by destroying
the cervix's capacity to serve as a reservoir for sperm or
by altering mucus production. Routine par smears are essential.
sst
Question: I have a problem with infertility.
My prolactin tested high and my doctor advised Parlodel (5
mg daily). Last month the level was lower but still no pregnancy.
I want to know if there is any other testing or examination
that could be done? Could repeated infections be causing my
infertility? For the last 3 months I used Clomid (200 mg daily
for five days) and also last month I took gonadotropin injections.
Comment: Parlodel (bromocriptine) is
given to normalize the prolactin level. If the prolactin level
is only slightly elevated, maybe 2.5 mg is all that is needed.
Some prefer Dostinex™ (Cabergoline), which is a twice
weekly pill that sometimes has less side effects. It has the
same benefit as Parlodel. If the prolactin level is more than
slightly elevated, a MRI of the pituitary gland should be
performed to exclude a small benign tumor (adenoma) that produces
prolactin. It will sometimes take 6 months of having a normal
prolactin level before ovulation will start to occur. 200
mg of clomiphene is a very high dose. You should allow several
months for this to "wash out of the system” and
try at only 50 mg. I would suggest a consultation with a reproductive
endocrinologist if you are not already seeing one. More medicine
is not always better. sst
Question: had thyroid cancer at 16 and
this resulted in complete thyroidectomy and radioactive iodine
treatments. I am and have been taking medication to replace
the hormone since, but have been not very good at taking it
regularly. In fact, only for the past couple months have I
been good about it. Is this the most likely reason I have
not been able to get pregnant? Are the effects of hypothyroidism
permanent? I wrote to my specialist and he said not to worry.
I can't stop though, because after all, I am not getting pregnant.
Comment: It is very important for fertility
that you keep up on your thyroid medication. You should have
periodic testing of thyroid stimulating hormone (TSH), which
is an excellent marker of adequate replacement therapy. It
should be kept in the mid-normal range. Too low, or too high
and ovulation may become irregular. Too much thyroid replacement
can be more harmful than too little. Many people with low
thyroid hormone levels do not feel well. sst
Question: Why do I need a test for FSH?
Comment: Certainly, a baseline FSH determination
should be the initial step in the fertility evaluation of
all women over age 35 and should be considered in all patients
with “unexplained” infertility or re current pregnancy
loss. FSH can also be elevated at earlier ages if there has
been surgery on the ovaries, infections, endometriosis, or
other factors that damage the ovary. Measurement of FSH is
a useful marker of ovarian egg stores and how the ovary will
respond to stimulation with fertility agents. Higher FSH levels
seem not only to be indicative of diminishing egg number,
but also of poorer egg quality. sst
Question: What other tests besides FSH
can predict success in fertility treatment?
Comment: FSH levels are determined by
a blood test on cycle day 2-3. For the FSH measurement to
be valid, it should be accompanied by a measurement of estradiol.
In the natural cycle as the estradiol level rises, the FSH
level falls. Only measuring FSH may obtain a lower and falsely
reassuring FSH level. An estradiol level should be less than
50 pg/ml. Some have used an elevated estradiol level alone
on cycle day 2/3 as a marker of altered fertility potential.
Some centers use the FSH rise that occurs in response to clomiphene
(clomiphene challenge test, CCCT) to further evaluate egg
stores. AN exaggerated FSH response on cycle day 10 of over
twice the day 3 level usually suggests compromise egg reserves.
Some women, especially those over age 35 that have borderline
CCCTs still are reasonable fertile. Inhibin, a protein made
by the cells of the follicle wall, has been used as another
marker of follicle number. The inhibin test is relatively
expensive and it is uncertain whether it adds sufficient additional
information to justify its routine use. Useful information
also can be gained by measurement of ovarian volume by ultrasound
scan. The smaller the ovary the less successful ovarian stimulation
with fertility drugs is likely to be. All fertility drugs,
whether oral or injections, work by increasing FSH. If the
FSH is already high prior to starting these medications, success
is reduced. sst
Question: Could you please tell me what
the norm is for FSH levels? I have had levels of 9.2, 11.2,
9.6 and two results below 8. I am 29 years old.
Comment: Follicle stimulating hormone
(FSH) is one of the two gonadotropins (gonad = ovary, and
trop = make grow) produced by the pituitary gland. (The other
is luteinizing hormone (LH) associated with ovulation.) FSH
is aptly named because it does what it says; it stimulates
the follicles of the ovary to grow. The periodic increase
of FSH into the blood stream is the stimulus that causes follicles
to emerge from their resting stage and grow toward ovulation.
There is one egg per follicle. The maximum egg number occurs
about 4-5 months before birth when a decline begins and continues
relentlessly until after menopause when all the follicles
(eggs) have been depleted from the ovary. As follicles are
lost each month of each year, as the ovary ages, the body
works harder and harder to maintain normal follicle development
and ovulation; thus FSH rises. Think of it as the ovary growing
progressively hard of hearing and the pituitary gland speaking
louder to be heard. Therefore, rising FSH levels signify decreasing
stores of eggs.
Depending on the laboratory used by
your doctor, the above levels could be normal or slightly
elevated. It is impossible to give absolute guidelines for
FSH levels. They can vary considerably between labs and each
center will have its own experience with interpretation. There
is a remarkable consistency with all four levels reported
and more details of your history must be known for interpretation
of these results. Reproductive potential should still be good,
although if the FSH levels are elevated, this may be an indication
to be more aggressive with therapy. As a rule of thumb, fertility
potential is severely reduced with FSH levels above 20 IU/L.
Fertility is usually compromised at levels above 10 and there
is a decreases in ovarian responsiveness with levels as low
as 7. sst
Question: I was diagnosed with PCOS
6 years ago. My husband and I have been trying to get pregnant
naturally for the last 2 years. We are in our mid-twenties
and would like to get pregnant naturally if possible. My gynecologist
doesn't seem to want to help us. All she wants to do is load
me up with hormones. Could you give me any suggestions on
things we could do to get pregnant naturally?
Comment: There is excellent evidence
that lifestyle changes such as weight moderation, increased
physical activity and smoking cessation can have significant
impact on fertility. This said, you should avoid rapid weight
loss or aggressive physical activity that may put additional
stress on the system and worsen fertility. We aim for a 10%
reduction in body weight in our PCOS patients who are overweight
and suggest a lower carbohydrate diet. You also should be
using 1 mg of folic acid daily. Once you have done your best
on lifestyle, the next step would be to investigate the possibility
of insulin resistance using a glucose tolerance test and insulin
level. Metformin (Glucophage), while a potent drug for the
treatment of diabetes and certainly not effective in all cases
of PCOS, is not hormonal and does not increase the risk of
multiple births. Some women report that they feel better and
weight loss becomes easier while taking the drug. sst
Question: I was diagnosed with PCOS
and have undergone ovarian drilling. I have been ovulating
normally after the procedure, but have not been able to conceive.
My husband's seminal profile is normal.
Comment: The first question is, are
you sure that you're really ovulating? Regular cycles (28-32
days) are suggestive, but not conclusive proof of ovulation.
Overall the hormonal situation is improved as evidenced by
regular cycles, but maybe not quite "over the hump."
I would add use of an ovulation prediction kit, basal body
temperature chart and a progesterone test 7 days after you
think ovulation has occurred to fully document ovulation.
If ovulation has been clearly occurring by this group of tests
and if the pelvic anatomy was truly normal except for the
polycystic ovaries, I might then try clomiphene, possibly
with an insemination as an empiric trial. As discussed above,
you might also be checked for insulin resistance. A known
risk of ovarian drilling is the formation of adhesions (scar
tissue) around the ovaries and tubes. While this occurs much
less often and the adhesions are less severe compared with
the old ovarian wedge resection procedure, still they can
occur and reduce fertility. sst
Question: My husband has a very low
sperm count. Luckily, we were able to conceive naturally last
winter. Do you have any suggestions to increase our chances
of this happening again in the future? This pregnancy took
6 years to achieve even with two artificial insemination attempts.
Comment: If the problem is solely male
factor, great news! Treatment of male infertility is extremely
effective. I might suggest cycle tracking with basal body
temperature (BBT) and an ovulation prediction kit (OPK). Properly
timed intrauterine insemination (IUI) can also be of value,
both as a method of evaluating semen quality and providing
therapy. I suggest not more than 3 cycles , others say up
to six cycles of IUI. If the easier less expensive options
fail, chances of pregnancy after assisted reproduction-- in
vitro fertilization (IVF) with sperm injection (ICSI) should
be excellent. sst
Question: I am almost 37 and am currently
breastfeeding my 9-month-old daughter. There is a 6-year gap
between her and my middle child although my husband and I
did nothing to prevent conception. My first two children were
conceived very easily. I have not yet had a return of my menstrual
cycle. My husband and I are currently trying for our fourth
child and have been since my daughter was 2 months old. Is
there anything that can be done to induce ovulation in a breastfeeding
mother without weaning?
Comment: A lack of ovulation and poor
uterine lining can often accompany breastfeeding, at least
initially. Breastfeeding has been a very important mechanism
for our survival in the past. To be pregnant and breast feed
at the same time is internally perceived to be too taxing
on nutrient stores, therefore the body in its wisdom inhibits
ovulation. The evolutionary mechanism does not take into account
our capacity to go to the food market and buy the food that
our offspring and we need. Many will become pregnant in the
later stages of breastfeeding as the strength of the signals
to the brain and pituitary gland become less. I gave you this
long introduction instead of just saying no. Fertility drugs
will work during this time, but there are very few drugs proven
safe during breast-feeding. I guess progesterone could be
used for menstrual regulation. Check with you physician. Even
this natural hormone is secreted in breast milk, although
in probably inconsequential amounts. I suggest stop nursing
and ovulation may spontaneously return. sst
Question: I've got PCOS and now I'm
pregnant with my first child, with help from the medicine
"Clomid.” Do I have a chance to conceive without
help from medicine in the future?
Comment: Sometimes a second pregnancy
will follow the first without any additional help. It largely
depends on whether ovulation will more likely or more frequently
occur. You should not think that you are either infertile,
or that you might not need additional therapy. The fact that
you became pregnant after clomiphene suggests that your ovulatory
disturbance was not too severe. If you do not want to become
pregnant and have stopped breastfeeding, I usually suggest
oral contraceptives. Do not wait, but try to become pregnant
the first month off the pill. The miscarriage rate may be
slightly increased, but so is the pregnancy rate. Try to keep
weight down and exercise up. This will go a long way toward
improving fertility. sst
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