Homepage How your menstrual cycle reflects your egg quality
Category: DiagnosesJune 29, 2008 6:45 pm
As you may know, there is no one perfect test for egg quality. So, we look at a host of different variables. One of the most helpful is your menstrual cycle.
Each menstrual cycle is governed by the growth of a single egg. This is how it works: over the course of 10-14 days the egg will grow from immaturity within an antral follicle, and turn into a large, hopefully-soon-to-be-fertilized, mature egg in its dominant follicle. Both the egg and the follicle have to be functioning properly for the cycle to go well.
The dominant follicle makes estrogen, and once you ovulate, progesterone. Estrogen and progesterone together govern the activity of your uterus, which you experience as your menstrual cycle
If you have a healthy egg, you have a healthy follicle, and you expect a healthy menstrual cycle.
This means the reverse is true too: when we think that your menstrual cycle is going well, we strongly suspect that you must be making healthy, high quality eggs.
Here are the factors that we look at when deciding if a given menstrual cycle is going well.
Menstrual Cycle History
Day of ovulation
Ideally ovulation will occur days 11 or 12. Delayed ovulation -day 13 or later- is not a sign of egg quality concerns; in fact, it is more commonly a sign of an excess ovarian reserve, generally a good thing. But early ovulation -days 8,9, or 10 of the cycle- implies lower quality eggs.
Premenstrual Spotting
Once the egg is released, the leftover follicle (now called a corpus luteal cyst) makes progesterone. Progesterone stabilizes the lining of the uterus.
A low-quality follicle is less likely to be associated with enough progesterone, and therefore the woman may notice a shorter luteal phase, and/or premenstrual spotting.
Cycle Length
Long cycles are ok, but short cycles are not. If previously-28-day-cycles are now 26 days, it suggests egg quality is failing. Cycles are shorter because of the early ovulation and shortened luteal phases described above.
Menstrual Cycle Lab Values
Peak Estrogen
Just as the woman is about to ovulate, estrogen will be at its maximum level. Estrogen effects may be noticed as spinnbarkeit. We can also measure estrogen levels through blood tests; peak estradiol is between 500 and 1000 pmol/litre per healthy follicle. When cycle monitoring, ask your clinical team what your peak estrogen was: bigger numbers are better. If the level is towards 500 (or lower) per mature follicle, then egg quality may be a concern.
Peak Progesterone
Progesterone is made by a healthy corpus luteal cyst. Peak progesterone values, traditionally measured on “day 21″ of your cycle (but more accurately recorded 7 days after ovulation) is usually 30 ng/ml or higher for a fertile cycle.
Summary
I can write to all this in greater detail if you are interested; the relationships between eggs, follicles, hormones, and the menstrual cycle is complicated but fascinating. (Well, fascinating if you are a Reproductive Endocrinologist…)
But the important part is that, because of these inter-relationships, we can help you to maximize the likelihood of releasing a good egg in the next cycle by manipulating hormones in this cycle. It is called estrogen priming, and will be the subject of another post.
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Andrea
Is late ovulation problematic (Day 20-22) in your opinion and is it related to lower progesterone levels?
TGH replies:
Andrea, late ovulation is generally thought to be not problematic at all.
It can make timing of intercourse (or inseminations) difficult of course, but the eggs released have equal chance of being good quality as a woman who ovulates on days 11 or 12. Late ovulation is usually associated with a high antral follicle count ie a good ovarian reserve.
For an accurate reading of progesterone levels, you would ask for a measurement 7 days after ovulation ie in your case, about day 28. If you measure on day 21, it might be a bit early, and then, yes, progesterone could look low.
najia nadeem
What kind of food and vitamins is good to increase the amount of progestrone.
TGH replies:
Najia,
One study suggests that Vitamin C 500-1000mg/d helps to boost the efficacy of your natural progesterone.
You can take Vitamin C throughout your cycle.
s
I had a consistent 28 day cycle until after a failed IVF attempt earilier this year. My typical cycle is now 22 days.
Initially, I was not an IVF patient because of a fertility issues, only because I need to have PGD to avoid passing on a genetic disorder. Now I’m being told that I am a poor responder.
Is it possible that the drugs used in the IVF protocol have caused this to occur? It seems to be a rather big coincidence that my cycle changed so dramatically right after the IVF attempt.
Thank you for your time.
TGH replies:
S,
Our current understanding is that fertility medications “rescue” only the eggs available that month.
We don’t think that the stimulating medications take away your future eggs…just like we don’t think the birth control pill, which prevents ovulation, protects your future eggs.
I’m not able to answer the underlying question of why shortening cycles may be happening to you; I would need a proper consultation to be able to offer a useful opinion.
I hope that you can find resolution to your concerns.
PB
You mentioned previous cycles being 28 days and then decreasing to 26. …..If my cycle have always been 26 days long and very regular, does that indicate that I have always had poor egg quality?
TGH replies:
PB, You asked if cycles were always 26 days, does that mean there is a problem? I would suggest that no, there is not necessarily a problem at all. Cycle length is only one of the variables we consider.
MC
I have been trying unsuccessfully to conceive since October 2006. I went to my doctor and she recommend the FSH… I did and she said it is normal. I am 29 yrs… 1 live birth in ( C- Section)2 abortions- 1 in 96 amd the other in 2000.
What other test can be recommended. Doc sd this is normal and time(age is on my side).
TGH replies:
MC,
I won’t be able to answer your worries in this forum. But you mention that you are 29y old. You are right: you really should have an excellent chance at pregnancy…and it shouldn’t be taking very long for it to happen.
I would suggest that both you and your partner get a full check. After all, most fertile couples achieve an ongoing pregnancy within 3-6 months. Yes it can take longer sometimes, but 2 years is too long.
Marie
I was told after an ultrasound that the size of my corpus luteum was very small (1.1mm) and that it was indicative of poor egg quality (should be at least 2 mm). Is that true?
TGH replies:
Marie,
The corpus luteum (CL)is the cyst seen on the ovary after ovulation. It is a normal and expected finding.
Yes, the CL can be an indirect measurement of egg quality, but we gauge that by serum progesterone levels (blood test), not by size on ultrasound. A normal luteal progesterone can be as low as 15, but is usually 30 ng/ml or more.
Hope that helps
SM
Dr. Hannam, I’m 31 with unexplained infertility. I’m currently in the midst of IVF round 2 but not overly impressed with my current clinic unfortunately. On-line, I’ve heard great things about your clinic. Your reputation is growing and If this IVF fails, I may seek your consulting.
I have a question. On my last IVF, I made 20 eggs, 15 were mature, 8 fertilized, 6 made it to day 3, no blast, so zero frozen. However, I did have 2 grade A, 8 cells transfered on day 3… negative. Do you think that because none made it to blast, that I could potentially have an egg quality problem? I have 31 day clockwork cycles, I’m physically healthy otherwise, no history of infertility in my family at all, been trying for almost 4 years and one chemical miscarriage this year from a natural pregnancy. My lining only ever reaches 8-9 on an IVF cycle but still acceptable, and my husband’s sperm is great with and not fragmented. 3 REs puzzled after a series of tests…including my current RE. I feel like hit and miss, X factor and really wish someone could give us an answer. Do you think you could?
TGH replies:
Dear SM,
A second opinion is very reasonable.
I don’t need to tell you that unexplained infertility is one of the most stressful ‘diagnoses’ we provide. How to proceed when all tests are normal, but the ongoing pregnancy won’t happen?
IVF often provides the greatest success rates in such circumstances.
However you have tried IVF twice already, and you are right: you should have a greater number of embryos reaching blastocyst by day 5 (though I would not jump to ‘egg quality’ as the only reason that it may not be happening…stimulation, sperm, and laboraotry factors all contribute).
A second opinion will be most helpful to you when we can review documents from previous experiences. Often, clinics will copy the stimulation sheets but neglect the embryo reports –make sure you have both.
Daniela
If you do an ultrasound after ovulation and you don’t see too many follicles is that a sign of poor ovarian reserve? Should you only measure follicles on the 3rd day of the menstrual cycle?
TGH replies:
Daniela,
An ‘antral follicle count’ is usually the most accurate near the beginning of a cycle, when no cysts should be present. Midcycle, with a follicle or corpus luteal cyst present, the underlying ovarian structure can be more difficult to see and the count may be less accurate.
Antral follicle counts are technician dependent: this means that it matters who does the scan, and how well they are able to see the ovaries. More on ovarian reserve tests here.
Jen
Hi,
I just got a progesterone level of 6.5 7 days after ovulation. I’m 30 years old, have 28-32 day cycles and typically ovulate on days 16-18. My luteal phase is anywhere from 10-12 days.
I am doing IUI with frozen sperm and it is costing a fortune so I’m trying to get this right as soon as possible. Would you recommend any more tests? That is, do you think anything else could be off?
Thanks for your help.
TGH replies:
Jen,
The lowest-normal peak luteal progesterone level -measured about 7 days after ovulation- is 15 ng/ml, but many women are in the 30-50 range. So 6.5 is low. You might wish to repeat this test, through a monitored cycle, before continuing with inseminations. Sometimes it is a timing issue (just in case it wasn’t 7d), and sometimes lab error (the assay doesn’t work). But if repeat levels are low as well, you and your doctor may wish to consider progesterone supplements in the luteal phase.
Through our clinic, we do daily hormones (estrogen, LH, progesterone) and ultrasound in the days leading up to insemination.
You are right to want to get everything perfect for every cycle. It is not unusual for a fertile couple to take up to 6 months to become pregnant, but you wouldn’t want to have to go through that many treatment cycles if you could help it.
You ask what other things you can do. I’m sure you’ve looked to lifestyle already. Make sure that you are taking folate; some suggest up to 5mg daily. To really boost chances you can consider ovarian stimulation medications such as Puregon or Gonal F. You mentioned financial concerns and unfortunately these products can double the cost per cycle for you. You may also substantially increase your rate for multiple pregnancies, especially twins. But your pregnancy rate per cycle can also double (or more).
RR
TGH
I am 30 yrs old and have been trying to conceive for 6 months. We have been using Ovulation Predictor kits to increase our chances of conceiving but I have not seen a positive LH test (surge). Sometimes I see a faint line on the test but it is not as intense as the control line. I noticed that the faint LH line is noticeable around day 12-13 of my cycle. (I have read the instructions thoroughly and I am assuming I am following them correctly - I usually buy two kits so I am testing for about 14 days) Could this mean I am ovulating around day 12-13. If so, could this imply a luteal phase defect. I have a shorter cycle which ranges from 22-24 days. Any suggestions you could provide would be very much appreciated.
RR
TGH replies:
Dear RR,
Urinary LH detection is the gold standard for determining ovulation from home. Some women have a smaller LH surge than others; it may be difficult for your kit to pick up the start of your surge.
For other women, the kits don’t pick anything up at all.
In other words, this “gold standard” doesn’t work for everyone.
Not all brands are exactly the same. Most women prefer to use Clear Blue Easy.
One way that you can validate your kit is to monitor a cycle with a fertility clinic at the same time as you test at home. The clinic can confirm your LH levels through blood tests, and confirm that you’ve released your follicle (egg) through ultrasound.
You are right: 22 day cycles with day 14 ovulation implies a luteal phase defect. So it is worth your while looking into this further.
Wanda
Hi, my name is Wanda & I’m 39 years old. My husband & I have been trying to conceive for 2 years. His sperm count is high so I’m the culprit. I had 1 tubal pregnancy when I was 25 & they removed part of my right tube. In 2006 we miscarried at 6 wks. I have follicles that develop on both sides, but really only my left side to work with & usually not very many. My dr put me on letrozole but that only produced 1 follicle & 2 failed IUI’s. He put me on injectibles & I ended up developing a cyst so he had to stop procedures. We ended up getting pregnant on our own that month but it ended up being a “chemical” pregnancy (I hate that term). This month they have me on injections again & I have 3 follicles on my right, the largest at 15 & 4 on my left, the largest at 18. My 3rd IUI is scheduled this friday so we’re praying it works. They have prescribed progesterone this time to take 3 days after my iui. Do I have enough follicles to work with? How do I know I’m not producing “rotten eggs”? Any advice would be so much appreciated, & I’m so grateful you’re out here for all of us who need advice. Thank you, and good luck to all of you who are in the same boat! I pray your wishes of motherhood & fatherhood are delivered to you.
TGH replies:
Dear Wanda,
Thank you for writing; your concerns and fears are palpable. I hope that by the time you are reading this, an ongoing pregnancy is a reality.
The challenge has been that you are limited to left sided ovulation: for most women, the right ovary responds better than the left. So it can take increasing doses (with increasing side effects, such as cysts) to have a moderate chance on any given cycle.
If this is indeed the only issue that you face, then you would have an excellent prognosis through IVF ie bypass the tubes entirely and be able to access those numerous right-sided eggs.
If you wish to stay with IUI cycles, then cycle fecundity (chances for pregnancy) won’t be as high.
IVF isn’t right for everyone Wanda, and it isn’t required for you (you’ve been able to get pregnant without it) but it is reasonable to bring IVF up after 3 IUI cycles as part of the discussion for how best to move forwards.
R
I am 37 years old. I have been getting regular periods each within
28 days normally. For the first time it has been delayed till 33 days.
Is it that i am having some problem. Or has my reproductive age finished ?
please reply
TGH replies:
Dear R,
All women have some variation to their cycles. A single long-ish cycle should not be a concern.
Cindy kay
My hubby and i have beenTCC for 1years 6moths and he is 35yrs and 30yrs. I ovulate on my own between day 9-10 and i’m like a clock 28 days cycle. both check and he is fine but one doctor claim i have PCOS but another did not find anything. he put me on clomid for 4mths but did not get pregnant. I need advise should i go for IUI with injectable or with clomid? or you think i should go straight with IVF?
TGH replies
Dear Cindy-Kay,
I cannot provide advice without meeting with you and getting the full story. But it might help you to know that:
-doctors disagree on how to define “PCOS” so two reasonable people can disagree on whether or not that label applies to you. (I would have to meet with you to provide an opinion for you personally).
-clomiphene can be a good first-line medication but isn’t associated with the same pregnancy rates as the other medications. I prefer to use it for 3 cycles at most; after that, the side effects can become a bit much.
-IVF is very effective for many diagnoses, but it isn’t always necessary. From what you’ve written so far, it strikes me that you may yet have alternatives.
anna
Hi Dr, i have found your web site very interesting and seek you opinion on the following; I am 36 years old, i had a missed miscariage jan 2008 at 14 weeks and in august 2008 an ectopic pregnancy (at 8 weeks- tube removed).
(On this cycle) I used a fertility monitor which has identified LH rise day 21 and 22. However on day 21 i had light spotting which quickly disappeared. This is the first time this has occurred, do you have any suggestions why this has suddenly occurred? should i seek medical treatment? Thanks Anna
TGH replies:
Dear Anna,
Cycles can be a little more irregular than usual for 1-3 cycles after a pregnancy.
After ovulation, there is a temporary dip in estrogen levels. Some women can experience spotting at this time, and as long as it is no more than that, lasting a day or two, it should not be a concern.
I would not suggest medical treatment for that issue alone.
The fact that you became pregnant so quickly in 2008 is the silver lining to your difficult situation; thank you for sharing your story. I hope that you find ongoing success soon.
ines
I have IVF transfer nov. 1, only 1 embryo since i only one egg retrieve. But unfortunately it turns out negative its very upsetting to both of us since thats the only hope were wating for. I have ectopic pregnancy last june 2007, laparascopy nov. 8, 2007 and found out my left fallupian tube is blocked. We decided not to have another IVF bec. of financial reason, we just want to keep trying naturaly, any suggestion from you be greatly appreciated. Thank you very much.
TGH replies
When tubes are obstructed, they can sometimes (not always) be re-opened. The procedure is called “tubal cannulation” and is done by a radiologist. Your doctor may be able to make a referral for you. In Ontario, the tubal cannulation is not completely covered by OHIP, but it is much less expensive than IVF.
Melissa
Hello, I have just had an unsuccessful IVF cycle. I am unfortunately 43 yrs old, had 2 natural pregnancies, both ended in miscarriage. During the IVF stimulation, my initial day 3 count was 6 follicles, and but ended up with one mature follicle measuring 20mm right before retrieval. When my RE went in, there was no egg and no cells indicating there was one. Does this mean I should give up? or is there something to be said about diet, excercise and acupuncture?
TGH replies:
Dear Melissa,
Please don’t give up based on my advice here.
That said, your concerns are reasonable. Many clinics don’t publish IVF success rates for women >42y for that very real worry that there won’t be enough successes to provide guidance. Unfortunately, the “empty follicle” during your retrieval fits that picture.
Lifestyle modification, alternative care like acupuncture, and supplements can make some differences in some situations. Other women will look to donor eggs, or adoption.
I strongly suggest that you see a fertility counsellor. Your choices ahead will be necessarily very personal.
Leslie
Hello, I have been diagnosed with pcos and was wondering what that means and what are my chances that I will conceive. What are the next steps I should take with this?
TGH replies,
Dear Leslie,
I really have to write a full blog post on PCOS. My answers here will be insufficient. But the super-condensed version:
-nearly all women with PCOS will, in the end, achieve a healthy ongoing pregnancy.
-Pregnancy can take some time to achieve (several months at least). PCOS implies too many eggs, which can lead to irregular cycles and hormonal imbalances that have to be carefully balanced.
-you and your doctor should make sure, before you become pregnant, that you are not hypothyroid or diabetic (both conditions are easily screened with simple blood tests).
Bee
Dr. Hannam, I’m 34, I have been trying to have my first BB for over one year. Started from Feb08 till now, I have been conducting four full cycle monitoring and began to take colmid in Nov. So far, no any luck yet.. I really want to seek for a second opion from you whether I need any tests (my husband sperm result is good, for me,besides blood test and ultrasound, my current doctor didn’t give me any further exam..)or I should take further medication to keep on trying… I plan to require my doctor to refer me to you.
Many thanks.
TGH replies:
Dear Bee,
The best way to get an appointment is by emailing michelle@hannamfertility.com. Michelle is a fertility nurse with over a decade of experience in the field; she can help you to get set up with us. I look forward to meeting with you.
PK
Hi
I am 37yrs old and had laparoscopic surgery in July of 2008 to see if I had endometriosis. When they did the surgery he found I had stage 4 endometriosis and, my tubes were inflamed and blocked. I was told that a “natural” conception would probably not be possible and that IVF was my only option. He told me that I should probably consider having my tubes removed due to the inflammation - the toxins could harm the embryo and therefore decrease my chances of having a successful pregnancy. I am supposedly being referred to a clinic that is covered by OHIP (since my tubes are blocked I am apparently covered for 3 rounds of IVF) but I am getting very concerned about my fertility / egg quality. My cycle was like clockwork before the surgery. It was every 28 days. After the surgery my first 2 periods were 27 and then 29 days. Then on the 3rd month after surgery I dropped to a 26 day cycle. Now all of a sudden I am down to 25 day cycles. This concerns me greatly as it seems to indicate that my egg quality may be failing. Do you think this is the case?
TGH replies:
Dear PK,
You are right: shortening cycles can be a concern, particularly in the context of your diagnosis. But we cannot know the full picture without more tests in hand.
As you know, endometriosis is categorized into 4 stages…..with stage 4 being the most severe. “Severe”, in a surgeon’s opinion, will involve pelvic adhesions (scar tissue). The more adhesions there are in the pelvic area, the more that blood flow can be compromised to the ovaries. When this happens, egg development can be affected.
Might that be happening to you? It may; but there are some tests that you can do to help you find out. Your new clinic will be able to help you with the following tests:
Day 3 FSH (a blood test)
Antral follicle count (ultrasound)
AMH level (another blood test, but not covered by OHIP)
No one test is perfect, but the results, in combination with your personal history, will provide greater accuracy than any one feature alone. More on ovarian reserve testing here and on general egg-quality testing here.
It won’t be possible to understand your prognosis until we have all the facts. Stage 4 endometriosis is a serious diagnosis at any age. That said, many women with similar disease have found success.
For more information on endometriosis, you may wish to look to the ASRM website.
Finally, please note that all IVF clinics in Ontario, private and hospital based, will be able to provide OHIP subsidized IVF for you. Currently, OHIP only supports cycles in women who have bilateral (both) fallopian tubes blocked. In July 2008 the Ontario government created an expert panel to look at extending funding to other couples as well. Please consider adding your voice to the panel, through this website here.
Laura
Dear Dr. Hannam,
I am 35 1/2 years old and I have been trying to conceive for 3 1/2 years. The first year, my husband and I took the natural route, but when nothing was happening, we started seeing a fertility doctor. We then did a year of cycle monitoring and that didn’t help. All my tests are normal and so too are my husbands. We are now on our 3rd attempt at IUI and am considering doing IVF if this third attempt doesn’t work. One concern I have is that in the last two cycles of IUI I’ve only produced 2 eggs while on Serophene and Gonal-F, whereas our first attempt at IUI I responded with 5-6 eggs. Is the decrease in the number of eggs an indication of a problem and if I go the IVF route, will I likely face the same issue (ie. too few eggs)?
TGH replies:
Dear Laura,
We usually approach unexplained infertility with IUI cycles -I suggest up to 3 in my practice- but IVF has much better success rates for this “diagnosis”…it makes sense to me that you would now consider this next step.
Yes, you would hope for 10-15 eggs to mature during the IVF stimulation. But during IUI, we usually opt for milder stimulations, in the range of 2-5 eggs. Any stimulation involving clomiphene citrate (Serophene) is, by definition, a milder stimulation protocol.
Clomiphene usually works best on the first cycle of trying, but is less efficaceous (useful) with every cycle thereafter.
This means: you may well still be able to make many eggs. I would expect you can based on age alone (and your 5-egg-response on the first cycle).
If you are waiting for a few months before starting IVF, and really worried about this, you could ask for an AMH test. This new blood test correlates quite well with the odds for a successful IVF-type stimulation.
Best,
Tom Hannam
TB
My husband (31) and I (29) have been trying to conceive for 18 months now with no success. I have hypothyroidism, which is controlled through Synthroid but other than that, am very healthy and in good physical shape. My docor tested for PCOS because my estrogen dropped from 119 on Day 3 to 93 on Day 10 of my 21 Day progesterone test, but all the tests and UC for PCOS were negative. I have three specific questions:
1) What could be causing my estrogen to drop? I normally have 35-36 day cycles, so it seems that the 21 day progesterone test should have been done to accomodate my cycle. It showed my progesterone at 2.1 on Day 21, but I ovulated on Day 20, accordin got my Clearblue Easy Fertlity Monitor. Would that make a difference?
2) On my latest ultrasound, which took place on Day 2 of my most recnt cycle, my ovaries were shown to have a number of follicles and not enlarged, which the doctor said was normal and healthy and thus, not PCOS. But from reading what you wrote above, it seems that I shouldn’t alreayd have follicles on Day 2. Should this be cause for concern?
3) As I mentioned above, my cycles are normally 35-36 days, like clockwork. However, I am currently on Day 11 (of the same cycle that showed all of the follicles on Day 2), and my Clearblue Easy Fertlity Monistor starting detecting an LH surge on Day 10 and again today, so I assume I’ve ovualting any time instead of on Day 19 to 21 liek I normally do. Is this potentially problematic?
Any help or advice you could offer would be greatly apprecaited. My healthcare team keeps punting me to someone else and I can’t seem to get consistent answers or guidance.
TGH replies
Dear TB,
(1) You ovulated on day 20….or at least, had the LH surge. It can take a 2 or 3 days after the LH surge for progesterone to rise. (Immediately after an LH surge, estrogen drops…and then picks back up again).
It is called a “day 21 progesterone test” because it should be measured about 7 days after ovulation…..which for most women is day 14. In your case, the progesterone level should be measured about day 27.
A more accurate name for the test would be the “mid luteal serum progesterone level”. You will hope to see a number of at least 15; more commonly it will be in the 30-50 range.
(2) It is normal at the beginning of a cycle to have immature follicles present. Ten to 15 is the usual number between the two ovaries. As the cycle progresses towards ovulation, one follicle will mature and release the egg.
(3) It can be difficult for women with long cycles to use home urinary LH detection….long cycles are often associated with a borderline high LH level so the kits pick up “false positive” readings all the time. The best way to resolve confusion of this sort would be to do Cycle Monitoring through a fertility clinic, during which we measure the actual serum (blood) levels of LH. It is the most accurate method, and will help to answer your other questions about estrogen and progesterone levels too.
syan
I am 30, I ovulate generally every 36 days, my Day 3 FSH is nml as per my RE. I have had 2 miscarriage in the space of 4 months, (I have been trying for 4 months. What could be the differentials for the miscarriage? NO OB/RE can find out why my menstrual cycle is so bizarre.
TGH replies:
Dear Syan
You are facing two different concerns. I’ll start with your cycle, which, in the end, probably is just fine.
The 36 day cycle
The “average” woman ovulates on day 14, as part of a 28 day cycle. But in practice, every woman -and every cycle- is a little bit different. Most commonly, a long cycle is associated with an above-average ovarian reserve. That is to say, you have more antral follicles (partially developed, but still immature eggs) than most women.
There are two tests that would confirm an above-average ovarian reserve:
1. antral follicle count. This requires a transvaginal ultrasound, and the clinician literally counts how many antral follicles can be seen. The usual number, adding left and right ovaries, is 10-15. If you have 30 or more, the diagnosis is made.
2. AMH. This is a new blood test. Not all clinics offer it. But a high value (>20) is associated with above-average ovarian reserve.
It is highly likely that your cycle reflects an above-average ovarian reserve. All things being equal, this is really not such a bad thing. After all, you are ovulating, and able to get pregnant. It is staying pregnant that is the deeper concern here.
Two early losses
Syan, I am happy for you that you get pregnant so quickly, but the reasons behind your early losses could be tested further if they haven’t been done so already. Even as you keep trying -and I hope you are- you should be offered a set of tests that include
-a sonohysterogram
-karyotypes for you and your partner
-a DNA fragmentation test for your partner’s sperm
-autoimmune, coagulation, and hormonal screens for you
Finally, though I hope you don’t suffer a third loss, if you do, please ask your clinical team for a “genetic analysis of the products of conception”.
Not all of these tests are covered by provincial health plans, but most are, and it may well be worth your while to look into them.
Yours,
Tom Hannam
RR
Dr Hannam,
I am 31 years old and my husband and I have been trying to conceive for 8 months. I had an HSG test and my doctor says my tubes are clear but she mentioned a slight heart shaped uterus. She didn’t seem concerned about the abnormality. How does an abnormally shaped uterus affect fertility and pregnancy?
Also, I tracked shorter cycles for the first 5 months (approx. 22-24 days) but for the past 3 months, since I’ve been taking vitamin b6 (100mg) my cycles have been 28 days in length. Initially, with the shorter cycles and slightly late ovulation, I thought I had luteal phase defect - should I sill be concerned. I appreciate your thoughts.
Thank you,
RR
TGH replies:
Dear RR
A “heart shaped uterus” is a reasonable descriptor for a variation we call an arcuate uterus.
Most women have a rounded uterine cavity. If yours is arcuate, it means there is a slight indentation coming down the middle. By “slight” I mean less than 1cm long.
If the indentation is more than 1cm, we call it a septum, and your doctor would have expressed more concern. A septum is not considered a very good place for embryos to implant, and we usually recommend surgery.
So the key is to differentiate whether you have an arcuate or septate uterus. I’m sure your doctor suspects the former. But if you want to be certain, the gold standard test is a 3 dimensional sonohysterogram.
Traditionally, an arcuate uterus is thought to be a version of normal that should not affect your chances for becoming, or staying, pregnant. It is my personal opinion that the endometrial biopsy intervention may be of particular help to women with arcuate uteri, but that is not an evidence based opinion. Further studies need to be done.
I am happy for you that your cycles have regulated recently; I hope that pregnancy is forthcoming.
Cassandra
Dear Dr. Hannam,
I am 39 years old and I have 5 IVF in the past. From the last two IVF cycles I got pregnant but I lost the babies at 20w and 24w because I have cervical insufficiency. Now I have to do another IVF. This morning I checked the 3-rd day hormones and I’m not so sure that they are OK. Seems E2 too high and FSH and LH too low!?
LH 3.09 mlU/ml ref.(1-18)
Prolactin 10.08 ng/ml ref.(1.39 - 24.20)
FSH 3.89 mlU/ml ref.(4 - 13)
Estradiol 120 pg/ml ref.(39 - 189)
Testosteron 0.33 ng/ml ref.(0.05 - 0.73)
Please I need your opinion.
Thanks in advance.
TGH replies
Dear Cassandra
Your day 3 results are good. If you wish to check your ovarian reserve further, you could ask for an Antral Follicle Count (ultrasound test) and/or an AMH level (blood test).
Your losses are a real tragedy. Cerclage is indeed an appropriate treatment for some women who have cervical weakness. The suture is usually placed at about 12 weeks of pregnancy. There is also a top gynecologic surgeon in Toronto who places the suture laparoscopically (surgically), before pregnancy.
Best,
TGH
(Cassandra, I was happy to answer your question, but in general, this isn’t a very good forum for time-sensitive concerns because I will sometimes take a while to answer)
bella
Dear Dr. Hannam,
I am a 45-year old woman, with no serious health problems. My period comes regularly every 28 days, and my tubes are normal. My hormone tests are normal, except my FSH. Last July it was at 26. Just two weeks later, it was 6.3. But in January it rose to 47. I’ve been trying to conceive for the last 10 months. Recently I visited a fertility clinic but I was told that the two follicules examined were empty. What do you receommend in my situation? Thank you!
Bella
TGH replies,
Dear Bella,
Fertility is terribly age-sensitive, and for most women, falls off dramatically from about the age of 38 years. Though women in their mid-40s can become pregnant, it is an unusual event. Most women >42y old receiving active treatment are receiving donor eggs.
You checked your FSH level. You can also check your Antral Follicle Count (by ultrasound) and/or AMH level (blood test). But I do not recommend further tests of this sort, for your prognosis was already set by the tests you did have.
You can maximize egg quality through supplements such as antioxidant vitamins and folic acid. There are other supplements too, but, I would caution you that they are more to consolidate fertility, rather than to build it.
Counselling can be of real benefit in situations such as yours Bella. Your situation is difficult, and you will need to seriously consider alternatives to natural conception with your own eggs.
Yours,
Tom Hannam
jane
I am a 37 year old woman with Crohn’s disease. I get regular infusions of Remicade (Infliximab.) I have read that this medication can have a positive affect on fertility. Have you read any studies that confirm or deny this?
TGH Replies
Dear Jane,
As you well know, Remicade is a relatively new treatment for Crohn’s and some other autoimmune conditions.
Remicade is a monoclonal antibody, part of a new class of medications called “biologics”. We don’t yet know exactly how these medications will affect fertility. The few reports that are out suggest that Remicade will likely not harm your fertility, but whether or not it will be of benefit remains to be seen.
To the degree that your treatments are improving your overall health, you are also helping to maximize your chances for conception.
Yours,
Tom Hannam
Katrina
Dear Dr. Hannam,
This is a question on behalf of my sister. She is 31 years old, has had her 3rd IVf unsuccessful treatment recently. Initially the doctor said the problem was with my bro-in- law having a low sperm count, so after few months of medications the first Ivf was done. After 2 unsuccessful attempts they tried a 3rd time recently and, now the doctor says that my sisters egg quality has gone bad. Its been a year since their first IVF treatment. What we dont understand is how can her egg quality suddenly go bad? Her reports never suggested that her egg quality was bad during and before her first IVF so now how can it suddenly be labelled bad after the third attempt? Is there any use of trying IVF again? What should be the next step?
Thanks
Katrina
TGH replies,
Dear Katrina,
The best success rates in a fertility clinic are usually seen on the first or second attempt at IVF. The reasoning is straightforward: for those that the process will be “easy”, success will be found on the first go. If necessary, we can then modify the protocol to account for what we saw on the first attempt, and create an even better second cycle.
When cycles are optimized, pregnancy often happens quickly. So three cycles, as your sister has done, is a significant committment. And now several choices must be considered. A fourth cycle? Donor eggs? Donor sperm? It is not an easy decision.
Your sister went into the process, one would expect, with excellent prognosis: age should be on her side, and the diagnosis (male factor) is one that is most amenable to treatment with IVF/ICSI. I would think that her clinical team started out as enthusiastic for her chances for success. In my clinic, for example, in 2008 for women under 38y when we had two blastocysts to transfer, we had a 78% ongoing pregnancy rate.
As each cycle passed, however, her doctors may have started to reconsider their diagnosis. Your sister’s eggs are unlikely to have irrevocably “changed” over this last year. More likely, the clinical team changed their minds as cycles progressed from one to the next.
A diagnosis of compromised egg quality in a young woman is a serious assertion. Your sister should definitely get a second opinion. And when she does, she should bring the records of her previous cycles with her. A fresh look could be most helpful.
Yours,
Tom Hannam
RR
Dr Hannam,
I am 31 years old and my husband and I have been trying to conceive for 9 months. I had an FSH Day 4 test and the doctor says my results were borderline (11). Also, I generally have shorter cycles (23-25 day) and ovulate on Day 15 (I get a positive LH surge on day 14).
Other tests appear normal. I had thyroid hormones checked - they are normal. Pelvic ultrasound is normal. An HSG was performed - results were normal except for a slightly bicornuate uterine shape. My husband’s semen analysis resulted normal.
I would really appreciate your thoughts.
Thank you,
RR
TGH replies:
Dear RR,
You mention a borderline high FSH and a short luteal phase. You could repeat the day 3 FSH tests, or get an AMH level, and it has “only” been 9 months. So hopefully you simply achieve pregnancy in the next cycle or two. But it may also be true that you have a limited ovarian reserve.
As a young woman, a limited reserve can be a surprising finding. Sometimes there is no explanation for it, and, sometimes, the lower reserve is associated with low egg quality.
But more often, an explanation can be found. For example, I have seen situations where endometriosis has affected egg reserve while egg quality remains intact. *Of course* this is not a diagnosis I can make here; and yet, a “slight bicornuate shape”/arcuate cavity can also imply endo.
My suggestions would include:
*Ask your doctor if they have seen any suggestions of endometriosis (ultrasound or MRI can sometimes see it; the gold standard for diagnosis is laparoscopy)
*Consider active treatments, like inseminations or IVF
*Allow yourself to continue to believe that pregnancy remains more than possible; your age sets you up for success.
I cannot provide more accurate or more thorough advice without reviewing your care in person.
Best,
Tom Hannam
Kendra
Dear Dr. Hannam,
I am 27yrs old and my Husband is 29yrs old. We have been trying to conceive for 2 1/2 yrs with no success. We have both been checked out by a fertility specialist and we are both “Fine”. We are diagnosed with “idopathic infertility”- unexplained infertility. My cycles are about 30 days long,and the only thing I am concerned about is that I spot for several days after ovulation and before my period. I have had a HSG done and my tubes are open, my FSH was great, progestrone levels were in the 60-80’s. I did 3mths of Clomid, I have done 2 cycles of IUI w/o any meds because my cycles look good. I am not sure what the next step should be for us? I havenot had any miscarriages or anything. I just don’t know what to do. I feel like I am wasting precious time waitng to figure this out, when it could be a simple answer to why this isnot happening for us.
TGH replies
Dear Kendra,
Sometimes an answer will not be simple to find. There are always more tests that can be ordered….you didn’t mention a genetic screen for example, or autoimmune or coagulation tests. You could so hysteroscopy and/or uterine biopsies to look into the spotting. I’ve listed many of the tests that we offer here.
But these tests do take time, and you noted that time is precious to you.
So even as you may or may not do further investigations, active treatment is more than reasonable at this point. Inseminations are often suggested, though with unexplained infertility >2y duration, IVF has been proven in a randomized controlled trial to likely be the most successful intervention.
I recommend creating a care plan for active treatment with your team, so that you can regain control over the months to come.
Yours,
Tom Hannam
ID
I’m 38 years old and have done 3 ICSI cycles due to male factor (mostly morphology issues). I produced over 10 eggs each cycle however there seems to be a problem with quality (dark color). The resulting embryos are graded high based on number of cells and fragmentation however the embryologist called them poor quality due to morphological appearance. We transfered 5 or 6 embryos each time and none ever implanted. We used a different drug protocol each cycle but this didn’t seem to improve the quality of the eggs and I’m not sure what else could be done. Your advise would be much appreciated.
TGH replies
Dear ID,
It is most reasonable to get a second opinion at this point, for these two reasons:
1. Are eggs naturally poor quality, or was it inherent to the stimulation? A poor stimulation can lead to poor egg quality, regardless of their underlying potential.
2. Is it certain that eggs are the problem? You mention male factor; sperm can certainly affect outcomes of course.
I cannot promise that a second opinion will illuminate your path forward. But I think that it would be worth doing.
sejal
Hi
I am 34 yrs — FSH- levels are 13.11 day 2, Prolactin - 24 day 2
my husband - detected with aesthenospermia . motility grade 4 is 7 % and grade 3 is 10 % .
my doctor has prescribed - lycored and cabgoline -0.25 mg twice a week .
she has planned for IUI this month , as my follicle growth was very good in last 2 cycles
should i proceed with IUI ,or switch to IVF?
TGH replies,
Dear Sejal,
IVF with ICSI will be the ideal treatment for you, given the male factor subfertility that you face.
Lycored is a product based on lycopene, an antioxidant. Other antioxidants include zinc, selenium, and vitamin E…all of which can be found in the type of multivitamim most women are taking with their folate. Antioxidants have been proven to potentially help sperm quality; I am less clear as to how they may help eggs.
Cabergoline treats prolactin levels. For more on prolactin, look here.
IVF is expensive, and it is very reasonable to try IUI cycles first. Many couples will try three IUI cycles before moving to IVF.
TF
Hello! I am 34 yrs old. I have been off BCP since Sep. 07 but had been taking them nonstop for almost 15 yrs. I have been trying since May ‘08 by tracking my cycle. I have 32d cycles almost like clockwork. In Nov ‘08 I finally got pregnant (but the pregnancy stopped growing at 7 weeks). I had a D&C on Feb 4th and got my period again on March 5th. This last month I detected an LH surge on day 16 but at the same time had a temp spike of 1 degree which I thought was supposed to come after ovulation. My temp has been staying up about 0.4 degrees from basal of 97.2 since the surge but not as high as the spike. My husband and I had intercourse 2 days before the surge, day of, and for the next couple. However, it still doesn’t seem that I have achieved pregnancy. Since, I had such a hard time getting pregnant before and now even with timing am not seeming to have much luck (I have no symptoms of pregnancy) I am worried that my eggs are of poor quality. Is it possible to detect an LH surge and not ovulate? Also, my cycle is regular but I don’t get any PMS symptoms anymore which I am worried is a sign of anovulation. No cramps, medium flow, no breast tenderness, etc. Please give me any advice possible. Im wondering if I should see my doctor about getting on an ovulation stimulating drug.
thanks
TF
TGH replies
Dear TF
I edited your question a little for length, but kept the essential points intact:
It shouldn’t matter that you were on the birth control pill for a number of years; what matters is what is happening with your cycles now.
The best way to confirm ovulation, at home, is with urinary LH detection. Basal body temperatures fluctuate for all kinds of reasons…I don’t usually recommend that approach.
I am sorry for your early loss. I’m sure, by age, your doctor would reassure you that pregnancy should happen again.
My suggestions would be:
1. Try timing intercourse, at home, as you did, for 3 cycles.
2. If that doesn’t work, it would be more than reasonable to visit a fertility clinic, to see if fertility treatments would help, for by then, it will have been over a year, and time to take things to the next step.
Nia Green
Hi Dr. Hannam
Thank you for taking the time out to address our fertility concerns!I am 26 yrs old soon to be 27 and my husband is 30. We have been ttc for 1.5 yrs now with no success! My cycle is 29-32 days with ovulation around day 14-15 of cycle. I have been seeing my GYN who is also a fertility Dr. we have had numerous testing done hubby is fine, but my progesterone levels came back at 5.5, estrogen levels are fine, and tubes are not blocked…. I have never been pregnant before! My Dr. recommended Clomid, however i’m hestitant and wanted to try something more natural. I have done research and found info on Vitex agnus-castus and False Unicorn root! Are you familiar with these natural remedies that claim to balance female hormones? and if so would this be an option for me? If not what would be your suggestions besides Meds if any? Thank you so much for your time and patience. Have a great day Dr.
TGH replies,
Dear Nia,
There are a myriad of supplements, most of which I’m not familiar with…or at least, unable to support as I cannot find trials that prove their effectiveness.
But I don’t have to tell you that 1.5y is a long time for such a young couple. Please make sure that your partner is doing his tests too, before you go too far into supplements (whether herbal or prescribed). And: you might want to check your “day 21″ progesterone level again….by day 21 of a 28d cycle, progesterone should be 30 or higher. A value of 5.5 suggests that you had not ovulated at the time of the test.
Good luck Nia,
Tom Hannam
Susan Dale
Dear Dr. Hannan
From the uk.
Please can you advise. We have just finishd our first cycle of ivf which was unsuccessful. I am forty years old and have been ttc for two and a half years. All test results were ‘normal’ however was shown to have a slightly lower e2 on day 3 oc cycle. Not low overian reserve and protocol used was clomid/menopur 150-225/gonal-f 225. Produced 16 follicles with 8 eggs three of which fertilised. All transferred on day 2 - 2 x 8 cell and 1 x 6 cell said to be excellent quality.
It was shown that I had a small fibroid 1cm x 2cm at the fundus of uterus which was removed two months prior to cycle. On the day of my last scan prior to collection my consultant stated that he could see regrowth of fibroid which was not detected during stimulation scans. He said that he was not now anticipating a good result but that we had come to far into the cycle to stop. due to an anteverted uterus and a “difficult” to access cervi I was to have GIFT. During procedure it was found that both my tubes are completely damaged not blocked but scarred and I was converted to ivf under anaesthetic. The dr who initially tried to transfer embryos was aware of my problem but was nconcerned however she was unable to access my uterus and my consultant was called in to complete procedure. I was very aware of the importance of an untraumatic transfer and was assured that everything went well.
I obviously had an implantation problem or our embryos stopped developing.
After reading your comments I am keen to have your advice. My cliic is the top rated clinic in the UK (HFEA stats) so I have no doubts as to their capabilities. However your comments withregard to the 1st or 2nd attempt being the optimal I am very concerned as to whether we should continue as my problems appear to have been the reason for my failure to conceive. Do your have any advice for us.
Thankyou Susan.
TGH Replies:
Dear Susan
You mention a low estrogen level on day 3…but that is ok. “Too low” may mean the ovaries are very suppressed after being on the birth control pill, but it doesn’t imply anything about egg quality.
You also noted the myomectomy (fibroid excision). But very commonly, the first hysteroscopic myomectomy doesn’t remove it all…and a second procedure needs to be done. So far, then, your care is standard-to-form (if immensely frustrating and expensive).
The GIFT-to-IVF conversion, however, is unusual….and a difficult transfer compounded the challenges. So there were several factors at this point that conspired against your embryos not having a good chance to implant.
And yet: all of these factors are modifiable. If you chose to do IVF again, you could (a) ensure all the fibroid was removed first (b) plan for IVF and (c) ensure a mock transfer was done beforehand….so that the real transfer itself is ideal
At that point, the only significant variable would be related to your embryos. It sounds like the last set had potential…you might hope that the same could happen again. For that reason, IVF #2 might be expected to work better than your first attempt.
Susan, this is not a real second opinion; I just don’t have enough information of course. But I hope these comments provide some direction for yourself, and other patients considering a second IVF attempt. It is often a reasonable choice, because we may be able to build a better plan the second time. I hope that you have better success to come.
SN
Hi Dr Hannam,
I am 38 yo and just completed an IVF cycle which ended in a chemical pregnancy at 5 weeks. Does the fact that I was able to achieve implantation and early pregnancy help to predict my chance of a positive outcome again if I do another cycle(IVF is my only option),or b/c of age could egg quality be a reason for the chemical pregnancy and perhaps a sign of things to come. I have had success with ivf in the past.
TGH replies
SN, as you are well aware, there are competing signals both good (pregnancy) and concerning (early loss).
My suggestion is to compare the embryo reports from this recent cycle to your previous, successful one. Are they more-or-less the same? If they are, then despite this recent setback, your prognosis should still be good.
Susan F
Dear Doctor Hannam,
My husband and I are trying to achieve pregnancy with donor sperm. After how many cycles do you recommend changing donors? I have proven fertility, having had one miscarriage immediately prior to conceiving our now three-year old. She was conceived naturally with my husband. (We must now use donor sperm, as husband’s counts have almost flatlined to nil, even having had varicocelectomy and no apparent hormone problems).
Your comments are greatly appreciated.
sf
TGH replies
Dear sf,
I responded to your question with a new post. I hope it helps.
Susan F
A million thanks for your commentary on the donor sperm. We just found out our second attempt was unsuccesful, but we are going forth with brave hearts for a third attempt, this time with new donor.
Thanks for your timely and informative response. You are amazing!
sf
Jen
Hi,
I am 36. My husband and I have been trying to get pregnant since August 2008. I did not have a menstrual cycle in September nor October 2008 (my cycles had been irregular before I went on the pill 15 years ago), then became pregnant after my November cycle. A 6-7 week ultrasound showed a fetal heartbeat and then I had a missed miscarriage starting in January 2009 at approx. 10 weeks. I didn’t pass all of the tissue until end of April, but have been bleeding every day since the miscarriage began in January (except for approx. 3 weeks in Feb/March). It is now end of May 2009, I still have daily cramping, moderate bleeding, bloating and have even gone back on the pill to try and stop the bleeding and get a cycle going. I have had an HCG level of 7 for the past month. I have been seen by my family doctor and two hospitals throughout this pregnancy and loss. I am quite frustrated at being told that a 4 month plus miscarriage is normal … do you feel this is really true? Is there anything else that I can be doing/trying to stop bleeding and have another normal menstrual cycle?
Thank you for your time!
TGH replies
Jen, you are right, it is not normal to bleed (even if its just a little bit) for four months in a row, even after an early loss. I hope you’ve had your iron levels checked recently; such bleeding can leave you quite run down.
An HCG of 7 might be…normal. Some women –even when not pregnant– can have levels as high as 15. If you have had ultrasounds also confirming that they are no longer retained products of conception, then it is reasonable to assume you are clear from this recent pregnancy.
So why the ongoing bleeding? I cannot provide a definitive answer in this forum, but I can tell you that the two most common reasons are (a) a lining that’s a little too thin (under 4mm) or (b) a lining that is a little too thick (over 8mm). Either can happen to women with irregular ovulation, such as yourself.
You will need to find a doctor who has the time and expertise to help you get back on track. Steps will include
*making sure the bleeding is nothing dangerous (pap test; endometrial biopsy if you have a thick lining; serum iron levels)
*making sure its not a bladder infection or hemorrhoids (I know that sounds improbable, but its something we’d have to check)
*making sure you don’t have a bleeding disorder (say, a family or personal history of easy bleeding).
Once those issues have been addressed, management may include a steady-dose birth control pill like Marvelon, even double doses for while, +/- tranexamic acid to help stop bleeding. But you need all the above checked off first before management begins; it isn’t safe otherwise.
Once you’ve regained control of the bleeding, your clinical team can stop the pill, expect a period, and…hope that you to ovulate 12 days later. It sounds like ovulation is not a reliable event for you, however, so you might wish to help that along with fertility medications. But Jen I’m really too far along here: you need to see someone to get on top of the bleeding before anything else.
You became pregnant really very quickly the first time; for that reason alone I would expect that you will be again.
SC
I am 39 years old on a 20 - 21 day menstrual cycle. This has dropped from 28 to 24 to 21 days over the last few years. About 10 years ago I had an abortion. Can I still get pregnant, do I have “poor eggs” and if I do have a child are the possibilities of the child being healthy very low. I have occassional sex and am not ready to get pregnant. I would like to understand the answers to mentally prepare myself either way.
Thank you.
TGH replies,
SC, are you measuring cycle-day-1 to cycle-day-1 ? Twenty-one day cycles are very short, and it is well worth going to your doctor to set expectations to discover if, in fact, the cycles are related to eggs. You should ask for tests of ovarian reserve, a sonohysterogram (to make sure you don’t have a uterine polyp, which can cause bleeding), and a pap test. You then should have the answers you need.
Coco
Hello Dr Hannam,
I had my IVF cycle recently. Eighteen eggs were retrieved but only 2 fertilized ( I was told that the sperm test was normal and eggs appeared to be mature). I had mild OHSS right after egg retrieval. Two embryos were transfered on day 3, but they did not survive.
After my menses period, the pain still exists on both sides. I went to my IVF doctor who told me that my right ovary is enlarged with fluid in it. And the left one is collapsed, with no follicles seen. I used to have 3 - 4 follicles on the left.
I was assured that there’s no permanent damage caused by this cycle. Will those follicles grow back on the left ovary by itself and start ovulating again?
thanks,
Coco
tHannam
Dear Coco
During an IVF cycle, we aspirate (puncture) all of the follicles that we can see. We usually hope to retrieve 7-15 mature eggs; 18 was a very good number though can be associated with hyperstimulation as you described. Hyperstimulation leads to inflammatory fluid collecting around one or both ovaries, but more commonly around the right as most women have more eggs on the right hand side.
Following an uncomplicated cycle, we expect the ovaries will then “return to normal”, with the same number of eggs and follicles as before treatment. But it can take up to 3 cycles before they do. You would then expect to start ovulating normally again, with no new pelvic pain.
I cannot read your note without commenting on the relative lack of fertilization (2/18 eggs). Despite the fact that the sperm tests appear to be fine, next time you should consider ICSI, where the sperm are placed into the eggs. You should have more healthy embryos as a result, and thus a much better chance for pregnancy.
Allison
Hi Dr. Hannam,
Firstly–thank you! I have found your blog to be so helpful. My husband and I are both 32 y.o. Naturally TTC for 1 year. Over this year my cycles went from 27-28 days to 24-26 days so 15+ cycles in the calendar year. With home LH monitoring, we pinpointed ovulation between day 11-13. We are now at a fertility clinic-my concerns are low progesterone, my husband has low sperm court, motility, high abnormal and borlerline fragmentation. We are starting IVF. Lupron was started day 21. I worry that an early period will affect the process going forward, as I have expereienced brown-pink discharge but I have only been on Lupron for 6 days. ALso, I have had no communication that there are concerns about my egg quality but after reviewing your tutorial, I am concerned.
Many thanks,
tHannam
Dear Allison,
IVF (with ICSI) makes sense for significant male factor subfertility.
Cycles can be short for several reasons, but in your case, you ovulate at a normal time (day 11-13) so the short cycle is likely related to low luteal progesterone. That is a treatable situation: I’m sure during your IVF cycle they will give you progesterone support after transfer (it is routinely given to everyone).
In fact, your clinic must think that with normal ovulation, and your age, that you have very good eggs because they have put you on the long protocol. Hopefully, then, the cycle will go well. Based on the information you told me, it sounds like you should be good prognosis.
usha
Hi doc
For IVF , which one is ideal, day 3 transfer or day 5 transfer.
TGH replies,
Usha, the best day for transfer depends on your personal circumstances. For more, check out this post.
RR
Dear Dr. Hannam,
I am 31 years old. I have had two FSH Day 3 blood tests - one at 11.2 and the other at 10 (borderline normal values). Also I have had an AFC (ultrasound). One ovary contained 10 follicles and the other ovary contained 5 follicles. What do these values mean? Are my results normal? Based on these numbers do you think I would respond medications and IVF successfully?
In addition, I have had an HSG and a sonohysterogram - both tests confirm no spillage but fluid does enter the fallopian tubes. Are there any other tubal tests that can be conducted to confirm these results?
Thank you very much for your advice.
RR
TGH replies
Dear RR,
You have to get the tubal issue sorted out. There are three ways:
1. A ‘tubal cannulation’, an HSG where the doctor pushes a catheter through the fallopian tubes to clear them out.
2. Laparoscopic surgery to confirm the diagnosis (they push a blue dye through the tubes and watch it spill out)
3. Bypass the fallopian tubes and do IVF
I cannot tell you which way is best for you; you will have to ask your clinical team. Any of the options may be reasonable.
As you are under 35y old, you would expect to have many, many high quality eggs, but the FSH test results are only borderline-ok. (The antral follicle counts seem to be fine). Why might your ovarian reserve be low? Please ask your doctor if they suspect endometriosis or another condition that might have caused scarring of both your tubes and ovaries….that one explanation would account for both of your findings.
You could do an AMH test if your clinic offers it.
Another option: try fertility medications….if you respond well, then you know that everything should work out fine.
I hope that helps RR. I cannot provide better guidance without a proper meeting.
carrie b
Hi i am 32 years old and have recently had an appt with the regional fertility clinic and have been told that my follicle count is 4 which i understand is very low.
I have Graves disease, could this have caused my counts to be low like they are?
I have seen on many websites that a count of 4 has a very low probability of pregnancy. will they even suggest IUI or IVF for me ? thank-you
TGH replies
Carrie, Grave’s should not affect your ovarian reserve. For more on Grave’s and fertility, go here.
I agree, an AFC of 4 is low. But AFC is highly technical -sometimes they u/s people simply get it wrong. I strongly advise you also find out your day 3 FSH levels and, if available, your AMH. We can still hope for good news there.
But if all of the tests suggest that there is a low ovarian reserve, you may have primary ovarian insufficiency. POI is a difficult diagnosis, and beyond the scope of this blog format. Do not hesitate to call our office if you find that you need more help. But in the meantime, get those extra tests done.
Connie
Hi, I am 31 years old, my husband is 33, and we have been trying to conceive for 8 months. My cycle, until 9 months ago, used to be 28 days, like clock-work. However, my cycle varies now from month to month, some months with a 25 day cycle, some months up to 31 days. have also started spotting prior to my cycle, usually a brownish-pink discharge, and it happens approximately 24 hours prior to my cycle. This never used to happen before.
I have been using ovulation predictor kits, and it shows an LH surge usually on day 14, which I assume means I will ovulate any time between days 15 and 17. My doctor says that my change in cycle length is still in the normal range, and that they usually don’t consider any of this an issue until I have been trying for 12 months. However, I know my body, and I know that a lot of these things have changed and it’s not normal for me to have a cycle that varies from month to month. I also realize that if I ovulate on day 15 and have a 25 day cycle, then I may have a luteal phase defect.
Is there any advice you can give on what steps I should take next, or what possible treatments would be beneficial for someone in my predicament? I know you cannot “treat” me in this online forum, but what should I do next to start ruling out any problems with hormone levels, etc.? Thank you.
TGH replies,
Connie, I think you have done as much as you can from home. It is time to visit a clinic and do some basic tests.
The key for you will be to clarify ovarian reserve (antral follicle count, Day 3 FSH, and AMH if available) and peak hormone levels (estrogen should be at about 1000 on the day of ovulation, and progesterone over 30 one week later). From this information, you will be able to set your own expectations properly.
Noelia
I am 24yrs old and my husband is 25 we have been having unprotected sex for the past 5years and have never been pregnant. Last year we decided to go to a fertility clinic and I have done 2 cycles with 50mg of Clomid and 1 cycle of IUI with Clomid and 1 cycle IUI with Puregon but never got pregnant. Should I keep trying IUI’s or should I just wait for IVF?. My Cycles do come every month it will either come late or too early but for the past 4 months they have been every 30days. Any advice will be greatly appreciated.
Dear Noelia,
I think you should do IVF next.
For most couples with more than 2 years of regular cycles and well-timed intercourse behind them, IVF pregnancy rates are usually much, much higher than IUI. In your case (five years and all the advantages of age on your side) there is really no comparison at all.
But IVF is expensive for any couple, and the financial burden is usually hardest for younger couples, so I understand the significance of my advice…it may mean putting off your dream for some time. If you can get one, a proper second opinion is a good idea at this point.
Yours,
Tom Hannam
Erin
I am writing on behalf of my 31 year old friend who has been struggling with fertility problems (excess prolactin but regular periods) for 2 years in Toronto. I myself had a successful experience with PCOS - Metformin worked immediately after 1.5 years of other, more invasive interventions. My friend is taking bromocriptine and has been unsuccessful with IUI/ovulation induction. She feels that higher level interventions such as IUI and IVF will not be successful until her hormone issues are confirmed to be solved and she is producing healthy eggs and an environment for implantation. Do you have any recommendations before higher level interventions? I sincerely appreciate your professional opinion.
Dear Erin,
You are right that it is always preferable to have a clear assessment of the underlying causes of subfertility of before embarking on expensive and invasive treatments. Your personal experience validated that very approach.
Will solving your friend’s prolactin concerns be enough to help her achieve pregnancy? That would really be ideal, because prolactin control should be possible.
However, prolactin is rarely the only cause of subfertility (for more on prolactin, you could point your friend to my post here). There may be more to the story.
Jennifer
Dr. Hannam:
I am wondering how important cervical mucous is to conception. So far, all of my blood tests and ultrasounds have indicated that I am ovulating, and my progesterone level is apparently good. However, I have difficult tracking my CM. I normally have to bear down to produce a sample, and it is not abundant by any means. Does this indicate a problem?
TGH replies
There are two common risk factors for low cervical mucous:
1. cervical procedures (after an abnormal pap, some women may need multiple “LEEP” procedures and/or a cone biopsy)
2. low estrogen levels (seen in women with a BMI <18.5, or when egg quality may be falling, often age related)
Of course, there is also a natural variation between individuals.
Cervical mucous is thought to protect the sperm from the otherwise-harsh vaginal pH. As you may know, only about 1% of sperm will actually make it up into the womb…so, yes, some cervical mucous (and a reasonable ejaculate volume) are probably helpful.
That said, several oft-repeated solutions to improving the permeability or volume of cervical mucous (such as Robitussin cough syrup) have never been proven to improve fertility rates. So I suspect that, for most couples, the amount and consistency of cervical mucous is not a key variable.
That said, if it is a concern for you, the treatment would be intrauterine insemination. With IUI, you can bypass the cervix….ensuring that millions of sperm should reach the eggs.
Nathalie
Dr. Hannam:
My husband and I have been trying to conceive for almost two years. We had two failed IUIs. The first failed cycle I was taking Gonal-F 75 units. I started bleeding 7d after ovulation even though I was taking progresterone suppositories. The last time it failed I was taking Gonal-F and progesterone injections (1 cc) and started bleeding 10d after ovulation. My doctor assures me that I was prescribed more than enough progresterone. I am now doing a mock IVF cycle with Estrace and progesterone injections. A sonohystergram done recently was completely normal. What else could be the problem? Is there anything I can do to make sure I don’t start bleeding early?
Dear Nathalie,
Once other causes of irregular bleeding have been ruled out (eg normal sonohysterogram, normal pap, normal blood coagulation studies), we look to hormones to support the uterine lining in the luteal (post ovulatory) phase.
In my opinion, the ideal luteal support regimens include both estrogen and progesterone, as per your current cycle.
The relative safety of progesterone is relatively well documented; recent evidence supports the estrogen as well.
The next step, if anything more need be done, would be to add in HCG injections as well. But this is rarely necessary.
It sounds like you are receiving good care to this point, as you escalate the treatments in response to your particular situation.
Olive
Dr Hannam:
I’m just wondering if my age is the reason I’ve had 3 miscarriages.
I’m 44 and have been pregnant 3 times in the last 10 months, the first one lasted approx 7 weeks, the second approx 3 weeks and the last was 8 weeks. My periods are very regular and last 33 days. I had a sonohysterogram and the Dr said everything looked good I had a little “Dent” in my Uterus but he said that wouldn’t cause my miscarriages.
Any insight you can give me would be great, I’m trying again now and hope to be able to have the next pregnancy go full term but am a little scared I will have another miscarrigage.
Dear Olive,
Unfortunately, the risk for miscarriage rises with age, particularly over the age of 42y. It wasn’t so long ago that most Canadian clinics simply refused to see women over the age of 42 for that very reason. So, yes, the losses and your age are quite likely related.
On the other hand: you’ve been able to get pregnant each time rather quickly. One might continue to hope that an ongoing pregnancy is quite possible. From what you have written, it seems reasonable for you to continue to try at this time, despite the real emotional risks that you will be taking.
Shelly
Hello,
As I sure many women who write their questions are frustrated, I’m no different.
I’m type 1 diabetic with pcos. I get my period once a year if I’m lucky.
I’m on metformin and insulin and have been trying to get pregnant for 3 years.
Is there any hope for me?
TGH responds:
Dear Shelley:
Such irregular ovulation makes it very unlikely, if not quite impossible to achieve pregnancy.
But, PCOS is a diagnosis predicated on the assumption that the ovaries contain multiple immature follicles – that is multiple immature eggs.
When many eggs are present, we expect that the odds are high that there will in turn be enough good quality eggs that a pregnancy can usually be expected.
Of course, your sugars have to be in good control, you might want to get a uterine biopsy to ensure that the lining has not overdeveloped, a thyroid screen, and of course the other basic investigations for a subfertile couple including a semen analysis for your partner.
But with all that in place, there are a myriad of treatments for PCOS that can and should result in ovulation. Indeed, with active treatment the concern can quickly switch from too few mature eggs as you have now, to suddenly too many and the risk for multiples. I strongly recommend working closely with a fertility clinic, for three years is too long, and your prognosis could well be excellent. Good luck.