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.

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.

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.

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.

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.

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

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.

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.

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.

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.