Am I Fertile or Not? Tests and Treatments

WebMD Live Events Transcript

Are you experiencing roadblocks on your journey to pregnancy? If you have been trying to conceive and thought you would be pregnant by now, join us to find out when to get help, and discover the reasons why you might be having problems conceiving. Eric Surrey, MD, joined our Preserving Your Fertility cyber conference on Sept. 29, 2004, with a look at the diagnosis and treatment of infertility.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

MEMBER QUESTION:
I've been on Clomid 50 milligrams for six cycles now and this is going to be my last cycle if unsuccessful. I've been trying to conceive for about 11 months now. My husband's SA came out above average. What should my next step be?

SURREY:
Typically the majority of women with unexplained infertility who conceive with the use of Clomid will do so within three cycles. We do see additional pregnancies in the subsequent three cycles; however after six cycles pregnancy rates are extremely poor. This is a time to complete one's evaluation. If a HSG has not been performed it should be performed at this time, as should both the ovarian reserve testing (day 3 FSH and estradiol levels). Many centers will also evaluate antisperm antibodies.

Typical options for therapy at this point would be to consider:

  • Laparoscopy
  • More aggressive fertility drugs
  • Gonadotropins with insemination
  • In vitro fertilization

MEMBER QUESTION:
What is ovarian reserve testing?

SURREY:
Ovarian reserve testing is a way of evaluating the likelihood that a woman will conceive with her own eggs. The most universally accepted test is to evaluate serum levels of FSH (follicle stimulating hormone), estradiol (a form of estrogen), and luteinizing hormones (LH) on the second day or third day of the menstrual cycle. Significantly abnormal tests suggest that a woman's likelihood of conceiving with her own eggs is extremely compromised. This is independent of her age. Unfortunately if the test is normal it does not mean she will conceive.

There are more sophisticated tests of ovarian reserve that are used by many centers. These include a measurement of "resting follicles," a Clomid challenge test, and less commonly used, a "lupron challenge" test.

I feel that some form of testing should be performed as part of the initial evaluation for all women complaining of infertility, regardless of their age.

MEMBER QUESTION:
Do you feel a laparoscopy is necessary to determine infertility?

SURREY:
That's an extremely controversial issue. Laparoscopy is not a mandatory part of the evaluation. Laparoscopy does provide information about pelvic anatomy that is not appreciated at either ultrasound or by hysterosalpingogram. Studies have shown that when women with otherwise unexplained infertility undergo laparoscopy abnormalities are identified in about 40%. These abnormalities include endometriosis, pelvic adhesions or scar tissue, and tubal abnormalities.

The goal of laparoscopy is solely not to be diagnostic, but also to be therapeutic. However, with the exception of a blocked and dilated fallopian tube (hydrosalpinx) there is very little that would be gained with performing laparoscopy in a woman who is planning to undergo in vitro fertilization. For example, we have recently published a paper that showed that surgical treatment of endometriosis does not improve pregnancy rates from in vitro fertilization, in comparison with a group of women undergoing in vitro fertilization with endometriosis who did not have their disease treated surgically.

"Although there is no question that the risk of miscarriage goes up as a woman gets older, that does not mean that you cannot have a perfectly healthy pregnancy."

MEMBER QUESTION:
I am 40 years old with a 9-year-old son. I have been trying to get pregnant for seven years. I have had three miscarriages (15 weeks, six weeks, eight weeks). The latest was yesterday. I have tried Clomid. It was no help. Previously, the doctor's advice has been "keep trying." Once I hit 4-0 the tune changed to "you should consider whether you want a child at 40." Any suggestions?

SURREY:
My heart goes out to you. Having a third miscarriage in a row creates a very different picture. I would strongly recommend that you consider undergoing an evaluation for possible causes of recurrent miscarriage, even though you have had a healthy child. We define recurrent miscarriage as a woman who had has had three pregnancy losses in a row. I would advise that you consult with a specialist who will help rule out possible structural causes, genetic causes, and immunologic causes. It would make sense to me to consider undergoing this evaluation before trying to conceive again.

Although there is no question that the risk of miscarriage goes up as a woman gets older, that does not mean that you cannot have a perfectly healthy pregnancy. But now is the time to evaluate.

MEMBER QUESTION:
I'm 40 and have been trying for a year to get pregnant with donor sperm via IUI and IVF. I ovulate plenty, but probably at my age many of my eggs are not good. Nothing seems to be wrong with any of my parts. Still, I wonder if there is anything I can do to improve my chances. Any suggestions?

SURREY:
This is a great question. It would be very important you also undergo ovarian reserve testing if this has not already been done. I recommend that women under 38 undergo a Clomid challenge test, which is a more sensitive test of evaluating ovarian reserve. If this test is normal, and the quality of embryos in your prior IVF cycles has been good, it would be reasonable to make sure that the embryos are genetically normal, a likelihood that declines as a woman ages.

You may be a good candidate to consider using preimplantation genetic diagnosis (PGD) in a subsequent IVF cycle. It might also be reasonable to consider changing sperm donors, particularly if the donor who you are currently using has not been involved in a prior pregnancy.

MEMBER QUESTION:
What options are there for the over-40 crowd with "high" FSH (17-24) besides egg-donor? All other numbers were in normal range and I am ovulatory. What are chances with IVF? Thank you.

SURREY:
There is no question that the combination of age over 40 and consistently elevated FSH levels join together to result in an extremely low likelihood of conceiving with your own eggs. In general, success rates with in vitro fertilization would be less than 5% in the best of hands. Unfortunately, most but not all women who conceive with elevated FSH levels tend to miscarry. This is primarily due to the fact that as FSH levels rise, the likelihood of genetically abnormal eggs begins to rise.

Fortunately, egg donation does represent a highly successful, although not ideal, approach. Alternative therapies can lower FSH levels, but unfortunately, merely lowering the level does not change the fundamental problem with egg quality. There are certainly women who conceive with in vitro fertilization or spontaneously in your situation, but the likelihood is extremely low.

MEMBER QUESTION:
I just turned 42 and have been TTC for eight months. When do you recommend I see a specialist? I have never been pregnant before.

SURREY:
Although the textbooks define infertility as a year of unprotected intercourse, I recommend that women over 38 seek evaluation earlier because there is less time to work with. I recommend this group of women consult their physicians after six months of unprotected intercourse to begin an evaluation.

MEMBER QUESTION:
Dr Surrey, Is there any way to know in advance if you're going to have trouble conceiving? Hubby and I want to put off TTC for a year or two, but if we're going to have difficulty, I'd rather start sooner than later.

SURREY:
There is no way to know absolutely whether you would have difficulty or not. However, two simple tests can be performed at this time with relatively little expense and virtually no risk to give you a partial impression. These would be the day 3 blood tests, which I have described (FSH, estradiol, and LH). If these are abnormal, this would tell us that you may not have much time to work with. It might also be reasonable for your husband to have a semen analysis.

Although these tests do not cover the full gamut of testing that we perform in an infertile couple, they will give you a snapshot of where you stand today.

MEMBER QUESTION:
I am 30 and my cycle was regular a year back. But now it's fluctuating between 27-33 days. And my flow stays for only a day or at the most 1 1/2 days. Do I have to do any tests or is this OK?

SURREY:
If you are not trying to get pregnant this is not a critical change. However, if you are trying to get pregnant I would recommend a simple evaluation to include the day 3 blood work, thyroid function testing, and measurement of a hormone called prolactin. If there are abnormalities, your doctor may want to institute a different form of therapy.

MEMBER QUESTION:
I am the mother of five. All are about 20 months apart. I am 35 and my husband is 33. We have never taken longer than two months to get pregnant before, but we have been TTC for the last five months and are still not pregnant. My husband has only one testicle. I have heard that sometimes after having so many children you need to have a D&C in order to conceive. My husband is wondering if maybe his sperm count is getting lower because of his age. Is there any truth to the D&C story I heard and is there some things my husband can do to increase his sperm count and any other tips you might have to help us conceive?

SURREY:
Congratulations on your five children. In the absence of any abnormalities in your uterus, which can be evaluated by an ultrasound evaluation, or so-called sonohysterogram, there is no evidence to suggest that a D&C plays any role in improving the likelihood that you will conceive. I would recommend that you consult your physician to consider testing sperm and ovarian reserve first. Good luck on No. 6.

MEMBER QUESTION:
Do you think it is important to find out the cause of irregular periods -- if you have always been severely irregular -- before starting something like Clomid? It seems like the same thing that is causing lack of periods could be a health problem during pregnancy.

SURREY:
I completely agree. I would not recommend starting Clomid therapy until an evaluation is done by your physician to see if there is an underlying problem that might be the cause of your irregular cycles. There are many things that can cause many conditions that can cause cycle irregularity. In fact, it is possible that after the result of your evaluation, it may be determined that Clomid is not the right treatment for you. So please request an evaluation first or consult a specialist in this regard.

"There is no evidence to suggest that a D&C plays any role in improving the likelihood that you will conceive."

MEMBER QUESTION:
My doctor has prescribed Clomid for LPD. Before that, she advised me my progesterone was too low and my LP too short. The first month I took 50 milligrams and was told my progesterone was still too low. I started 100 milligrams today. What is "normal" and how common is LPD?

SURREY:
LPD (luteal phase defect) implies that either a woman is not producing enough progesterone or the uterine lining is not responding well to the progesterone that is being produced. A short luteal phase (less than 12 days) can theoretically make it harder to conceive and increase the likelihood of miscarriage. It is interesting, however, that there has never been a research trial that has shown that LPD is a cause of infertility.

Clomid can stimulate the ovary to increase progesterone production. An increase in dose to 100 milligrams is not unreasonable. It is also reasonable to consider adding progesterone supplementation during the luteal phase.

MEMBER QUESTION:
Should FSH and LH only be checked on CD3 or can they be checked at other points in the cycle?

SURREY:
When FSH, E2, and LH levels are checked to evaluate ovarian reserve they should ideally be checked on cycle day 2 or 3. The E2 level begins to rise after this point. The FSH level begins to rise after cycle day 5.

MEMBER QUESTION:
Can those day 3 tests to get a "snapshot" of current fertility be done while I am still taking birth control, or do I need to stop for those tests to be accurate? If so, how far in advance should I switch to a nonhormonal method?

SURREY:
That is an excellent question. Birth control pills will falsely lower FSH levels. That is one of the ways in which they provide birth control. I would recommend that a woman be off of oral contraceptives for at least one full cycle before testing. Clearly, a nonhormonal form of contraception should be used during that time.MEMBER QUESTION:
My cycles are extremely long -- 56 days to be exact. What can I do to improve my chances of conceiving so as not to have to wait every other month to try to conceive? Does this mean that I might not ovulate?

SURREY:
Normal menstrual cycle length is from 26 to 32 days. It is possible that you are ovulating extremely late in the cycle, but this cannot be assured. The likelihood of conceiving with such long cycles is a bit compromised. I would recommend that you consult your gynecologist, ob-gyn, or a reproductive endocrinologist in an effort to figure out if there is an underlying problem that might be causing these long cycles, and to consider medical therapy to induce ovulation in a timelier manner.

MEMBER QUESTION:
I've tried four IVFs with donor sperm. I get about 12 eggs per cycle and most fertilize and grow, but no pregnancy. All tests are normal for hormones, patent tubes, and blood flow. Is there anything I can do to improve my chances?

SURREY:
There are two possibilities: One would be to evaluate the presence or absence of a protein that has been identified in the uterine lining, called the integrin. This protein seems to be more likely to be missing in women with unexplained infertility and endometriosis. This protein appears to play a role in implantation, although there are many other factors involved. Some researchers have shown that the protein returns and pregnancy rates go up after prolonged pretreatment with the drug Lupron or medications like it. This is certainly a controversial approach, but something, which we have had great success.

The other factor that should be addressed is whether the embryos are genetically normal. This can be evaluated by employing preimplantation genetic diagnosis (PGD) in a subsequent cycle. Then lastly, I would confirm the donor has previously been involved in pregnancies. If not, it might be reasonable to consider changing donors.

"The fact that a woman does not ovulate on a low dose of Clomid does not mean that she will fail to ovulate at all."

MEMBER QUESTION:
I recently had surgery for multiple ovarian cysts (approximately 50). I have PCOS and we were hoping this would stimulate the ovaries into ovulation. We had one failed round of Clomid -- no ovulation. Is it worth it to keep trying when I'm not even ovulating? Is there anything that I can do to ovulate on my own?

SURREY:
Not all women with PCOS respond in a similar fashion. The fact that a woman does not ovulate on a low dose of Clomid does not mean that she will fail to ovulate at all. There are many strategies that have been used. These include:
  • Increasing Clomid doses
  • Adding low doses of steroids to Clomid
  • Using an insulin sensitizing agent, such as glucophage in conjunction with the Clomid
  • Using more aggressive fertility drugs, such as the injectable drugs, called gonadotropins

I can't really tell you what is right for you, but you might consider seeking the help of a reproductive endocrinologist. It is unlikely that you would be able to regulate your cycles and ovulate regularly without medical help.

MODERATOR:
We are just about out of time. Do you have any final comments for us, Dr. Surrey?

SURREY:
I think it is important for women with concerns regarding their fertility to gain as much information as they can and to seek qualified, caring, and knowledgeable assistance to help make the right decisions for them.

MODERATOR:
We are out of time. Thanks to Eric Surrey, MD, for joining us. For more information about this and other fertility issues, be sure to explore all the TTC info here at WebMD, including our message boards and regular live chats with Dr. Amos Grunebaum.
You can also explore the web site of RESOLVE: The National Infertility Association, at www.resolve.org.



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