[kelliebelle]

My name is Kellie and my husband and I have been trying to conceive for 1 1/2 years. I took 6 months of clomid without success, so last month we visited a fertility specialist. Because of my age (39) the doc suggested aggressive treatment. Nothing like feeling like an old lady. He suggested we do blood tests and a clomid treatment first. Yesterday I went and had my blood taken for the first test. I'm not a baby (well, not too bad) but that tech wasn't very good at drawing blood. It hurt, and she took 4 vials of blood which kind of surprised me. If the blood tests are ok, I start my first dose of clomid monday and take it until friday. Then I go back to have my blood taken again next saturday. I am scheduled for an ultrasound and HSG on February 3rd. They told me to take 800 mg of ibuprofen prior to that. Yikes, must be in for some pain. But hopefully it will all be worth it. Then the doc will schedule the IUI and we'll see what happens. He did say that he recommends only trying the IUI 3 times and then the next step would be IVF. I hope it doesn't come to that, obviously.

[kelliebelle]

I called the doctor today for the results of my blood work. The nurse said that my level was 9.2, and normal is from 4-10. My level is high, but it's still within normal range. I am taking clomid for 5 days and then I'll have my blood tested again. The nurse said it would be good if my level goes down at least a little bit. Then next week it's the ultrasound and HSG which I'm not looking forward to but know it needs to be done. I don't even remember what exactly the blood work was testing for, but the nurse said the lower the better. They give me so much information that I don't remember half of it 5 minutes after I hang up the phone. It's all overwhelming. I'm also A positive which I think I knew in the past but had forgotten. Good thing to know.

[kelliebelle]

Day 3 follicle stimulating hormone: FSH
Follicle stimulating hormone (FSH) is one of the most important hormones involved in the natural menstrual cycle as well as in pharmacological (drug-induced) stimulation of the ovaries. It is the main hormone involved in producing mature eggs.

FSH is the same hormone that is contained in the injectable gonadotropins which are used to produce multiple eggs for infertility treatment.

When a women goes into menopause she is essentially running out of eggs in her ovaries. The brain senses that there is a low estrogen environment and more FSH is released from the pituitary gland in an attempt to stimulate the ovaries enough to produce a good follicle and estrogen.

You can think of it like stepping on the gas pedal in the car to get going. The FSH is the gas, and the pituitary gland releases FSH to get a follicle "going" at the beginning of every menstrual cycle. If there are less follicles left (and perhaps lower quality follicles) the "gas" has to be increased to get a follicle to start developing. In a menopausal woman, the gas pedal is on the floor for the rest of her life - even though there are no follicles (or eggs) left that are capable of developing, the woman's body never gives up trying and FSH levels are permanently elevated.

Women in menopause usually have FSH levels that are above 40 mIU/ml. As women approach menopause their baseline FSH levels (day 3 of their cycle) will tend to gradually increase over the years. When they run out of follicles capable of responding, their FSH will be quite high (over 30-40 mIU/ml) and they will stop having menstrual periods.

By measuring a baseline FSH on day 3 of the cycle (we do it on either day 2, 3, or 4), we can often get an indication that the women is closer to menopause and has relatively less "ovarian reserve". Another way of saying this is that if the baseline FSH is elevated the ovarian reserve (how many eggs are left) is reduced and sometimes also the egg quality is reduced. In other words, an elevated FSH represents a reduced egg supply (in numbers of eggs remaining) and it might also reflect a compromise of egg quality. However, in general, the best quick and easy "test" for egg quality is looking at the woman's drivers license - her age.

There are some practical problems associated with this test:
The cut off values used to say that egg quantity is good, ok, or poor is very laboratory dependent. What this means is that a given level of, for example, 12 in one laboratory may reflect good ovarian reserve and egg quantity - whereas the same level in another laboratory using a different assay may reflect poor ovarian reserve, poor egg quantity, and low live birth rates with IVF. See below for more on interpretation of results.
While an abnormal result (high baseline FSH) tends to be very predictive of poor egg quantity and quality, a normal result does not necessarily mean that the egg quantity and quality is good. There are a significant number of women with normal baseline FSH values that do have poor egg quantity and quality that is not being reflected in their FSH value.
This is particularly true for women in their 40s. An infertile 44 year old woman with a normal FSH (for example 6) still has a very low probability of conceiving and delivering with in vitro fertilization - or with any other fertility treatment. The fact that she is 44 greatly diminishes her chances - even if her FSH is normal. This is why IVF programs have age cutoffs. The oldest women accepted by IVF programs varies somewhat - most programs have a cutoff somewhere between age 42-45. Infertile women older than this will rarely be successful using their own eggs. However, women in their 40s are excellent candidates for in vitro fertilization with donor eggs.

Interpretation of day 3 FSH levels
In our fertility center we are currently using a DPC assay run on an Immulite machine. We consider normal for this assay to be under about 10. As levels go above 10 we often see a reduction in response to ovarian stimulating drugs as illustrated in the table below. If your levels were run with a different assay, you can not compare the results to those shown here with any confidence at all! For example, with some assays, a level of 14 is perfectly normal.

Day 3 FSH level Interpretation for DPC Immulite assay - 2007
Less than 10 Reassuring level. Expect a good response to ovarian stimulation.
10 - 12 Fair. Response is between completely normal and somewhat reduced (response varies widely). Overall, a somewhat reduced live birth rate.
12- 15 Reduced ovarian reserve. Usually show a reduced response to stimulation and some reduction in egg and embryo quality with IVF. Reduced live birth rates on the average.
15 - 20 Generally show a more marked reduction in response to stimulation and usually a further reduction in egg and embryo quality with IVF. Low live birth rates. Antral follicle count a very important consideration.
Over 20 Perhaps a "No go" level in our center. Very poor (or no) response to stimulation. "No go" levels must be individualized for the particular lab assay and IVF center. Antral follicle count a very important consideration.

Some caveats about day 3 FSH testing
In general, your ovarian reserve and your egg quantity is as bad as your worst FSH. If you have an FSH of 15 in one cycle and have it repeated in another cycle and get a 7 - the situation is not improving. Some women do "bounce around" with FSH levels in the normal to abnormal range - but they will generally respond and have chances for pregnancy more like those women who are consistently at their higher FSH level.

Waiting for a menstrual cycle with a lower FSH level and then stimulating quickly for IVF is probably of no benefit at all.

Young (e.g. under 35) women with elevated FSH levels stimulate better and have a higher IVF success potential than "older" women.

Day 3 estradiol
A blood estradiol level on day 3 (we do it on any day between days 2 and 4) of the menstrual cycle is a way to potentially discover some of those women with a normal day 3 FSH that may in fact have decreased egg quantity and quality. What we would like to see on day three is a low FSH level in conjunction with a low estradiol level. If the FSH is normal but the estradiol level is elevated, the elevated estradiol may be artificially suppressing the FSH level in to the normal range.

The idea of using day 3 estradiol levels as an adjunct in evaluating egg quantity and quality is relatively new. Clearly defined cutoff values for normal and abnormal are not well defined and are also lab-dependent. I like to see the day 3 estradiol less than about 80. In our experience, levels of 80-100 are borderline, and over 100 is abnormal. We like to repeat any borderline results in another cycle.

There is not much data that suggests that an elevated day 3 estradiol is a problem in itself. The problem is more so that it is potentially "masking" the detection of the poor ovarian reserve by suppressing an FSH level that would otherwise be elevated.

Clomiphene challenge test
A clomiphene challenge test is a dynamic type of test that can discover some cases of poor ovarian reserve that are still showing a normal day 3 FSH.

This test is done by:
Obtaining a day 3 FSH and estradiol
The woman takes two tablets of clomiphene (100 mg) on days 5-9 of the cycle.
Repeat an FSH level on day 10 of the cycle
The normal test would show a low FSH on day 3, a low estradiol on day 3 and also a low FSH on day 10.

Cut off values for the day 3 and the day 10 FSH values are very lab dependent and must be determined by experience with the laboratory being used. In other words, only your infertility specialist can interpret your results.

[kelliebelle]

Had my HSG today, and found a 1.5 cm fibroid/cyst and another smaller one in the right side of my uterus very close if not blocking that fallopian tube. The procedure itself wasn't that bad. I did have some aching in my lower back and alot of bleeding, but other than the fact that I had my legs spread in front of 5 people for a prolonged period of time, it was relatively painless. So my ultrasound for next week is canceled until I have surgery to remove the cysts/fibroids. It's an outpatient surgery, but I won't be awake for it. It's the first time I'll be under anesthetic, so I'm a little nervous about that, but I'm sure it will be fine. RE still wants me to finish up my clomid and have b/w taken again tomorrow. I sure hope my insurance kicks in alot for this, because I know it won't be cheap having all these tests and procedures done. But it will be worth it if everything works out.