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Polycystic Ovarian Syndrome

Be sure and read the articles on polycystic ovarian syndrome (PCOS). Many overweight women who do not ovulate regularly may have elevated levels of male hormones (androgens) due to PCOS. PCOS occurs in both slim and overweight women.

Our articles discuss the diagnosis and treatment of PCOS in great detail. Several reproductive endocrinologists have submitted articles on this topic.

Fertility Tests -Hormonal Assessment

FSH/LH- Developing follicles produce estrogen which signals the hypothalamus to increase or reduce the amount of FSH produced by the pituitary gland. When "good" follicles are not developing, estrogen levels are lower and more FSH is produced. This leads to higher levels of FSH on day 3.

Day 3 FSH fertility test is not the only parameter used to assess ovarian reserve. Poor ovarian reserve is indicated by an FSH of >9, a high FSH/LH ratio (>2.5) even in the presence of a normal FSH or a high E2 level (>60 pg./ml). We also use the clomiphene citrate challenge test to help determine ovarian reserve.

A woman who has poor day 3 hormonal results, especially if she is older, should consider using an egg donor. Success rates are high and match the donor's age group. For example, embryos from a healthy 23 year old that are placed in a 45 year old will retain the pregnancy rate of the younger female.

b-hCG- Human chorionic gonadotropin (b-hCG) is produced by the placenta and elevated levels indicate that pregnancy has occurred.

Thyroid-Thyroid hormones are produced by the thyroid gland and levels are measured with blood tests. Hypothyroidism (low levels) can cause anovulation and early pregnancy loss. Hyperthyroidism (high levels) is associated with many abnormal conditions including irregular ovulation, fetal abnormalities, and premature labor.

Androgens-Elevated androgen levels (male hormones) can case irregular or absent ovulation and are seen in conditions such as polycystic ovarian disease. Elevated androgen levels are also associated with obesity. Women with excess androgen usually have excess body hair and oftentimes a characteristic pear shaped body appearance.

Clomiphene Citrate Challenge Test (CCCT)-Each month one follicle will become dominant, develop under the influence of FSH, and be ovulated. Ovarian reserve is an indication of the "quality" of the eggs remaining in a woman's ovaries. Egg quality, and ovarian reserve, naturally decline as women age and approach menopause. Some women experience this decline earlier in life (for unknown reasons) and this is a common cause of sub fertility.

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Levels of the hormones FSH, LH, and estradiol are measured on day 3 in the infertility workup. An elevated FSH level on day 3 is one indication of poor ovarian reserve. The clomiphene citrate challenge test (CCCT) provides an another more accurate measure of ovarian reserve. It is performed by measuring the day 3 FSH and estradiol levels, the patient takes 100 mg of Clomid on cycle days 5-9, and her FSH is measured again on day 10. The test is abnormal if either the day 3 or day 10 FSH values are elevated or if the day 3 estradiol is greater than 80 pg/ml.
A poor CCCT test, regardless of patient age, indicates that their will be a decreased response to injectable FSH in assisted reproductive technology cycles. Pregnancy success rates are very low in these women and there is an increased chance of miscarriage.

Prolactin Levels

Prolactin is the hormone responsible for stimulating milk production in pregnant women. Elevated prolactin levels can cause irregular ovulation as seen in the condition known a "hyperprolactinemia".

Elevated prolactin levels in the absence of pregnancy usually indicate the presence of a small benign tumor on the pituitary gland. These tumors can be effectively treated with medication (bromocriptine) or surgery.

(Contributed by Muasher Center for Fertility and IVF)