Several methods are used to assess ovulation
and the "quality" of the eggs, which is referred to as "ovarian
reserve." As women age, both the number and quality of eggs continues
to decline. This decrease is termed "reduced ovarian reserve"
and is one reason why women in their thirties who are having difficulty
conceiving should not delay consulting an infertility specialist.
Menstrual history alone is sufficient
to establish a diagnosis of anovulation. Menses in normally ovulating
women generally are regular, predictable, consistent in volume and duration,
and typically accompanied by a recognizable pattern of premenstrual
and menstrual symptoms. Conversely, menses in anovulatory women generally
are irregular, unpredictable, or infrequent, vary in flow characteristics,
and exhibit no consistent pattern of symptoms.
The ovary produces progesterone
after ovulation, a natural hormone that supports pregnancy in the event
of conception. Progesterone increases the body's average temperature;
and accordingly, measurement of early morning basal body temperatures
is a method patients can use to monitor ovulation. The patient's temperature
is recorded every morning before leaving bed throughout the monthly
cycle.
An ovulatory pattern is one in which
the temperature before ovulation
( generally days 1 - 14 of the menstrual cycle ) fluctuates below 98
degrees Fahrenheit; after ovulation the temperature rises as much as
one degree Fahrenheit and fluctuates above 98 degrees Fahrenheit until
the next period. It is the rise in temperature that suggests ovulation.
BBT charts are less accurate than measurements of urinary hormone LH
levels. They are also inconvenient, as the temperature must be taken
daily. The main advantage of BBT monitoring is that it is much less
expensive than urinary LH measurements.
Another common method for evaluating
ovulation is to measure the blood progesterone concentration. In general,
any level greater than 3 ng / ml provides reliable evidence that ovulation
has occurred. A serum progesterone concentration is a simple, reliable,
minimally invasive, widely available, and reasonably cost - effective
test of ovulation.
A wide variety of different commercial
products now available allow women to determine not only if they ovulate
but also more precisely when they ovulate in advance of the actual event.
Generally known as " ovulation prediction kits " or "
LH kits ", these products are all designed to detect the mid cycle
LH surge in urine.
Ovulation predictor tests are performed for four
or five days during mid cycle beginning around cycle day eleven; the
increase in LH seen before ovulation is detected. There is a change
in the color of the test when the concentration of LH hormone increases
above a certain threshold in the urine. The interval of greatest fertility
includes the day of LH surge detection and the following two days.
This test predicts when ovulation will occur and is helpful in timing
inseminations ( IUI ) and intercourse to correspond
to the most fertile time of the cycle.
Endometrial biopsy is another test of ovulation,
based on the characteristic tissue changes resulting from the action
of progesterone. It is a relatively simple office procedure, usually
performed with one of the many disposable plastic aspiration cannulas
now widely available; complications are few. Pretreatment with a nonsteroidal
anti - inflammatory drug helps to reduce the pain or cramping associated
with the procedure. For women with prolonged ( chronic ) anovulation,
biopsy can identify or exclude endometrial hyperplasia that requires
specific treatment. In those few individuals who are suspected of
harboring a chronic endometritis,
biopsy can confirm what otherwise would go undetected.
Although still not providing positive
proof that ovulation actually occurred, serial transvaginal
ultrasound examinations offer detailed information about the size
and number of preovulatory follicles and provides the most accurate
estimate of when ovulation occurs
Studies originally performed at the Jones Institute
demonstrate that serum levels of the hormones that stimulate egg development
predict both the quality and quantity of eggs remaining in the ovary.
This is commonly referred to as "Day - 3
Labs" and consists of FSH, LH, and estradiol hormone level measurements,
typically performed on day three of the menstrual cycle.
Follicle
stimulating hormone ( FSH ) and luteinizing hormone ( LH ) are produced
by the pituitary gland after stimulation by GnRH produced by the hypothalamus.
The results of these measurements can help predict a patient's chance
of conceiving, determine the dose of FSH required for stimulation, and
provide several other details.
The Clomid challenge test is another way to
predict ovarian reserve. A poor result is an indication that advanced
reproductive technologies, using the patient's eggs, will not be successful.
Estradiol, FSH, and LH are measured on day three of the menstrual cycle.
Clomid is administered on day's five through
nine; the FSH level is measured again on day ten. An elevated level
on day ten is considered abnormal. Most patients who have an abnormal
Clomid Challenge test are advised to use donor eggs or seek adoption.
However, no one is automatically excluded from the IVF program at the
Jones Institute; based on this test, the couple decides if they wish
to proceed with IVF.
Anti-Mullerian Hormone
Anti-Mullerian hormone (AMH), is produced in granulosa cells of
ovarian follicles and is found in small follicles. Since AMH can be
measured in the blood, it can be used as a marker of ovarian reserve. We
at the Jones Institute, as well as others, have shown that AMH levels
can be used as a marker for ovarian aging, since the number of ovarian
follicles declines with increasing age. We have also shown that baseline
AMH levels drawn before the IVF cycle can predict oocyte number and
there is an association between low AMH levels and poor ovarian response
(fewer than 5 eggs) and high AMH levels and hyper-response (greater than
15 eggs).
Unlike other makers such as FSH, AMH levels can be drawn at any point
in the cycle, are not influenced by OCPs or Lupron and start to decrease
at an earlier point than the FSH levels increase. Since poor response in
IVF is associated with reduced AMH concentrations, this value can be
used counseling patients before a cycle, and can be used as a marker for
ovarian aging. The Jones Institute is currently involved in more studies
aiming to determine the true predictive value of AMH for ovarian
response to gonadotropins, as well as any association with pregnancy
results. AMH levels should be interpreted in conjunction with the other
more established markers of ovarian reserve, i.e., FSH, antral
follicular count and age.
Phone
800-515-6637 or 757-446-7100