QuestionQUESTION: Dear Dr. Ramirez,
I am 36 years old and recently started trying to conceive. My periods have always been irregular in length, and I have about 11 cycles per calendar year. Last month I had some unusual brown spotting and a delayed period, but home pregnancy test was negative. I had hormonal levels checked on day 3 of bleeding; fsh: 4.6, lh: 17, prolactin: 6.4
My gyn said all of these are normal, but that he thinks I should start taking clomid (after I have a pelvic ultrasound, and my boyfriend does semen analysis; my boyfriend is 46).
My question is, does this high lh to fsh ratio indicate a problem of some kind, or is it normal?
Would clomid be advisable simply given my age, even though we have only been trying to conceive for 3 months?
(I will try to see a fertility subspecialist once I can figure out how my insurance plan actually works for this).
Thank you for your advice,
S
ANSWER: Hello Susan,
You are wiser than your Ob/Gyn doctor. Your high LH/FSH level is an indication that you have an ovarian dysfunction called polycystic ovarian disease (PCOD). Disregard the name "polycystic" because it has nothing to do with that. In this disorder, there is a dysfunction within the ovary whereby the ovary is not processing the hormones correctly, which leads to the lack of ovulation. This subsequently throws off the entire cycle. This is not to say that you can't get pregnant naturally, many PCO's do, but it will be much more difficult. If you were younger (<30), you could continue trying on your own for at least a year. However, at 35 yo, most fertility specialists will recommend a more aggressive plan.
Of course seeing a fertlity specialist will be better, because they have more experience with your type of disorder, and will be more effecient with your time. But keep in mind, unless you are in a state that mandates fertility benefits, you may have to pay out of pocket. Most insurances don't cover infertility.
My approach would be as follows:
1. I would check a semen analysis, HSG, pelvic ultrasound and hysteroscopy to make sure all your basic functions are normal. Any abnormality in these would lead you straight to IVF, and rule out the option of ovulation induction.
2. Assuming these tests are normal, I would recommend ovulation induction with either timed intercourse or IUI. I would first try the ovulation induction with Clomid, as your doctor recommended. In your case, I would start at 150 mg and progress to 250 mg (max dose). The ultrasound should be used to monitor your progress with each cycle. That is, starting at cycle day # 10, an ultrasound should be done to look at the uterine lining and ovaries, count the number of follicles growing and measure them. If no response by cycle day # 16, then the cycle is terminated and your are given provera to start your period for 5-10 days. That way you can go directly into another cycle with a higher dose. If responding, then we monitor until the follicle is 18-20 mms at which point we give HCG to trigger ovulation. You then begin intercourse the following day for 4 consecutive days. This is then followed by Progesterone supplementation until the pregnancy test is draw two weeks later.
3. If Clomid does not work, then you have to move to injectable medications (gonadotropins) but because PCO patients usually respond to highly (greater than 5 follicles produced), most specialists would recommend proceeding with IVF.
I hope that this answers your questions.
Sincerely,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF
www.montereybayivf.com
---------- FOLLOW-UP ----------
QUESTION: Dear Dr. Ramirez,
This answer was very helpful, but I do have one further question. Can I be certain that this is PCOD based only on the lh/fsh ratio? Or is there some other possible explanation? Might the ratio vary from cycle to cycle? (based on stress for example?)
I am not obese: 5'4", 112 lbs, blood pressure is low, cholesterol low, I do not have oily skin or acne, no male pattern baldness, no excessive body hair, no diabetes, no sleep apnea, no unusual skin patches. When my ob/gyn checked my ovaries at last visit, he said they felt small (without evidence of cysts).
In most of my cycles, I notice egg white cervical mucus, and sometimes a spot of blood around mid-cycle.
Thanks so much for your attention to my questions.
Susan
AnswerHi Again,
You don't have the full form of PCOD, therefore you have periods. The problem is that your hormonal regulation is not normal. The LH/FSH ratio is sufficient to make the diagnosis. There are variations on the theme. Some patients are only discovered when they do an ovulation induction cycle and over-stimulate. As I mentioned, disregard the name "polycystic". This was given to the disorder a long time ago when they only noticed an abundance of follicles on ultrasound, within the ovary, and didn't know it was a hormonal disorder. You don't want to know the current real name because it is too long to say. Therefore, we continue to use PCO.
When the cervical mucus is properly estrogenized, it becomes clear and somewhat fluidy. You can stretch it between your fingers, called spinnbarkheit. That is what is tested when a post-coital test is done, although I don't do that test any more because it isn't of much value. The egg white mucus shows a lack of estrogen. It is possible that you may be ovulating at a later time in the cycle. You might consider using an ovulation predictor kit, but don't start it until cycle day # 12 or 13, just in case you ovulate later in the month. If the kit shows that you are ovulating, then starting the next day, have intercourse daily, only once per day, only one ejaculation per day, for four consecutive days. After that you can go back to your normal schedule.
Good Luck,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF
www.montereybayivf.com
