Are Your Periods Normal?

Reprinted with permission of IVF.com

Menstrual Cycle Evaluation
Ovulation assessment is an important part of every infertile couple's evaluation. A complete history and physical by your physician can often uncover obvious concerns. Although regular menstrual cycles suggest normal ovulation, that is not always the case. Normal ovulation is a complex process that requires many things to happen properly and at the correct time with the proper hormone levels. Often subtle hormonal imbalances or ovulation abnormalities result in "suboptimal fertility potential".

There are a number of tools that enable us to evaluate both overt and subtle disturbances of ovulation. We employ these techniques in performing an initial menstrual cycle evaluation or to assess the effectiveness of prescribed treatment plans. Thus, ovulation testing and monitoring become important tools for both detecting ovulation problems and monitoring the effectiveness of treatment.

A menstrual cycle evaluation may consist of many different components. You may need all or just some of the testing. This depends on which aspects of your ovulation ovulation we want to evaluate more closely. Thus, your cycle study will be personalized for your specific situation.

Evaluating your ovarian function may require the following tests:

•  BBT's (basal body temperatures)
•  Urinary LH testing
•  Transvaginal pelvic ultrasounds
•  Huhner's Test (post coital test)
•  Endometrial biopsy
•  Blood hormone testing (drawing blood to measure TSH & Prolactin. If you have excessive hairgrowth, obesity or acne we may add testosterone, DHEAS, 17-hydroxyprogesterone, fasting insulin and glucose, or dexamethasone suppression test).
• Evaluation of ovarian reserve (either cycle day 3 FSH/Estradiol hormone testing or a clomiphene challenge test).

You will be given specific information on each of the components that your physician has decided is needed to evaluate your ovulatory function. The results of these tests individually or in combination with other information will help your physician better determine the nature of your ovulatory function. The specific ovulation disorders that these tests are being utilized to rule out include:

1. Inadequate follicle growth patterns.
Each month (ovulation cycle) a follicle should develop and grow within one of the ovaries. This follicle is a small fluid filled cyst that contains the ovum (egg) destined to ovulate. It also produces the hormones estrogen and progesterone that ready the reproductive tract for conception and implantation. Disorders of follicular development can cause an inadequate follicular size or inadequate estrogen production which can interfere with implantation.

2. Premature luteinization.
In response to a sharp rise in LH, the follicle ruptures and the egg is released. The collapsed follicle forms a corpus luteum and begins to produce progesterone to ready the uterine lining for implantation (attachment) of a fertilized egg.

In patients with higher than normal serum LH levels, premature production of progesterone by the follicle may result in improper changes in the cervical mucus, tubal mobility, or endometrium (uterine lining). The elevated LH levels may also adversely effect egg quality. This problem is diagnosed by correlating follicle ultrasound results with hormonal testing.

3. Luteinized unruptured follicle syndrome (LUF syndrome).
Follicle rupture and release of the egg should occur within 38 hours of the urinary LH surge. Abnormal follicular development as well as pelvic adhesions can result in failure of the ovary to actually release the egg into the peritoneal (abdominal) cavity at the time of ovulation. This problem may be detected by correlating the follicle ultrasound results with urinary LH testing. HCG administration should correct this problem if it is due to a hormonal abnormality.

4. Inadequate luteal phase.
The uterine lining, stimulated by estrogen and progesterone, prepares itself each month to accept implantation of a fertilized egg. This preparation requires an orderly growth of the lining. Hormonal imbalances can result in the development of a uterine lining that is out of phase with the fertilized egg. Thus, implantation or attachment of the egg to the uterine wall does not occur appropriately. This problem can cause infertility as well as recurrent miscarriages and is called an inadequate luteal phase. An endometrial biopsy timed 12-13 days after your LH surge is utilized to assess the uterine lining development.

5. Diminished Ovarian Reserve.
With advancing age, egg quality and subsequently the chance of a normal pregnancy diminishes. The presence of normal, regular menses, does not necessarily mean you are releasing healthy eggs with each ovulation. This is most simply checked by measuring FSH and estradiol levels on the thrid day of the menstrual cycle. The predictability of this test can be improved by taking two tablets (100 mg) of clomiphene for five days and rechecking the FSH, LH and Progesterone levels. If the LH/FSH ratio is greater than 3 to 1, pregnancy is unlikely with clomiphene and other therapy may be indicated.

If the FSH or progesterone are elevated, you are demonstrating decreased ovarian reserve and may need to consider egg donation.

The clomiphene challenge and the cycle day 3 FSH are usually reserved for those with unexplained infertility or those over age 35.