Diagnosing Infertility

As technology continues to advance and more men and women are talking about their struggles with infertility, couples are becoming more proactive about their reproductive health and seeking the expertise of a fertility specialist. On average, it will take a couple 5-7 months to conceive, so there’s no need to become concerned if it’s taking you more than a few months to get pregnant. But as more time passes without success, how do you know when it’s time to seek help?

Physicians often suggest seeking a complete fertility evaluation after 12 months of trying to conceive with no success when the female partner is under the age of 35, after 6 months when she is older than 35, and after 3 months if 40 and over. Beyond age, it is important to be aware of several medical conditions that indicate seeing a fertility specialist sooner. If any of the following conditions apply to you, it is probably time to make an appointment with a fertility specialist:

1. YOUR PERIOD IS IRREGULAR OR SOMETIMES DOESN’T COME AT ALL

Irregular periods usually mean irregular ovulation and no periods at all may mean ovulation is not taking place, making conception feel like an uphill battle. While there are many reasons why you may miss your period, ovulatory disorders are the leading cause of infertility for women.

“Ovulatory disorders broadly break down into two groups: no ovulation and oligo-ovulation (frequently due to PCOS), which is when ovulation occurs infrequently or irregularly,” explains Dr. Bromer. Medications such as Clomid and treatment options such as intrauterine insemination (IUI) can induce ovulation and help patients conceive faster. No matter your age, if ovulation is irregular or never occurring, seeking the help of a specialist can help get your reproductive system back on track.

2. YOU HAVE BEEN TRYING…..BUT NOT REALLY….

“During initial consultations with patients, I have many who say, ‘We haven’t used any forms of contraception in the past three years, but we have only really been trying to conceive for about six months.’ So what does ‘trying’ really mean?” asks Dr. Jason Bromer. “No matter if you have been actively trying or not, couples having unprotected sexual intercourse for more than 6 or 12 months, depending on age, should seek a fertility evaluation if they are not conceiving.”

“We can order specialized testing to detect subtle causes of infertility,” says Dr. Bromer. Based on the information learned through testing, fertility specialists can offer several low-tech treatment options to start, which are often covered by insurance.

3. YOU HAVEN’T HAD A COMPREHENSIVE FERTILITY WORK-UP….AND TREATMENT HASN’T BEEN SUCCESSFUL YET

At Shady Grove Fertility, the very first thing your fertility specialist will do is review your medical history and initiate fertility testing for both partners.  It is very important that each of the following tests be performed prior to initiating any kind of fertility treatment, because a complete evaluation of the male and female reproductive functions are required to determine the cause of infertility and identify the most effective course of treatment.

These basic tests include:

• Day 3 bloodwork: tells you if your reproductive hormones are functioning normally.
• Anti-Müllerian hormone (AMH) test: tells you how many eggs you have.
• Hysterosalpingogram (HSG): tells you if your uterus is shaped normally and if your tubes are open.
• Semen analysis: tells you if your partner has enough sperm and if they are healthy.

4. THE SEMEN ANALYSIS IN YOUR FERTILITY WORK-UP CAME BACK ABNORMAL

While often considered a female health concern, 40 percent of all infertility cases are in part due to male factor infertility. If you have received abnormal semen analysis results, you should see a fertility specialist right away. When the male partner’s sperm count is low or of poor quality, it can make conception significantly more difficult. Seeing a fertility specialist can help to determine the severity of a potential male factor diagnosis and offer a range of solutions to help you conceive. “The good news if you have a low sperm count is it only takes a single sperm to make a great embryo,” says Dr. Bromer. Modern reproductive technology like in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) can help patients with even the lowest sperm counts overcome infertility.

5. YOU HAVE EXPERIENCED TWO OR MORE MISCARRIAGES

It is a common misconception that women who have miscarriages are just fine because they are able to get pregnant. “In fact, having multiple miscarriages is a very specific type of fertility problem that affects 1-3 percent of all couples,” explains Dr. Bromer. “The majority of miscarriages can be attributed to genetic abnormalities in the embryo, while other causes include hormonal problems like diabetes, thyroid disease, undetected structural problems in the uterus, and advanced reproductive age.”  Anyone who has experienced two or more miscarriages should see a fertility specialist.

IT’S TIME TO SEE A FERTILITY SPECIALIST

Making the move to see a fertility specialist is a big step for many people. Patients often second-guess themselves about the need to see a specialist, or they worry that it won’t work or how will they afford it. It’s best to take it one step at a time. By scheduling a new patient consultation–which is covered by insurance in 90% of cases–you will get the answers you need to help you move forward. Shady Grove Fertility’s specially trained reproductive endocrinologists are among the best in the field and are dedicated to working with each patient to overcome their infertility.

Medical Contribution by: Jason Bromer, M.D., of Shady Grove Fertility’s Frederick, MD office. 

Early intervention offers the best chances of success, so let us help you get started. To learn more about our simple fertility evaluation or to schedule an appointment, please call our New Patient Center and one of our New Patient Liaisons will happily assist you. Please call 1-877-971-7755 or click to complete this simple form.

At Shady Grove Fertility, we’re here to give you the caring support you deserve as you start or grow your family. As a leading fertility and IVF center of excellence, we offer patients individualized care, innovative financial options, over 30 accepted insurance plans, and pregnancy rates among the highest of all national centers. We offer patients the convenience of 19 full-service and 6 satellite locations across Maryland, Pennsylvania, Virginia, and Washington, D.C. More than 1,700 physicians choose Shady Grove Fertility to refer their patients, and more than 96 percent of our patients say they would recommend Shady Grove Fertility’s 35+ physicians to a friend. With 10 Shady Grove Fertility babies born each day, your dream of starting or growing your family is within reach.

As you enter into the journey of fertility treatments—whether it’s to conceive or to preserve your ability to conceive in the future through egg freezing—there are many tests that your doctor will order. One of these tests is to evaluate the number of eggs remaining within your ovaries, called your ovarian reserve. There are many tests that your doctor may use to help predict your ovarian reserve. One of these tests is your anti-Müllerian hormone (AMH) level.

Each egg in the ovary is housed in a follicle. The follicle is made up of cells that support egg maturation and produce hormones. The anti-Müllerian hormone is produced by the supporting cells of follicles—called granulosa cells. It’s from these granulosa (supporting) cells in follicles that recruit an egg from the dormant pool of resting follicles (but are not yet ready to be stimulated to ovulate) that AMH is produced. Because your AMH level is not influenced by where you are in your menstrual cycle, you can have your AMH level measured at anytime. While your AMH level is related to your ovarian reserve, and therefore your egg number, it does not necessarily provide information about your egg quality.

What does your AMH level reveal?

Studies show that physicians can use an AMH measurement to help predict the response to treatment, or the number of eggs expected to be retrieved. While it doesn’t predict the quality or potential of those eggs, the number of eggs retrieved is important because the greater the number of eggs, the higher the probability of pregnancy.

What does your AMH level say about egg quality? 

Unfortunately there is not a simple test for egg quality. As a woman ages, the size of her ovarian follicle pool decreases and her egg quality declines. Subsequently, the probability of a healthy pregnancy declines.

A woman’s AMH level decreases until it is undetectable at the time of menopause.

At Shady Grove Fertility, your doctor will use both your AMH level and your age to help predict your success with fertility treatment and determine which treatment options are good options for you. Similarly, if you’re considering egg freezing, your physician will test your AMH level to determine if you’re a good candidate for the process.

What is a normal AMH level?

Although the test has been in routine use for many years, experts have yet to reach a consensus when it comes to what’s considered “normal.” The graph below has AMH interpretation guidelines:

While each woman is different in where her ovarian reserve starts and the rate of change that occurs, the one thing in common is that ovarian reserve naturally decreases as women age. This is largely genetically determined; however, there are environmental factors that play a role as well. Smoking is a well known environmental factor that can damage the eggs leading to an accelerated rate of decline in egg numbers and early menopause.

What medical conditions affect the AMH level in your body?

Women with polycystic ovary syndrome (PCOS) generally have a higher number of early antral follicles resulting in a higher baseline AMH level. Women who are older, or who have undergone medical treatments that are toxic to the ovaries (such as chemotherapy or radiation therapy) may have a lower number of eggs remaining and therefore a lower baseline AMH level.

The most important modifying factor of ovarian reserve is age. A younger patient (<35 years old) who has a decreased ovarian reserve may still have high egg quality because of her age. Age—in combination with an assessment of ovarian reserve and the other elements of your fertility—is important when considering egg freezing.

How do physicians test the AMH level?

Your primary care physician, OB/GYN, or reproductive endocrinologist can order AMH testing as part of ovarian reserve testing. The clear results provided through AMH testing—even better than follicle-stimulating hormone (FSH)—and its ability to identify a diminished ovarian reserve offers providers information earlier regarding a potentially serious fertility problem.

For more information about AMH testing and egg freezing, please speak with one of our New Patient Liaisons by calling 1-877-411-9292.
Medical contribution by Stephanie Beall, M.D., Ph.D., of the Shady Grove Fertility Columbia and Towson, Maryland offices.

When a woman is considering her family planning options—whether she’s actively trying to conceive or thinking of what her choices will be in few years—knowledge is power. Basic female infertility tests can provide valuable insight into a woman’s current fertility potential. Whether the infertility tests suggest reassuring results or paint a less than ideal picture, you will have information to make important decisions about your family planning.

Infertility Tests: AMH & FSH

For many women, the first step will be an appointment with their OB/GYN for blood tests to evaluate their hormone levels. One of the main goals when looking at a woman’s hormone levels is to predict the status of her ovarian reserve. Your ovarian reserve tells your physician roughly how many eggs you have remaining, which can give your physician an idea of how your fertility compares now relative to other similar aged women.

Physicians generally start with two hormone measurements to determine current ovarian reserve: follicle-stimulating hormone (FSH) and anti-Müllerian hormone (AMH). Together, FSH and AMH give your physician the greatest insight into your current ovarian reserve.

What is follicle-stimulating hormone (FSH)?

Follicle-stimulating hormone (FSH) is released by the pituitary gland and is responsible for recruiting and developing follicles in the ovary which usually contain an egg that’s released during ovulation. Traditionally, testing a woman’s FSH levels is one of the most common infertility tests performed.

As you age, the number of eggs you have remaining decrease, your pituitary gland needs to work harder to recruit a follicle. As a result, the pituitary gland produces a higher level of FSH, which is then seen in your day 3 bloodwork. This high level of FSH is correlated with infertility.

FSH levels fluctuate throughout your monthly cycle. To determine the most accurate FSH level, infertility tests are done on days 2, 3, or 4 of your menstrual cycle along with estradiol.

“While the FSH level is helpful for your physician, it certainly isn’t without limitations,” explains SGF reproductive endocrinologist, Jeanne O’Brien, M.D. (Rockville, MD). “For example, the level of FSH can vary from month to month. One month the level may be high where the next month it would fall into what we would consider to be a normal range for the patient’s age,” Dr. O’Brien adds. Your physician will obtain multiple assessments of your ovarian reserve as no single test is conclusive. A comprehensive picture is obtained by factoring your age, FSH, estradiol, AMH and antral follicle count on ultrasound.

What is anti-Müllerian hormone (AMH)?

In 2015, the American College of Obstetricians and Gynecologists (ACOG) issued new recommendations and criteria for ovarian reserve testing. While doctors only used FSH to determine ovarian reserve in years past, ACOG now recommends that doctors include AMH testing as well. Unlike FSH, which may vary day to day and month to month, AMH is more consistent and, when combined, AMH and FSH provide the best insights compared to FSH alone.

AMH is produced by the granulosa cells that line the tiny follicles within the ovaries. Your physician can test AMH at any time as the number of granulosa cells remains consistent throughout your menstrual cycle. As the number of available eggs in a woman’s ovarian reserve begins to decline so does the corresponding AMH level. AMH has been found to reflect the quantity of remaining eggs. A low level of AMH reflects a lower ovarian reserve where as a high level of AMH would indicate a higher ovarian reserve.

Beyond providing insights into a woman’s ovarian reserve, AMH also helps your physician determine the appropriate type of treatment and subsequent protocols. “Women with higher AMH values will likely respond more positively to ovarian stimulation and treatments such as egg freezing, intrauterine insemination (IUI), and in vitro fertilization (IVF),” explains Dr. O’Brien.

“We have found that women with lower AMH levels tend to require greater amounts of stimulation medication and produce smaller numbers of eggs. As a result, when AMH levels are lower than expected, your physician may recommend more advanced treatment options sooner such as IVF or IVF with donor egg,” explains Dr. O’Brien. For women interested in egg freezing this may indicate that additional cycles may be needed to achieve the desired number of mature eggs to freeze.

When should I transition from my OB/GYN to a fertility specialist?

Most recommendations for when to seek the help of a fertility specialist are based on the female partner’s age and how long the couple has been having unprotected intercourse. For example if you’re younger than 35 and have been having unprotected intercourse without conception for 1 year, it is appropriate to get a complete fertility evaluation, which includes a semen analysis for the male partner.

For women with decreased ovarian reserve, despite the female partner’s age and length of time trying to conceive, it is appropriate to complete infertility testing immediately since the window of opportunity may be smaller. In these situations we recommend seeking a complete fertility work-up from a fertility specialist. This saves patients time and gives them access to advanced fertility information and treatments that otherwise are not available at an OB/GYN’s office.
Women who are interested in egg freezing, should consult with a fertility specialist to assess their available options.

References:

American Society of Reproductive Medicine. (2015). Diagnostic testing for female infertility. Reproductive Fact Sheet. 

Ovarian reserve testing. Committee Opinion No. 618. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:268–73.

Wilkes, S., Hall, N., Crosland, A., Murdoch, A., Rubin, G.  (2009). Patient experience of infertility management in primary care: an in-depth interview study. Family Practice Advance Access. 26(4), 309-316.