Evaluating Ovarian Function
One of the most common fertility diagnoses, ovulation disorders are usually easy to treat. The female ovaries provide two key functions: they produce a mature egg to be available for fertilization each month (ovulation) and they deliver the hormones estrogen and progesterone, which are essential to establishing and maintaining pregnancy. A hormone is a ‘chemical messenger,’ that influences a given cell, organ or function in the body. Hormones regulate vital functions such as growth, metabolism, sexual function and reproduction. While up to 20 percent of infertile couples are diagnosed with ovulation disorders; 90 percent of women are able to achieve ovulation, with most all becoming pregnant depending on a woman’s age.
There are a number of ways to tell whether a woman is ovulating regularly and producing sufficient amounts of hormones:
Medical examination. The first step in assessing ovarian health is to receive a complete physical and pelvic examination, as well as a detailed medical history. Such an exam will also note:
- Menstrual history (the patient’s history well as that of relevant family members). If a woman is not having regular periods, or is not menstruating at all, this is a clear indication that there is a problem with ovulation.
- Sexual and contraceptive history
- Any previous pelvic surgery
- Marked weight gain or loss, and assessment of nutritional status as well as diet and any history of anorexia or bulimia
- Recent stressful events
- Exercise level
- Health of the adrenal, thyroid and pituitary glands, responsible for moderating key reproductive hormones
Pelvic ultrasound. Ultrasound exposes part of the body to high frequency sound waves in order to produce an image of that area. The ultrasound is brief, non-invasive and painless. For a pelvic ultrasound, a slender instrument called a transducer is inserted into the vagina. The transducer sends out high frequency sound waves and then listens for returning echoes from tissues in the body. The resulting image, viewed in ‘real time,’ can indicate the health of the ovarian egg follicles as well as any problems such as ovarian cysts.
Serum Progesterone, Thyroid and Prolactin blood tests. These are blood tests to measure hormones essential for establishing and maintaining healthy pregnancies:
- Serum progesterone test. This measures levels of the ovarian hormone progesterone, which plays a vital role in pregnancy. Given approximately one week before the menstrual cycle begins, this blood test can provide one of the simplest and accurate methods of detecting ovulation. Since progesterone levels can fluctuate normally throughout the day, measuring the progesterone value is not as helpful as once thought in determining the hormonal quality of the ovulation.
- Thyroid Stimulating Hormone (TSH) test. Thyroid hormones impact the reproductive system. Both high and low thyroid levels can interfere with hormonal functions essential to ovulation and establishing pregnancy.
- Prolactin test. This hormone is responsible for producing breast milk and is important to pregnancy, however, a high level can inhibit ovulation.
Basal body temperature graph (BBT). This is a way to chart the menstrual cycle in order to see when a patient tends to ovulate. The day after ovulation, and through the end of the monthly menstrual cycle, there is a rise in the progesterone hormone. Progesterone supports the endometrium or uterine lining, creating a nourishing environment for the fertilized egg. With this rise in progesterone comes a rise in body temperature. By tracking these temperature changes, one can estimate their ovulation pattern.
While basal body temperature charting is a simple and inexpensive way to make sure ovulation is occurring, normal variations in temperature can sometimes be misleading and the rigors of taking one’s temperature every morning can be frustrating. In addition to this, the temperature does not rise until AFTER ovulation has occurred so charting cannot be used prospectively to time intercourse. For these reasons, we no longer routinely recommend BBT testing.
Ovulation Predictor Kit (OPK). This provides the only method of actually predicting when ovulation will occur. The test requires a woman to urinate on a stick. The stick then indicates whether there is a rise in the LH or luteinizing hormone responsible for triggering ovulation. For most kits, a positive result means that ovulation will occur within 24 hours. The kit is useful for timing intercourse or insemination. Because it measures the key hormone responsible for ovulation, it can also indicate whether ovulation is or is not actually occurring. We recommend the “Clear Blue Easy” brand of digital test sticks, found in most drug and grocery stores.
Evaluation of egg quality. The other key ovarian function, egg production, can be evaluated through blood tests given at key times in the menstrual cycle. Such tests can indicate the quality of a woman’s eggs, and also the status of the body’s egg supply or ovarian reserve.
It is important for the patient’s physician to know the status of egg production and quality, in order to make treatment decisions that make sense for them. Even when hormone levels indicate that there is diminished egg quality, a woman’s body is often perfectly capable of supporting a pregnancy. In these cases, egg donation (in which a recipient mother uses the eggs of a younger woman) can be very successful.
FSH (follicle stimulating hormone) and Estradiol blood test. Given on day 2 or 3 of the menstrual cycle, this test measures FSH, the primary hormone responsible for prompting egg production, and also estradiol, the most important estrogen hormone, responsible for ovarian health and the growth of the reproductive organs. As women age and egg production decreases, FSH and estradiol levels will increase. This increase signals that the body is having difficulty making eggs and is working harder to ‘make up’ for this shortfall. The ideal FSH level on cycle day 2 or 3 is between 4 and 8 mIU/mL. Lower levels are better than higher levels. Any level greater than 10 mIU/mL suggests a problem with ovarian reserve. The ideal Estradiol level is between 30 and 50 pg/mL and mostly helps to validate that the FSH was drawn at the correct time of the cycle.
Anti-Mullerian Hormone (AMH). A newer test is the Anti-Mullerian Hormone test. This hormone is directly produced by developing follicles in the ovary and is less dependent on where a woman is in her cycle. The ideal level is 1.0 or higher. Higher levels are better.
CCT (Clomid challenge test). This is a more extensive measure of egg supply, in which FSH and Estradiol hormone levels are measured before and after the woman takes the fertility drug Clomid.
Evaluating lack of menstrual cycle. Women who appear to have no menstrual cycle may be given a progesterone-like drug called Provera in order to prompt menstruation. If menstruation after Provera occurs, this indicates that the estrogen hormone is being produced, which in turn indicates a healthy uterus. Lack of menstruation after receiving the Provera may be a sign that the brain’s pituitary gland, responsible for controlling hormone output and balance, is unable to function properly. As long as there is no indication that the woman has entered menopause (such as very high FSH levels), the condition causing lack of ovulation can usually be remedied.
Evaluating fallopian tube function. The delicate fallopian tubes are the pathway to fertility. At ejaculation, sperm are deposited in the vagina and then swim through the cervix and uterus and into the fallopian tube, where they meet and fertilize the egg. Contractions of the fallopian tube smooth muscle and movements of microscopic fimbriae lining the tubes moves the fertilized egg (embryo) back down through the tube to the uterus. Because any blockage or damage to this fragile mechanism can interfere with conception, assessing tubal health is a primary step in evaluation. In many cases, tubal problems can be treated. The following tests are commonly used to determine tubal health:
Hysterosalpingogram. This is an X-ray exam, during which a small amount of dye is injected into the uterus and fallopian tubes. The X-ray is viewed on a screen as the exam is conducted. As the dye disperses, it illuminates any blockages (such as scar tissue or fibroids) that could prevent eggs from traveling to the uterus. The procedure also enables the doctor to view the structure of the uterus itself to see that it is ready to accept a fertilized egg. HSG is performed in the 2nd week of the menstrual cycle (i.e. after menstrual bleeding has stopped but before ovulation). The entire exam takes about 10 minutes. Side effects, if any, include cramping and pelvic pain. Taking Ibuprofen prior to the procedure can help with these symptoms. Most women can resume daily activities right away.
Conditions that may cause infertility
A thorough infertility evaluation can alert a patient’s doctor to conditions in the male or female reproductive system that may be leading to infertility. Click on the below links for a detailed description of some of the more common disorders as well as information about diagnosis and treatment.