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Archive for the ‘estradiol level’ tag

Reasons to Consider Annual Fertility Screening

By David Kreiner MD

December 19th, 2014 at 8:01 pm


credit: akeeris/

What Is Fertility Screening?

Fertility screening starts with a blood test to check the levels of FSH (follicle stimulating hormone), estradiol and AMH (antimullerian hormone). The FSH and estradiol must be measured on the second or third day of your period. The granulosa cells of the ovarian follicles produce estradiol and AMH. The fewer the follicles there are in the ovaries the lower the AMH level. It will also mean that less estradiol is produced as well as a protein called inhibin. Both inhibin and estradiol decrease FSH production. The lower the inhibin and estradiol the higher the FSH as is seen in diminished ovarian reserve. The higher the estradiol or inhibin levels are then the lower the FSH. Estradiol may be elevated especially in the presence of an ovarian cyst even with failing ovaries that are only able to produce minimal inhibin. However, the high estradiol reduces the FSH to deceptively normal appearing levels. If not for the cyst generating excess estradiol, the FSH would be high in failing ovaries due to low inhibin production. This is why it is important to get an estradiol level at the same time as the FSH and early in the cycle when it is likely that the estradiol level is low in order to get an accurate reading of FSH.

The next step is a vaginal ultrasound to count the number of antral follicles in both ovaries. Antral follicles are a good indicator of the reserve of eggs remaining in the ovary. In general, fertility specialists like to see at least a total of eight antral follicles for the two ovaries. Between nine and twelve might be considered a borderline antral follicle count.
As you start to screen annually for your fertility, what you and your doctor are looking for is a dramatic shift in values from one year to the next.

What Does the Screen Indicate?

A positive screen showing evidence of potentially diminishing fertility is an alarm that should produce a call to action. When a woman is aware that she may be running out of time to reproduce she can take the family-planning reins and make informed decisions. The goal of fertility screening is to help you and every woman of childbearing years make the choices that can help protect and optimize your fertility.

Although none of these tests is in and of themselves an absolute predictor of your ability to get pregnant, when one or more come back in the abnormal range, it is highly suggestive of ovarian compromise. It deserves further scrutiny. That’s when it makes sense to have a discussion with your gynecologist or fertility specialist. Bear in mind, the “normal” range is quite broad. But when an “abnormal” flare goes off, you want to check it out. It’s important to remember that fertility is more than your ovaries. If you have risk factors for blocked fallopian tubes such as a history of previous pelvic infection, or if your partner has potentially abnormal sperm, then other tests are in order.

Regardless of the nature or severity of the problems, today, with Assisted Reproductive Technology and the latest Egg-freezing technology, there is a highly effective treatment available for you.

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Have you had a fertility screening yet? Did you find it helpful? Do you have any questions for Dr. Kreiner?

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Infertility Podcast Series: Journey to the Crib: Chapter 6 Have You Had A Fertility Workup?

By David Kreiner MD

March 18th, 2013 at 7:33 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Six: Have You Had a Fertility Workup? You, the listener, are invited to ask questions and make comments.  You can access the podcast here:

Have You Had A Fertility Workup?

A fertility specialist called a Reproductive Endocrinologist, who has performed a three year fellowship training in IVF and infertility after an Obstetrics and Gynecology residency, will initiate the fertility workup by conducting a history and physical examination.  The exam includes a pelvic ultrasound of a woman’s uterus and ovaries to determine if there are any abnormalities that may affect implantation or pregnancy, as well as assess ovarian activity and the presence of endometriosis.

Different causes of infertility will be tested.  The most common factor, that affecting the male, is easily tested with a semen analysis.  Tubal obstruction preventing a woman’s eggs from reaching the sperm can be ascertained by a hysterosalpingogram, a radiograph of the uterus and fallopian tubes performed after injecting radio-opaque contrast through the cervix.

Other tests to better delineate problems in the uterine cavity may be performed such as a hydrosonogram, where water is injected through the cervix and the cavity inspected by vaginal sonography or with hysteroscopy, where a scope is placed through the cervix to directly inspect the uterine cavity.

Blood tests may be performed to assess ovarian activity, in particular day 3 FSH and estradiol levels and AntiMullerian Hormone.  Prolactin and TSH levels are checked to rule out other hormonal disorders that may affect ovulation and fertility.

Treatment can be directed at the cause of infertility, such as ovulation induction for women with ovulatory disorders or surgery to remove uterine polyps or it may be independent of the cause such as with ovarian stimulation and intrauterine insemination or IVF which will improve success rates regardless of the cause of infertility with some exceptions.  IUI will have limited success for tubal factor, male factor infertility and endometriosis.  IVF will have limited success in women who have diminished ovarian reserve or abnormal eggs unless they use eggs donated by young fertile women.  Today, there is a highly successful treatment available for all.

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Was this helpful in answering your questions about what to expect from a fertility workup?

Please share your thoughts about this podcast or ask Dr. Kreiner any questions here.

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When You Can’t Conceive Again: The Pain of Secondary Infertility

By Dr. Allison Styne-gross

June 6th, 2010 at 6:00 pm

In this generation, a large percentage of my patients suffer from secondary infertility. Secondary infertility is defined as difficulty conceiving despite having successfully conceived and delivered a baby in the past. These patients often feel a lack of empathy from physicians, peers, and fellow patients with whom they share a waiting room (potentially for hours upon hours).  This lack of empathy has even been described as resentment — How could they be so upset or frustrated by the process when they already have a child? Taking my “doctor hat” off, as a mother of two, I can offer an explanation…

Every woman has a certain image of how they wish their lives to be. Some envision being married, some prefer to be single.  Some women envision having children, and some prefer to live without them. Whatever their dream may be, a woman will be determined to see it through.

After I conceived my daughter I started to realize that I had not yet fulfilled my own vision.  My original dream was to have at least one child. However, I grew up with a brother and once I had my one beautiful daughter, I realized the importance of providing her with the gift of a sibling. This now became the most important thing to me. I wanted to provide her with what I thought was this best gift of all. It became all that I thought about, and I was going to see to it that it happened.  I couldn’t imagine life without a sibling for her.  I finally did conceive again but this pregnancy ended in a loss. I was devastated. At this point, I started to fear that my dream was an impossibility. As an infertility specialist, I knew a little too much – this even worsened my fear. I knew that I was getting older.  I knew that my ovarian reserve would be declining, a common cause of secondary infertility. Was this the reason for my loss? Would I ever be able to conceive or are my ovaries too far gone? At this very time in my life, I was able to completely empathize with my patients. But especially with those who were suffering secondary infertility, those who felt shunned by all the other patients in the waiting room. I realized the importance of having a sibling for my daughter and of course it becomes more significant when it feels unattainable.

Fortunately, I did overcome this obstacle and had a second beautiful girl.  I am telling this story not only out of empathy, but also to provide some hope for those who suffer from secondary infertility.

There are many reasons why women suffer from secondary infertility. The most common being advanced reproductive age, tubal obstruction (from prior surgery, i.e. cesarean section or ectopic pregnancy), a worsening of a borderline male factor, endometriosis (which may have made the first time around more difficult but now seemingly impossible).  The beginning of every evaluation should include an evaluation of ovarian reserve. As women advance in maternal age, the ovaries may start to decline in function. With such a decline there can be an associated increased risk for chromosomal abnormalities leading to miscarriage. The evaluation of ovarian reserve includes a baseline ultrasound to assess the health of the ovary (looking for antral follicle number) and a blood test on day 3 of the menstrual cycle. The FSH and estradiol level included in the day 3 blood test is the most sensitive assessment that we currently have to screen ovarian reserve. 

The next step in the evaluation should include a hysterosalpingogram which is used to check for any intrauterine abnormalities that may affect implantation (i.e. polyps, fibroids, scar tissue) and to establish tubal patency. These are variables that may be compromised, especially following delivery via cesarean section or a pregnancy complicated by a peri-partum infection (endometritis, difficulty in removal of placenta, etc). Intrauterine pathologies and tubal obstruction are issues that can be corrected or bypassed and overcome. 

Reevaluation of the male partner is recommended because a borderline male factor can worsen with time.  Borderline sperm counts and endometriosis may make it more difficult to conceive so that it is not unusual that it took longer than expected to conceive the first time, and now it is more difficult to successfully achieve pregnancy the second time around.

Secondary infertility, like primary infertility, may be unexplained which, although not uncommon, is the most frustrating type of infertility to experience as a patient and physician. We all need a certain amount of control over our destiny and unexplained infertility relinquishes some of this control as we have no identifiable answers.  However, the good news is that there are several options for treatment including insemination with hormonal stimulation and if not successful, in vitro fertilization.

It is a long and emotionally draining process but taken from a doctor who has been through some ups and downs, it makes you a better person and a better mother.

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