Ask Dr. Marc: Detecting Ovulation

Dear Dr. Marc,

Is there any way to tell if you are actually ovulating ? After surgery, my tubes are now clear. I have no history of any other fertility problems ( they were blocked with endometriosis). I’ve done 3 rounds of Clomid and well nothing so far…. I get positive OPK tests every month…

Thanks,

Kim

 

Hi Kim,

People have been trying to pinpoint ovulation for generations.  The information is just as useful for those who are trying to avoid pregnancy, as those who are trying to conceive.  Unfortunately, no one method is perfect for everybody.  Fortunately, there are multiple options and most women can find at least one that works for them.   The following methods are listed in chronological order (earliest to latest in the menstrual cycle):

Ultrasound: Transvaginal ultrasound can detect the dominant follicle 6-8 days before ovulation.  With sequential ultrasounds over multiple days, one can predict ovulation with significant reliability.  Further, once the follicle disappears, you can be confident that ovulation has occurred.  This method requires multiple visits to the doctor and therefore can be quite expensive and time consuming.  Additionally, follicles can occasionally ovulate then fill back up with fluid making them look as if they have not ovulated when they actually have.

Cervical mucus change:  In the 1-3 days preceding ovulation, many women notice a change in the consistency of their cervical mucus.  The mucus becomes thin and stretchy, similar in consistency to raw egg whites.  This method involves checking the mucus on a daily basis with your fingers.  Some women are not comfortable with this method.

Ovulation prediction kits: These kits are designed to detect, in the urine, the surge of lutenizing hormone (LH), which induces ovulation.  LH is released by the brain and ovulation follows 24-48 hours later.  This method is very reliable, but also has some potential problems.  One problem is that LH is always released in small amounts by the brain.  Sometimes this small amount can be mistaken by the test for the “surge” and thus cause a false positive.  Additionally, the water content (diluteness) of urine fluctuates significantly throughout the day.  If the urine is too dilute (too much water) it can result in a false negative result.

Mittelschmerz: Abdominal pain associated with ovulation.  Many women do not feel anything with ovulation, while others recognize a vague pressure sensation in their lower abdomen for a few minutes to hours surrounding ovulation.  Some women however, suffer significant abdominal pain related to ovulation.  Consistent Mittleschmerz pain recorded on a menstrual calendar is a reasonably reliable sign of ovulation.

Progesterone level: Once ovulation occurs, the follicle from which the egg was released begins to produce progesterone.  An elevated level of progesterone is a reliable sign that ovulation has occurred.  Usually it is tested 5-8 days after ovulation to get the peak level.

Menstruation: Menses occur only after a rise then fall of progesterone.  The only thing that can cause progesterone to rise and fall is ovulation.  Therefore, menses is a reliable sign that ovulation has occurred (usually about 14 days prior to the first day of bleeding).  As with all the other methods however, vaginal bleeding does not always indicate prior ovulation.  This is because not all vaginal bleeding is actually menstruation.  If bleeding is due to an endometrial polyp or PCOS for example, it is not true menstruation and therefore does not indicate prior ovulation.  With that being said, regular, predictable periods are almost always a sign of prior ovulation.

Pregnancy: Pregnancy is the only 100% reliable test that ovulation has occurred.

Hopefully that is helpful Kim.  If your OPKs are becoming positive as expected, it is reasonable to believe that you are ovulating.  We know that women with endometriosis tend to have a more difficult time becoming pregnant even if their tubes are open and they are ovulating regularly.  Considering this, I’d recommend that you discuss your situation with your doctor or a fertility specialist.

Best of luck,

Dr. Marc

 

Ask Dr. Marc: AMH & Morphology

Dear Dr. Marc,

I am 36. Husband is 42.  Neither one of us has kids, and I have never been pregnant. 

In my early twenties I had a laparoscopy done due to bad cramps, and slight endometriosis was found.  It was lasered.  A few years later I was on Lupron to assist with endometriosis.  I had been on the pill when not on Lupron since age 18.  4 years ago I went off the pill. 

A year ago I had another laparoscopy and stage 1 endometriosis was found.  No serious concerns from the Dr. I also had my tubes checked and all was clear. 

I went on Clomid 50mg first month then 100mg for another 2 months.  In September and October we tried Clomid with IUI. 

My husband’s sperm was checked in April and again in August and it showed less then 1 percent morphology.  High count though. 

We then did a round of IVF using Bravelle and Menopur. I was on the pill for 21 days to suppress ovulation and then began injections with a 3 to 1 ratio.  No response.  Increased to 3 to 2 ratio, very little response. 

Converted to IUI.  Not pregnant. 

Had an AMH level drawn and it showed .16.  We were encouraged several times to consider donor eggs due to low ovarian reserve. We decided to do another round of IVF. Pill first then using maximum dose of Bravelle and Menopur 4 to 2 ratio.  Had an excellent response with a retrieval of 6 eggs.  4 fertilized and one split to make 5 embryos.  Did a day 3 transfer.  The other 2 did not make it to be able to freeze. 

Not pregnant. 

We got a second opinion and some more labs drawn.  My husband’s sperm was 23% morphology.  However, first two sperm counts were done using strict criteria.  This last one, which showed an improvement, was done not using strict criteria.  However my AMH this time was .56.  My FSH was 7.2 done at day 2.

The second opinion suggests another IUI this time. 

I have asked about the significant difference in the AMH level and the second opinion feels the first test was just simply wrong.  He feels that yes donor eggs would increase my chances drastically but did not think that was necessary yet.  We feel strongly about trying as hard as we can to have a child genetically our own if possible.  I feel confused by the numbers but also feel we are sort of going backwards by trying an IUI again. 

Any thoughts would be greatly appreciated.

J.

 

Hi J,

I can see how you might feel confused and a bit frustrated at this point.  Let me address a few points from your question.

Why did your AMH change?

Doctors use a variety of tests to predict how the ovaries will respond to stimulation (ovarian reserve).  The most common of these tests include FSH/estradiol, AMH and antral follicle count.  Importantly, none of these tests by themselves are perfect.  There can be significant variation in their results from month to month and from lab to lab.  When the tests are combined with a complete history and physical, doctors can usually do a pretty good job of anticipating the right dose of medication required and the number of eggs a woman will produce during and IVF cycle.  With that being said, no single test should be relied upon too much.  Remember, the human body is always changing, but the tests reflect a static moment in time.   Interestingly, AMH was popularized in the past few years as a more stable test of ovarian reserve.  As it is being used more commonly now, we are finding that it is not as stable as once believed.  Your case demonstrates that perfectly.

What about the sperm morphology?

Morphology, the percentage of “normally” shaped sperm, is the trickiest part of a semen analysis.  The 2 most common grading criteria for “normal” are the WHO (world health organization) guidelines and the Kruger (strict) guidelines.  The WHO is considerably less stringent and therefore, a higher percentage of sperm are considered “normal”.  The Kruger, or strict, criteria are more stringent, thus less sperm are considered “normal”.  It is difficult to compare WHO to Strict, but either way, it sounds like there are a low number of “normal” sperm.

Is doing another IUI a step backwards?

In your situation, yes, IUI is a step backwards.  As a rule, the chance for success with IUI is less than that for IVF.  Considering that you demonstrate some degree of diminished ovarian reserve and that your husband has low sperm morphology and you have already been unsuccessful with IUI, you are best off trying to optimize each cycle going forward.  To optimize, IVF is a better choice.

I hope this helps, good luck!

Dr. Marc

Share Your Story: Jessica

Byline: Jessica Blanco-Busam

Jessica wrote this story on April 23, 2012.  The next morning, she had two embryos transferred.  One didn’t make it through the thawing, and she is waiting for results on the second.  Please send Jessica good thoughts while she waits for news.

This is my first time sharing my story in a public forum. It’s funny, because tomorrow will be my final attempt at getting pregnant for the second time.

After many years of painful periods and hearing from my doctor that I had a low pain threshold, I convinced her to do an exploratory laparoscopy. She tried to assure me that everything would be okay. Unfortunately, I knew better. It turned out I had stage IV endometriosis: scarring all the way up to my diaphragm and down to my intestines, bladder, rectum, you name it. I was 26 years old and luckily, happily married. My husband and I knew our plan to wait until 30 wouldn’t do anymore. We had to try immediately and we were told IVF was the way to go.

I switched doctors, got on lupron to improve my chances, had another surgery where my appendix and one fallopian tube were removed, and then went through my first cycle. I almost quit right in the middle of the transfer because the doctor could not get the catheter into my uterus and was causing me such indescribable pain (talk about messed up anatomy and too much scarring).

It failed, but I was blessed enough to get pregnant on my second try. Complications lead to a c-section during which my doctor said the endometriosis was even more extensive than before. How that happened after being period-free for 10 months is beyond me. I guess I’m just lucky that way.

In 2011 we knew it was time to try again. Our son deserved to have a brother or sister. My doctor said I would need a laparotomy instead of a laparoscopy to give me a fighting chance at getting pregnant again. That February, I had the surgery. He had to get an oncologist in on the surgery because the damage was more severe than he could handle. He did the best he could but said a hysterectomy was my best shot at ever helping the endometriosis. Basically, good luck getting pregnant again.

We failed 3 times: we had an FET, then an IVF cycle, then another IVF cycle. Each time my body did worse and worse with the meds: OHSS, painful and difficult transfers, you name it. I looked like and felt like the walking dead.

I was a miserable human being, truly a shadow of my former self. It was beginning to wear on me – and on my marriage.

My husband and I had the talk. We decided this FET would be our last attempt. My son needs me, my husband needs me, my students need me. My life will not revolve around failed attempts to get pregnant and 14 day periods during which I’m on codeine for the first 3 days just to be able to walk and hopefully make it to work. I pray that tomorrow 1 or more of my 3 embryos will thaw and that I will get pregnant. Of course it’s a stretch – a huge one given my history with this horrible disease.

As sad as it is, I know it probably won’t result in a pregnancy. But the finality of it all, the fact that a hysterectomy is in my future at the age of 30, gives me hope. I can move on. I can get that “quality of life” I’ve longed for, for so many years. And I have my miracle baby and he is amazing. That’s my story. I’m not sure if it’ll help anyone at all, but maybe it will.

Jessica- you are incredibly brave to share this story with others.  Please leave Jessica good thoughts in the comment form.  You do not need to be a blogger to leave a comment, you just need a name and an email address.  And be sure to join us over in the Forum, where we are already sharing stories and providing support.