I am Dr. Matrika Johnson.
I am a reproductive endocrinologist and infertility physician at Reproductive
Specialists of the Carolinas in Charlotte, North Carolina
and I will be answering some questions
about fertility testing.
What is fertility testing?
What am I testing?
So I'm testing a lot of different things.
So the first thing that I'm looking at is what's called ovarian reserve.
Ovarian reserve is defined as your level of fertility
and I'm specifically looking at your AMH level,
your FSH level,
and your antral follicle count to give me what your ovarian reserve is.
As far as looking at the ovarian reserve,
you know, a lot of the numbers, they all go together,
so the antral follicle count is going to be your follicles.
It's the number of follicles you see. The FSH,
you know, tells you, you know,
how well someone's going to respond to medications. If the FSH is really high,
they may not respond.
If the FSH just less than ten, you would expect them to respond.
And then as far as the AMH level, it kind of tells
you about, you know, how many eggs you think that you're going to get.
The higher the AMH level, the more eggs
you're going to get. The lower the AMH level, you know,
the fewer eggs that you're going to get.
As far as for me,
what those numbers mean to me is it's, it's how I use medications for IVF.
Like I purely look at those numbers and that's how I know
what's going to be the best treatment and how to dose medications.
The menstrual cycle is a very predictable thing.
It's divided up into two phases.
The first phase is the follicular phase.
The second phase is the luteal phase.
So we usually do
testing in the follicular phase because that is when your hormones are baseline.
And so technically, that's done sometime between Cycle Day 2 and Cycle Day 6.
And we do it at that time because we know that the estrogen levels are low.
And so your FSH level at that point should be, you know, what it normally
is going to be at that time.
So that's why we picked that sweet spot
of Cycle Day 3 to go ahead and look at those labs.
AMH, everyone comes to me and they say, I want to know what my AMH is.
My girlfriend told me to get my age checked.
So AMH stands for Anti-Müllerian Hormone and I will tell you that,
you know, as a fertility physician,
it is probably one of the single most important tests that I do.
And the other important thing about AMH that you should know, is that,
you know, it's not cycle dependent.
We talk about these Cycle Day 2/3 labs.
Yes, I can only check your FSH on those days.
I can check your AMH at any point in your cycle.
I can even check it on birth control pills,
I can check in with an IUD in, I can check at any point.
So that's why it's a little bit more versatile.
In an ideal world, I like it AMH level that is greater than or equal to one.
As far as your AMH level, the
biggest predictor of what your AMH level is going to be is your age.
As you age, your AMH level goes down.
And there's nothing that I can do or nothing that the average fertility
physician is going to be able to do to make that number go up.
And so as far as it being age dependent, I mean, it is
because it's going to go down with age.
However, that level that I want to see is, you know, is still 1.
So I have a 22 year old who's, you know, AMH level is less than 0.5,
which would be highly abnormal for a 22 year old.
What that tells me is that 1) her
ovarian reserve is definitely lower than it should be for her age.
What it also tells me is that there's a possibility
that she may go through menopause earlier than the average American age of 50.
And that she may be at risk of having something that we call premature
ovarian insufficiency, which is when the ovary stops working before 40.
A low AMH again in a 45 year old is just age appropriate.
It's really interesting because there's no textbook definition
of what diminished ovarian reserve is.
In my book, I call my patients,
my patients that have an AMH level that is less than 0.5,
I technically call them diminished ovarian reserve.
I know that other physicians will call their patients
diminished ovarian reserve with an AMH level, you know, under 1.
Other kinds of classifications,
you know, the normal antral follicle count is 9.
So if someone has a low antral follicle count,
they may be determined diminished ovarian reserve.
And if someone has an elevated
FSH level, someone might call them diminished ovarian reserve.
Specifically looking at the levels of hormones that that I test.
Most commonly, I look at the FSH level.
Generally, I want the
FSH level to be less than 10.
You know, if the FSH level is greater than 10,
the ovary is probably not functioning as well as it should be.
However, if I get an FSH level that's like 30 or above,
what that tells me is, not only is the ovary not functioning at the best level,
even if I give you medications, there's probably a chance that your ovary
won't even respond to the medications that I give.
When you're looking at, you know, kind of, the other hormones that we test
because we're looking at, we look at an FSH, look at an LH,
and we look at an estrogen level or what we call an E2.
So honestly, the only reason we check those things is to make sure
that they're all baseline.
In order to properly interpret
an FSH level, the estrogen level has to be less than 80.
And so I'm not really looking to see like,
there's not a good estrogen level or a bad estrogen level.
I'm only checking your estrogen to know that the measurement of your FSH
is accurate.
If I check your FSA level and it's 9 but your estrogen level is
120, then that tells me that that day wasn't good for you.
And that FSH level isn't your true baseline FSH level.
When it comes to checking LH, we always check that at the beginning
of cycles because that's your hormone that we look at to see
if ovulation is occurring, and we do that at the beginning of treatment cycles
because we want to see it rise mid-cycle to see you ovulate.
We kind of do it at the beginning of your baseline testing so that we kind of know
what your baseline is to begin with before we would start any treatment.
The next thing that I'm looking at is your uterus and your tubes.
That's going to be tested by an HSG, or the full name of that
is going to be a hysterosalpingogram.
As far as getting an HSG done, generally, it needs to be done sometime
between Cycle Day 5 and 12.
And that way, if there is a small polyp in the cavity, we'll see it,
if there's a small fibroid, we'll be able to see it better.
And if there's just any other abnormalities in the uterus,
we'll be able to see it better with a thinner lining.
Additionally, in the female we also look at some other endocrine factors,
such as, you know, we may look at your milk hormone
like prolactin or your thyroid function, something called your TSH.
And then just whatever I get in your history,
there may be some other things that I might look for.
Thyroid function and infertility is like a slippery slope, and if you read five
you know, scholarly articles, it'll tell you that your thyroid
has to be perfect in order for you to conceive.
And if you read a different five,
it'll tell you that thyroid function doesn't affect it.
I'm probably in the camp that I feel like your thyroid function does affect it.
So for me, I want all my patients to have a TSH level that is less than 2.5.
If they have a TSH level that is greater than 2.5
then I will usually put them on Synthroid.
Additionally, I tell them, if you go see your PCP,
your primary care physician is going to say, "Your thyroid is fine.
I don't know why this fertility doctor put you on these medications."
And I will usually give them a diagnosis of what I call
subclinical hypothyroidism, meaning that the TSH is a little bit high.
That said, their free T4 is completely normal
and there are no TPO antibodies or anything there.
And so it depends on what camp you're in.
But there are definitely studies out there that show that women
that have a TSH less than 2.5 have an easier time conceiving.
There are also studies out there that say no,
but there's no studies out there that say that Synthroid hurts.
So, that is why I use it.
I want their thyroid to be normal prior to pregnancy.
So if it's someone doing an IUI treatment, then I'm going to want it done
before they start.
If it's someone who's doing IVF, I'm OK with their thyroid function not being,
you know, perfect perfectly euthyroid
at the time of their IVF cycle but I am going to want them
to be less than 2.5 by the time they get to their embryo transfer.
As far as recommending IVF over
IUI, there are a couple instances that I recommended it.
I would say the most frequent time that I recommend
it is for any women that are between the ages of 38 and 42.
There is a study out there that looked at women between the ages of 38 and 42
called the FORT-T trial
and basically what it showed is is that if you are between the ages of 38
and 42, doing IVF is the most effective way to pregnancy.
And by skipping IUIs and going straight to IVF, it's
the quickest way of pregnancy. As far as other reasons to do IVF first,
if someone had, you know, bilateral blockages of their tubes,
that would be another reason why. If someone has diminished ovarian reserve
or a lower ovarian reserve, I would recommend moving first to IVF.
If someone has a low sperm count or a low sperm motility,
those are other times that I would recommend moving straight to IVF.
Final answer.