“I ovulate, what next?”

Part 2 of the layperson’s guide to the fertility work-up. You have verified that you are in fact ovulating on a regular schedule, but you still aren’t pregnant. What next? Well, it depends. The party line is that it can take the average couple up to one year to get pregnant, which is true. But the doctor in me thinks that’s a pretty crappy way to diagnose something. It is tricky, because the only symptom of infertility is often failure to get pregnant. The work up can be expensive, and the treatment can be really expensive, so the prudent approach would be to wait until you are unlikely to get pregnant on your own. Then take the next step. That won’t change anything though… if you have a low sperm count at 4 months, you are going to have a low sperm count at 12 months, and you will have lost 8 months of trying to conceive. If you have low ovarian reserve (you have old ovaries) wouldn’t you rather know that sooner than later? I don’t know what the right answer is, but if you are worried… get checked out.

Here’s what to check:

Sperm count. This is easy. This is cheap. Men are sometimes reluctant to do this, but it is the cause of infertility 1/3 of the time. So get it done.

Ovarian reserve. You want to make sure those eggs you are ovulating are good eggs. You need to check you FSH and estradiol on day 3 of your cycle. FSH is the hormone produced by the pituitary that stimulates your ovaries to make eggs. If you FSH is high, it means your pituitary is having to work harder than normal to make eggs. Over 10 is high, and it will gradually go up until menopause, when your FSH will be over 40. Estradiol is the hormone released by the follicles in the ovaries. If it is low, you might not be making good eggs. If it is high, your ovaries may be trying to make a lot of eggs to compensate for the fact that the ovaries aren’t working well.

Other hormones. You can have a small pituitary tumor that produces a hormone called prolactin. This is fairly common, and usually causes irregular menstrual cycles due to low estrogen. So this should be checked. Thyroid should be checked, but it isn’t usually going to be the underlying problem.

Structural problems. Sometimes your fallopian tubes can be blocked. Eventually you should get this checked, sooner if you have a history of STDs or symptoms of endometriosis. And sometimes people have anatomic anomalies of the uterus (a septum or polyp) which can cause problems.

If all this comes back normal? You wait until you hit the one year mark (6 months if you are over 35). Then you are diagnosed with “unexplained infertility.” Welcome to my world.

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