Spencer Richlin, MD

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As a reproductive endocrinologist, I meet with countless couples who are surprised that they are having trouble getting pregnant. While their reactions and emotions are often similar, the couples do not fit one mold. They can be in their 20s, 30s or 40s; they can be healthy and fit or obese; they can be any race or religion.  It is important for us as doctors to remember and to communicate to our patients that we cannot determine a patient’s reproductive health by appearances. 

At my practice, we determine a woman’s level of fertility based on her medical history, age, basal antral follicle count, day 3 follicle stimulating hormone (FSH) and anti-mullerian hormone (AMH) level. Collectively these factors give us a complete picture of a woman’s reproductive health; however, AMH testing is the most recent ovarian reserve test and generally considered to be the most reliable.  

AMH levels are measured by a simple blood test. Because AMH tests measure the protein as it secretes in to ovaries, it is not affected by estrogen and other hormones, and can therefore be tested at any point in the menstrual cycle and even in patients on birth control pills levels.  Healthy women under 38 years old typically have AMH levels of 2.0 - 7.0 ng/ml. 

Women with low egg/ovarian reserve have several options.  If they are considering having a family, they may decide they are ready to start trying. If they are not ready to start a family, they can freeze eggs for the future.  Alternatively, they can continue to monitor their egg reserve or seek further testing to get a better understanding of their reproductive health.  All of these options benefit from early detection; the earlier we know if there is an issue, the more we can help.

While it is true that the likelihood of getting pregnant decreases dramatically after 35 years of age, any woman in her reproductive years can be affected by infertility. Women should be able to get pregnant within a year of trying. If they have not, then they should see a fertility specialist. If they are over 35 years old, they should see a reproductive endocrinologist after trying for six months.

Reproductive Medicine Associates of Connecticut is hosting two events in October with free AMH testing.  Each event will include an opening presentation about infertility, including an explanation of the AMH test.  Attendees will then have a blood test taken and a nurse will call with the results within 10 business days.  The events are being held:

RMACT Stamford, CT Office 
1290 Summer Street, suite 3200
October 11, 2012 at 6 p.m.

RMACT Danbury, CT Office 
67 Sand Pitt, suite 300
October 11, 2012 at 6 p.m.

We hope you encourage your patients to start thinking about their family plans in their 20s.  And if they are in the Connecticut area, we hope to see them on October 11.  
 

Articles

Anti-mullerian hormone testing is the most recent and reliable ovarian reserve test, and it can be used to help women make decisions about family planning early.

AMH Testing Can Help Patients Plan for Future Fertility

As doctors, we often consult closely with colleagues regarding treatment and diagnosis. However, for a reproductive endocrinologist like myself, sometimes the most important colleague is one who does not have an office down the hall. Ob/gyns are likely the first specialists to field patient questions about fertility, and patients rely on ob/gyns to alert them when they need to see a fertility specialist.

Fertility treatment is most successful when:

• Patients and doctors openly communicate about patients’ needs and wants

• Patients are referred to and seek help from a fertility specialist when needed

• Patients strive to have optimum overall health

This article provides ob/gyns with practical tips they can use when approaching patients about their fertility needs.

Pregnancy and, implicitly, sex can be uncomfortable topics for patients to discuss in the clinical setting. Patients can be reluctant to talk about trying to get pregnant-specifically, how long they have been trying and how often they have sex with their partners. Therefore, the ob/gyn may need to prompt the conversation for the patient to open up about her reproductive wishes. A patient’s ob/gyn is certainly the most relevant physician to ask about family planning, and women are most likely to be comfortable with their ob/gyns, who they consider to be their primary doctor.

Questions that you should ask your reproductive-age patients:

• How long have you been trying for pregnancy?

• Do you know the appropriate part of your cycle to time relations?

• Have any of your family members had difficulty becoming pregnant?

Patients who are approaching their 35th birthday should begin speaking with their ob/gyn about their family plans. If they do not start the conversation, then their ob/gyn should.

If the patient is trying to get pregnant, it is important for them to know when to seek help from a fertility specialist. Any patient younger than 35 years who has had 1 year of unprotected sex without getting pregnant should be referred to a reproductive endocrinologist. Women older than 35 years should go immediately. In addition, women who have had more than one miscarriage should see a specialist. It is well known that age is a key factor in successful fertility treatment, yet all too often we see patients who have waited too long to seek help.

Communication and education should go hand in hand in fertility. Ob/gyns face limitless questions from patients about how a woman’s body works. Common questions that patients have include:

• If I am menstruating, does this mean that I am ovulating? 

No, some women have anovulatory bleeding.

• Since my cycles are regular, my tubes must be open, right?

 No, the fallopian tubes function independently of ovaries.

Twenty-five to 30% of infertility is due to a male factor. Thus, check the sperm count. 

It is appropriate for the ob/gyn to conduct initial tests, such as a semen analysis, hysterosalpingogram, day 3 follicle-stimulating hormone/estradiol, anti-mullerian hormone, and an ultrasound. These tests are briefly described below.

. All men should have a well-timed semen analysis. They should refrain from ejaculation for 2 to 5 days before collection. Collection is by masturbation without lubricants as this may kill sperm. We want to see a volume of 1.5 mls, 20 million per ml, and 50% moving and looking morphologically normal. If the initial count is abnormal, repeat it in 2 to 4 weeks.

. HSG is scheduled in days 7 to 10 of the menstrual cycle. To minimize cramping we advise patients to take 400-800 mg of ibuprofen 1 hour prior to the procedure. The HSG is a mandatory study to make sure the fallopian tubes are open and the uterine cavity has the normal shape. The HSG will uncover intracavitary polyps, fibroids, or adhesions, which can decrease implantation and pregnancy rates. The test “tells” us that a patient’s tubes are patent, but this does not guarantee that there is a good relationship between her fimbriated end and the ovary for egg pickup, which is a limitation of this study.

Day 3 Follicle-Stimulating Hormone (FSH)/Estradiol and Anti-Mllerian Hormone Test (AMH). 

These tests are ovarian reserve indicators. A normal FSH is < 10 mI/ml with an estradiol < 75 pg/ml on day 2 to 4 of the menstrual cycle. It is important to order an estradiol test because a level greater than 75 pg/ml will falsely lower the FSH level. Remember that a single elevated FSH connotes a poor prognosis and decreased pregnancy rates. FSH levels have intercycle variability. Thus, in a patient with normal ovarian reserve, the FSH value should be less than 10 month to month. AMH is another ovarian reserve indicator. With increasing age, the number of primordial follicles decreases. This is accompanied by a decrease in AMH levels. AMH levels can be drawn at any time during the menstrual cycle. This is an advantage over FSH testing. In our experience, an AMH level < 1 ng/ml often correlates with a decrease in reproductive potential.

At the initial visit, a transvaginal ultrasound is a very valuable tool. When I am ultrasounding a patient, I keep the following checklist in my mind:

• Does the uterus have the normal shape? Are there any fibroids or anomalies?

• Is the endometrial stripe straight, or does it deviate with a possible intracavitary lesion?

• Is the endometrial lining the appropriate thickness for the day of their cycle?

• Are the ovaries in the proper pelvic position, adjacent to the iliac vessel? If not, think about pelvic pathology altering the relationship between ovary and tube.

• Count the number of antral follicles (a normal count is > 8).

• Look at the adnexae closely-Is there a hydrosalpinx?

The following Web sites are good sources to refer your patients to for more information:

Reproductive Medicine Associates of Connecticut (RMACT)

. This is my  practice Web site, which is comprehensive and continually updated.

American Society of Reproductive Medicine

. The Web site for our  national society.

Fertility treatment works best in conjunction with good overall health. At RMACT, we have started an Integrated Fertility and Wellness Program that is comprised of yoga, acupuncture, nutrition counseling, therapy, and peer groups. Through these services, we strive to have our patients improve their overall health and lifestyle choices. Below is a brief description of these services and how they might benefit infertility.

Yoga is great way to decrease muscle tension and stress. It facilitates relaxation and improves clarity of thinking and feelings of well being. Patients who do yoga communicate more clearly with their doctors and often sustain infertility treatment with a more positive perspective.

 Acupuncture is used to treat many ailments, including infertility. It can restore balance to the body. There are studies to support its efficacy in patients with infertility. We often use acupuncture before and after in vitro fertilization (IVF) embryo transfer to help increase pregnancy rates. We think that acupuncture increases blood flow to the uterus, aiding in implantation. Many of our patients use acupuncture as a restorative and relaxation tool.

. Patients can manage hormonal conditions and symptoms as well as improve overall health through good nutrition. We have found that patients benefit from individual counseling with a nutritionist. The RMACT program also includes seminars and one of Connecticut’s only Polycystic Ovarian Syndrome (PCOS) programs. Patients are able to make incredible strides toward improving their fertility by making good decisions about their nutrition in their homes, restaurants, and grocery stores.

. Often infertility patients need professional counseling during their journey to become parents. At times couples are at critical decision points in their treatment. Common questions that often arise are:

• Are we at a point where we should give up treatment?

Reproductive psychologists/counselors understand the emotional complexities of fertility treatment. They can provide counseling to individuals or couples. In our practice we have peer groups that meet and talk about their journey through fertility treatment. This is a great way for patients to support and learn from each other. Many patients become lifelong friends from our peer groups.

Many of these wellness services help patients manage their stress. We live in a competitive world that has an unbalanced focus on careers. Patients need to learn how their lifestyle choices, such as exercise, nutrition, and sleep, impact their overall health. They also need to have tools to help alleviate stress.

Stress management is especially important as patients start their fertility journey. Fertility treatment is emotionally taxing as patients ride waves of hope and disappointment and, ultimately, joy of a successful treatment outcome. Reproductive care requires time and effort as well as communication between partners on decisions that impact their lives together. This can also add additional stress to a patient’s life. We try to empower our patients with the tools to handle this stress.

For the more than 7 million people affected by infertility, having a supportive ob/gyn can be the key to making a family. I hope you will think of yourself as a partner with reproductive endocrinologists.

Author | Spencer Richlin, MD

Articles

AMH Testing Can Help Patients Plan for Future Fertility

Ob/Gyns and Reproductive Endocrinologists: Silent Partners in Fertility Treatment