When a couple is infertile, one of the first questions a Reproductive Endocrinologist (RE) wants answered is: does the female partner have a good supply of functional eggs available? In an effort to answer this question, the RE performs a test called a Clomid Citrate Challenge.
Clomid Citrate is a drug derived from Follicle Stimulating Hormone (FSH), usually taken from menopausal women. FSH is the hormone that stimulates the ovaries to ready several immature eggs, which come to the surface of the ovaries and ready themselves to be released. In a woman of normal fertility, there is a small FSH surge around day three of the menstrual cycle. The surge is usually small because a fertile woman’s ovaries and immature eggs respond quickly to small amounts of the hormone. In a woman who is in her late fertile period or who is entering peri-menopause, the FSH surge is much higher because her older ovaries and eggs do not respond as well to the hormone. This condition is either Diminished Ovarian Reserve (DOR) or Poor Ovarian Reserve (POR). When a woman has either of these conditions, she has a significantly lower chance of conceiving, even with Assisted Reproductive Therapies (ART).
The Clomid Citrate Challenge begins on Day 3 of the menstrual cycle. A blood test on day three determines the woman’s baseline level of FSH. If this is high, this may be an indicator of POR. On day four, the woman begins to take clomid citrate pills, which are sold under the brand names Clomid and Serophene, and continues for five days. This simulates the kind of FSH surge that characterizes menopause. If the woman’s ovaries are still functioning at optimal levels, the amounts of hormones that stop the FSH reaction will increase and bring the FSH level back to normal levels.
The interpretation of the Clomid Citrate Challenge results will vary depending on the RE who does the interpreting. The consensus among most REs is that a day 3 or a day 10 level higher than 12.5 indicates DOR, and signals that the woman will have a much lower chance of conception. A level of 14 is usually given a 10% chance of conception within six months. The RE may choose to repeat the challenge, hoping for better results in another month. Even if the levels improve, most doctors go by the rule “A woman is only as fertile as her worst result.”
Some skeptics say that the only reason doctors will not offer ART to women with FSH levels higher than 12.5 is that they do not want their publishable rates of success to look bad. It is true that such women will not respond as well to therapy because their eggs may not be healthy and stable enough to produce a full-term pregnancy. Doctors assert that they do not offer some ART to women with high FSH levels because putting such women through difficult treatments and cycle after cycle of disappointment does not seem like ethical medical practice. Some REs will offer donor eggs, which come from younger, more fertile women. Donor egg counselors strive to find donors who have similar genetics to the female partner.
Many practitioners of alternative medicine will offer treatments that promise to reduce FSH levels, which they say will improve fertility. This can offer hope for many couples who want to be biological parents, but there is a problem. The high levels of FSH do not cause infertility. The infertility is caused by the age and condition of the eggs and the ovaries. The higher FSH levels are a symptom of the age of the eggs. One study showed that in some extreme cases, where FSH levels were somewhat over 120, a small percentage of women conceived and bore healthy babies. This percentage was so small, however, that it was not offered as proof that any woman with a high FSH could have a full-term pregnancy.
FSH levels were once regarded as the definitive indicator of a woman’s fertility. Current wisdom says that FSH level is one indicator in a series of factors that can determine fertility. Every woman has a different body. For some, even if everything seems to be normal, conception is not possible. For others, even the most extreme problems can be over come. It’s just not fair, sometimes.