What does an ovary/egg health exam entail?

[danielsmom]

I've had 3 miscarriages, and without genetic testing, doctors put genetic defects or chromosomal abnormalities at the top of the list of causes. We wanted to do genetic tests on the last two, but they were unable to do it. I asked my doctor today if I'm getting too old for this. His first answer was "NO WAY!" (I'll be 33 this summer), but then he admitted my short cycles and history of miscarriages are reasons to look at my eggs on ultrasound the 3rd day of my next cycle.

Has anyone done this? What do they look for? How confident can they be? And I wonder if my insurance covers this, or if it's considered fertility treatment. Guess I can ask them about that.

[kerisue]

I've done some day 3 tests. I recently did one that tests for a hormone called FSH (follicle stimulating hormone). A high FSH can indicate peri-menopause and can give you information about your ovarian reserve. I also had my estrogen checked. Too high can indicate cysts; too low may mean ovarian suppression (but ask the doc what your level means, if anything). I think they sometimes also check LH, progesterone, and prolactin but I didn't have those ones checked. The "test" only consisted of blood being drawn. My insurance covered part of it.
I've had my ovaries/follicles looked at on ultrasound, but never on day 3- closer to mid cycle.

[angieb]

I've never ever heard of them being able to tell anything about your eggs on cycle day 3 via ultrasound.

What they should be doing is bloodwork, FSH levels and AMH levels specifically, which will give you an indication of how many eggs you have left.

The only way they can really see your eggs is if you do an IVF cycle and they actually go in and physically remove the eggs from your body, they can't really tell much about them on ultrasound, they just look like big blobs. Here's a good link that discusses ovarian testing: http://www.advancedfertility.com/ovarian-reserve.htm

While 33 is pretty young, it's possible to have issues with ovarian reserve or egg quality even in your 20's. The fact of the matter is that fertility begins declining at around age 27 for women, so yeah, that sucks. IMO, it's better to be aggressive sooner, and risk possibly jumping the gun a bit regarding testing or treatment, than to wait too long and really struggle as you fight the ticking clock of fertility too. So I would definitely push for testing and a consultation with a fertility specialist (in your case, repeat loss is definitely a justifiable reason to see them and it trumps the "try 1 year" advice.) Seeing an OB for fertility problems is like seeing a regular OB for a high risk pregnancy- some of them are better at it than others, but the people with the most experience and who really know what they are doing are the specialists. (In this case you'd want to see an RE- reproductive endocrinologist- they are awesome at keeping an eye on all of your hormone levels throughout your cycle and running all of the appropriate tests to see if they can figure out what is going on.) Honestly, it's a little disappointing that your OB didn't refer you automatically after your 3rd loss, although there's no reason why they can't run basic bloodwork while you wait. (Some RE's take as long as 6+ months to even get an appointment.)

[riehlism]

I haven't heard of that exam. However, from what Angie describes, I went through that. I requested that my OB refer me to a reproductive endo (who ended up being the director of the whole feritility and IVF department). He ran the tests that Angie and Keri mentioned above and did take a look at my ovaries through an ultrasound. But from the ultrasound the only thing they can visually tell is the size of the follicles you are producing (if they are being produced), and a very very gross assessment of their maturity by looking at size. It seems labs are the most important thing they look at.

For me, by the time I saw my RE I was already pregnant and didn't know it. I was so early nothing showed up on the U/S except that I ovulated recently. So while I didn't actually need his services, it was a good think he checked all my baseline hormones because it showed how low my progesterone was.

Keep us updated and good luck with all the testing.

[danielsmom]

Wow, thanks for all the information. That really helps me know what questions to ask.

Now I'm second guessing myself, wondering if I assumed that he'd look at it via ultrasound, if I read that somewhere, or if he actually said that. Maybe I'm hitting information overload... I don't know. I am confident with my doctor though. He is a regular OB-Gyn/DO/FACOG, but a very decorated one (many awards, many professional affiliations and past leadership positions), and co-founder of the practice which is not a typical OB office (ultrasound every visit, lab on site, some procedures done in patient rooms, etc.). He doesn't seem to hesitate to refer me to specialists when I need one though. I think there's some simple tests we can do before we get to that point on this issue.

We know that I have progesterone issues from early lab work each pregnancy, making us suspect a luteal phase defect. We've treated with progesterone supplements, but maybe not early enough. I've never had trouble getting pregnant, but I'd like to rule out bad eggs. I also know that I've got 2 giant cysts on my ovary right now. They're not giving me trouble, but I wonder if that could alter blood work results.

[tracym]

I read an article in my Sunday paper yesterday about an Egg Timer test that was developed here in recent years..I wonder if that is what you will be doing?

[danielsmom]

I got some answers. He wants to look at ovarian reserve (egg quantity/quality). While there are several ways to do that, he wants to start with ultrasound, looking at antral follicles. This article explains this in depth: http://www.advancedfertility.com/antralfollicles.htm. The author's opinion is that day 3 FSH levels and AHM blood levels are important variables with good egg quantity/quality, but antral follicle counts in addition to female age is the best tool for estimating ovarian reserve.

But along with answers brings more questions... *sigh*. I wonder if taking a look at this might also lend to diagnosing a luteal phase defect (LPD), and if LPD could be a function of good ovarian response or egg quality. LPD can be caused by 3 different breakdowns which can all occur in sequence: 1) poor follicle production (bad FSH levels follow), 2) premature failure of the corpus luteam (bad progesterone levels follow), or 3) failure of the uterine lining to respond.

Focusing on the first issue, follicle development, counts can tell us about reserve, but he can also measure them midcycle and test estradiol levels (blood test) to look at development. If the follicle development is normal, early extra progesterone might be the answer. We keep doing what we've been doing, but sooner, right after ovulation, not after a + test.

If follicle development is inadequate, Clomid can be used to help it mature, producing a better quality egg and a better functioning corpus luteum.

My insurance doesn't cover any of this (infertility/Poor pregnancy outcome isn't as tragic as erectile dysfunction to insurance execs... don't get me started). However, I think I'm going to plow down this road anyway. It's my life, my future baby's life... no price can be put on that. We'll see.