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AMH (Anti-Mullerian Hormone)

Hello to all. In this blog I will review the usefulness of Anti-Mullerian Hormone, otherwise referred to as AMH.  AMH is one of the hormones, along with estrogen and a few others, produced by the ovary.

Like estrogen, AMH is produced by the granulosa cells. The granulosa cells are the small cells that surround each egg.  These small cells are tightly attached to egg surface whereby they help to vitalize and, when the time is right, mature the egg.   This egg-granulosa cell unit is called the follicle.

No one yet knows what the function of ovarian AMH in females.  AMH is present in males, and we know that it has a very important role in the development of normal male sexual anatomy.  What we do know about AMH in females is that the more healthy follicles one has, the higher the AMH levels.

Measurement of AMH levels can help us predict a woman’s fertility, in a very general way.  We already said that estrogen is also produced by the granulosa cells, so why wouldn’t we just need to measure estrogen levels to find out about ovarian health?  Because estrogen only comes from follicle at a time; the one that is in the process of ovulation. A woman may have 100,000 follicles, but on most cases only one per month gets involved in ovulation and becomes an estrogen producer.   Follicles may make different amount of estrogen each month, so judging fertility based on an estrogen test is not helpful.

Many follicles at one time, however, are producing AMH. Now it’s not every follicle, but it is a large number.  It works like this. The ovary contains different follicles in different stages of maturity.  Here is a microscopic view of the ovary.

 

Some follicles are very immature and have few granulosa cells; just one layer surrounding the egg.   Some follicles are more mature and their granulosa cells have multiplied into more cells in multiple layers.  These are the ones producing the most AMH.  In general, if you have a lot of eggs, you have plenty of follicles in all of the stages of development, giving you higher AMH levels.  Lower AMH levels mean fewer follicles of all types.

Follicles are always making AMH therefore levels can be measured any day in the cycle. In fact, it does not matter if a woman is on oral contraceptives, AMH is still produced and can be measured.

AMH may turn out to be and excellent way to measure a woman’s fertility potential, but we are not quite there yet. We do know that a high AMH is good and a low AMH is bad. What’s a good high level? We are still not sure. We know a little.  Any level over 2 is really not bad at all. Certainly, higher than 2 is better still. We know that undetectable levels, less than 0.16, are bad.  But, we have had women with these low levels become pregnant.  The odds of pregnancy are much worse for women with low levels, but people frequently get pregnant with low odds.  Some women have asked me if the level can be too high.  High levels may indicate the presence of polycystic ovaries (ovaries with an above average number of follicles).  While it is true that some women with polycystic ovaries have trouble conceiving, a high AMH level is not the issue.

Recent studies (one was in the headlines a few weeks ago) have used AMH levels to predict IVF outcome.  But again, really high levels were shown to be good and really low levels bad, but overall, not predictive enough to tell someone they can or can not get pregnant.

What we typically do is to put all of the information we have together to estimate ovarian health.  If we use age, FSH levels, AMH, antral follicle counts, the prognosis becomes a bit more clear, but the system is still not perfect.

AMH testing will become more useful sometime soon. More and more women need to have the test done do we can compare levels to outcomes on a large scale. In addition the laboratories need to get better at the testing.  But once we get better with AMH levels, we may be able to do some very important things.

For instance, some studies have been done comparing AMH levels to the time of menopause. Again, not ready for prime time, but the concept may be very important.  What if we could measure AMH in a young woman and determine at what age she will start losing her fertility? Or at what age will she lose half her fertility? What if we could measure AMH levels in a woman destined for chemotherapy and determine if she should freeze her eggs first?

These would all be wonderful uses of this test and it may be that in the future we could reach these goals.

It’s more likely that newer tests will be developed to improve ability to predict.  As alluded to before, combination tests may be more accurate. For example labs are starting to market “fertility profiles” based on AMH, FSH, inhibin and other hormones.

But in the end, like in all of medicine, the genetic tests will dominate.  Scientists are looking for a gene or groups of genes that control the fertile lifespan of women.  As genetic testing becomes less expensive and as we increase our ability to look at more and more genes at one time, the goal of accurately determining a woman’s ovarian age and potential will be reached.

 

Thanks for reading and please don’t forget to read the disclaimer from 5.17.06

 

Dr. Licciardi

 

PCO and other Fertility Related Topics

PCOS (Polycystic Ovaries) and Ovarian Drilling.

Some sort of ovarian surgery has been used to treat PCOs for the last 50 years.The surface of the ovary, also called the cortex, is where the eggs are. This is a relatively thin layer covering the ovary. Beneath this layer, in the mid portion of the ovary, is the tissue that makes the androgens. PCO women have higher levels of androgens than women without, and it is possible that these increased levels are what interfere with normal ovulation. Androgens, by the way, are the hormones that get changed into estrogens, so androgens are absolutely necessary for normal repoduction, but in PCO the androgens are in excess. Opening this layer and removing or destroying the inner tissue, either by wedging out a piece of the ovary, or putting in multiple holes using an electrical probe or a laser, changes the hormonal balance of the ovary. It lowers the androgens and and somehow allows for more frequent ovulation. These procedures are not frequently performed because they do not always work, can cause scar tissue, and there are other alternatives.

There are other ways to stimulate ovulation, including clomid and FSH injections. Clomid works to cause ovulation in women with PCO in most but not all cases. FSH works in almost all cases. With FSH injuctions there is a high risk of ovarian hyperstimulation, unless the starting dose is very low. Certainly IVF is also an option.

Now some may ask why get involved with fertility drugs and the cost of monitoring when a simple surgical procedure will do the trick. In the case where the patient cannot afford complex fertility treatments, but can get surgery, the later does make sense. In addition some women just do not want to take any form of fertility medication, so the surgery may be the best thing for them. There can be complications from the laparoscopic surgery including the usual bleeding, infection and injury to internal organs. These are increased as the size of the patient increases, and more severely PCO patient may be more obese. But more specifically, the ovarian wedging or drilling can cause scar tissue and adhesions around the ovary, decreasing the chance of conception even if ovulation normalizes. This is is more common with wedge resection (taking out a wedge) vs. ovarian drilling.

So before surgery is considered, other methods of assisting ovulation need to be employed, such as weight loss, along with medical interventions such as those listed above, with the possible addition of prednisone and or metformin.

What if there is anovulation from PCO and you are having a laparoscopy for another reason such as pelvic pain, lysis of adhesions, endometriosis, or fibroids. Should you have drilling or wedging when the doctor is in there anyway? If the other methods of inducing ovulation are available to you, I would not cut into the ovaries because of the possible scar formation. Plus, wedging or drilling removes or destroys a large number of follicles. Reducing egg number is just something I like to avoid. If, however, you decide the drilling is best for you, the ovarian surgery is an accepted method and may lead to pregnancy rather quickly.

Other PCO Topics

Cysts from Clomid. Clomid makes follicles, which are the fluid filled cysts that contain the eggs. These follicles usually dissolve away 2 weeks ovulation but sometimes, especially when there are more than one, it takes longer than 2 weeks for them to go away. It is really rare that they are there after 4 more weeks. I have not had a patient have a cyst that lasts for months as a result of taking clomid. I have heard of such things, but they must be quite rare. It’s common to use the birth control pill to help make the cysts go away. Clomid causes the follicles to grow by upping the FSH produced by the pituitary. Birth control pills lower FSH levels so the theory kind of makes sense, but no one has really shown going on the pill makes any of these cysts go away any faster.

When should you come off metfomin, at the first pregnancy test or later in the pregnancy? Every doctor has a different idea. There is a prevailing thinking that PCO increases miscarriage rates. But there is at least one good study showing there is no miscarriage difference between women with PCO and women who normally ovulate. Plus there are other OK studies calling into question an association between miscarriage and PCO. However, there are a few studies in literature from outside the US showing metfomin reduces miscarriage rates in women with PCO, plus it reduces some pregnancy complications, including diabetes. This being said, the continuation of metformin during pregnancy is not standard among REs in the US.

Will provera increase your pregnancy rate if you have irregular periods? If you have PCO and have very infrequent periods, strongly consider taking to your doctor about clomid or FSH injections. Provera, except in rare cases, will do nothing to get you to ovulate. Even if you bleed after provera, you probably did not ovulate, you just bled.

Egg quality clomid vs FSH? Probably similar.

Is a clomid cycle that makes 6 follicles any different than an FSH cycle that makes 6follicles? Probably not, providing the clomid has not thinned out the lining of the uterus.

Sperm Topics:

Sperm quality 15 years after a vasectomy? Can really vary. In most cases the sperm is fine. Now if the sperm will be extracted via a needle, even if we consider the sperm quality excellent, we can only extract enough for IVF. But in some cases the sperm quality is lower than expected, but it’s rare that you can’t get a good IVF cycle out of what you find. If there are any changes for the worse, they may be unrelated to the vasectomy.

Can a CT Scan effect sperm? There is more and more discussion about CT radiation exposure every day. However, at this point, there is no evidence that a CT scan effects sperm counts, motility, or functionality in any way.

Should you have icsi with a sperm count of 12 million with 40% motility? This depends on how many sperm are recovered from the sample after rinsing and spinning (I know, sounds like there is a washing machine joke in here somewhere). Sometimes you can recover more than 5 million motile, sometimes only 2 million. Every lab has it’s threshold and will make a decision based on the number of motile sperm recovered. In our lab, 12 million and 40% motility usually means no icsi, but I would need to reserve judgment until we process the sample.

Is frozen sperm for iui less active than fresh? It depends on 2 things. One is the numbers and motility pre thaw. The more you have to start with the more you will have in the end. The second thing is how the sperm survives the freezing. Some really good samples just can’t handle the freezing and thawing. We do not know why this is; there are just differences between men that lead to different freezability. So the talk about frozen sperm is not as good for iui as fresh would only be accurate if post thaw counts or motility are low. Donor sperm has been put to the test. Anytime we freeze sperm we do a post thaw of a very small amount. If the post thaw is bad; bad donor. A good thawed sample is good; the good living sperm have not been weakened. Maybe some dies off, but the survivors are usually good survivors.

Most fertility doctors do not believe in the sperm penetration tests, especially when doing icsi anyway.

Miscarriage

What if you have had miscarriages, then surgery for a septum, and now can’t get pregnant? Start with repeating the HSG and getting a semen analysis. You never know, the septum may still be there, or maybe you developed blocked tubes or even a male factor. Also get the day 3 bloods.

Repeat biochemical pregnancies (yes I still hate that term) require the same workup as for miscarriages.

Frozen Embryos

Re-freezing embryos. There are a few papers showing that embryos can survive being frozen, thawed and then frozen again. Logic dictates that this should not be a first option, but there are cases where it seems like the right thing to do. If you thaw more embryos than you want to transfer, which is commonly done to select the best embryos, and surprisingly all the embryos look great, then refreezing the extras may be a good option.

What if you had a baby from a frozen cycle where 10 embryos were transferred, and you want to get pregnant again but only have 5 left? Even with your 1/10 success rate, 5 is plenty. In fact 5 may be too many.

General Topics

Is an endometrium of 14-16 mm too thick? Providing there is no hidden fibroid, polyp or hyperplasia, that thickness is probably OK. And what about an estrogen level that may be too high? There has always been talk about a too high estrogen level and this goes back to studies in mice. However, I have not see women whose problems are that their estrogen levels are too high. Some women with thin linings are put on estrogen injections or vaginal pills, and it is not uncommon to see levels over 2,000 in a frozen or donor egg cycle. Some women undergoing IVF have estradiol levels 5-10,000 (not a good idea for other reasons), and they have no trouble implanting.

Do I endorse Egg Freezing? I don’t really endorse anything. I am a fan of educating to the best of my ability, and allowing my patients to make informed decisions. Egg freezing is very promising, and some early studies show that is more successful that we thought it would be. But, it is still relatively new and expensive.

Both husband and wife diagnosed with hypothyroidism. It’s possible, but get a second opinion just to be sure. Some doctors over diagnose thyroid problems in everyone.

What if you had some questions about your luteal phase, so you were placed on progesterone but are still not pregnant? Don’t wait long. Talk to your doctor about starting clomid because it too is a treatment for luteal phase defect, and it may up your odds of getting pregnant as well.

How long do you need to be on OCP’s prior to an IVF cycle? In reality, you don’t need to be on them at all. One exception is the OCP microdose (also called microflare) IVF protocol. Here the recipe calls for ocps. But for all others, ocps are not necessary. Many programs use them to time the cycle. This means the program wants you to start on a certain day to time the retrieval/transfer. Or they want you to start in a certain week because they may have lab personal coming from the outside for a specified number of days. If you are relatively young and a good responder, the length of time on the pill probably does not matter. However if you are a marginal or poor responder, pill use, especially prolonged, could lower your egg production further.

Thanks for reading and don’t forget the discalimer posted 5/17/06.

Dr. Licciardi

Even More about Polycystic Ovaries

Should every PCO patient be on a drug like Metformin? This is up to you and your doctor. If you are diabetic or borderline diabetic, Metformin may be just what you need. What if you are a little overweight and have high cholesterol? This is more debatable.
What if you are trying to get pregnant? Say you are normal weight or above weight, no diabetes, don’t ovulate and were told you have PCO. Here, the early studies said yes; as very high rates of ovulation and pregnancy were reported. In fact, some studies showed pregnancy rates from Metformin were higher than Clomid. Many doctors went with this information and gave their patients Metformin rather than Clomid feeling that lowering the insulin levels was the key to natural ovulation.
And then as more studies were published, the results looked less favorable. Metformin did not allow for normal ovulation as often as advertised. I realize there are some of you who took Metformin, ovulated, got pregnant and swear by that system. I am very happy for you, but most people did not have your experience. Most ovulated rarely or never. I noticed this in my practice and found I was just extending the infertile time for my patients.
The New England Journal of Medicine recently published an excellent paper on PCO, written by members of the Cooperative Multicenter Reproductive Medicine Network. The title is “Clomiphine, Metformin or Both for Infertility in the Polycystic Ovary Syndrome”, published February 8, 2007. I hate to get too scientific, but I want to say a few words about this because the findings surprised even some of the authors. Most studies that are published are not of high enough quality to make doctors change they way they practice medicine. There are many reasons for the low quality including a low number patients studied, non-randomization, flaws in the statistics, and the list goes on and on. This paper is of very high quality. In summary, while 24.9% of the patients taking Clomid never ovulated; the rate was 44.7% in women taking Metformin. There was a 22.5% live birth rate in women taking Clomid, a 7.2% live birth rate in the Metformin group. Rates with Clomid were not increased by adding Metformin. So Clomid was clearly better for becoming pregnant than Meformin.
Now this is just one study and treatment needs to be individualized. I just wanted to present the case that as of 2/08/07, Metformin is being questioned as a reliable primary method of conceiving. I’ll finish up with PCO next time, and remember speak to your doctor and read the disclaimer 5/17/06.

References:

  • Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;19:41-7 (also Fertil Steril 2004;81:19-25)
  • Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, Steinkampf MP, Coutifaris C, McGovern PG, Cataldo NA, Gosman GG, Nestler JE, Giudice LC, Leppert PC, Myers ER; Cooperative Multicenter Reproductive Network. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007; 356(6):551-66.
  • Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Hum Reprod 2008;23:462-77 (also in Fertil Steril 2008;89:505-22.)
  • Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel SF; Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril 2009; 91:456-88.
  • Goldzieher JW, Axelrod LR. Clinical and biochemical features of polycystic ovarian disease. Fertil Steril 1963; 14:631-53.

Polycystic Ovaries and Insulin Resistance

Thanks for all the comments. I would like to address the very important comment about insulin resistance and PCO. I need to start by saying that, as with many things in medicine, we though we had this figured out but in the end, we may be a little off the mark.
What is the definition of PCO? 2/3 of the following:
1) no or infrequent ovulation
2) physical signs of excess androgens, or high levels of androgens in the blood.
3) polycystic ovaries on ultrasound (12 or more little follicles on each ovary)

The physical signs of PCO vary considerably. Some women are thin and just don’t ovulate, and have polycystic ovaries on ultrasound. The opposite is women who are heavy, abnormally hairy, have high levels of androgens; testosterone and the other male hormones. Even normal women have these hormones, but not in excess.
So your PCO may be completely different that your friend’s PCO. And the treatment of your PCO may also be different.
Now let’s get to PCO and insulin resistance.
Insulin is the hormone made by the pancreas that allows us to use sugar. Sugar (glucose) needs to get from our food, into the circulation and then into our cells. Cells can not function without glucose. It’s the insulin that allows us to properly use the glucose. No insulin, no proper glucose utilization, no life.
Diabetes is a condition where there is a problem with insulin. Without insulin, blood levels of glucose rise to dangerous levels. Type 1 diabetics don’t have insulin, and need to take insulin by injection.
Type II diabetics make some insulin. Some Type II diabetics make a small amount and need a little help with medications to improve the action of insulin. However, most Type II diabetics make more that enough insulin, but for some reason the insulin doesn’t work well and glucose levels rise. So they have high levels of insulin and glucose. These patients are “insulin resistant”. They also take medications to improve the actions of insulin.
Some women with Type II diabetes have PCO, some women with PCO have Type II diabetes. A number of decades ago, researchers noticed this relationship and started asking if PCO was related to diabetes and some progress was made in the area of insulin resistance. That is to say, it was determined that some women with PCO also have insulin resistance.
When all this came about, researchers were quick to say that all women with PCO have some degree of insulin resistance. They may not be diabetic, but their insulin levels are high. By the way, insulin resistance is not in the definition of PCO.
Here comes the most important point of this blog. Because insulin also acts a growth hormone, it can make people bigger and fatter. People who are insulin resistant, have higher levels of insulin and may be bigger. (Now I know that some of you are type II diabetics and have normal weight, but most type IIs are at least a bit overweight.) The idea was if we lower the insulin (with medications that help insulin work more efficiently) patients will lose weight, and ovulation will occur normally. And it’s not just about the weight, there may be other benefits of lowering the insulin levels that help women with PCO. Lowering insulin levels also may lower the androgen levels. Metformin, aka Glucophage, is the most commonly used drug for this purpose. We will get into this next time.

References:

  • Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod 2004;19:41-7 (also Fertil Steril 2004;81:19-25)
  • Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, Steinkampf MP, Coutifaris C, McGovern PG, Cataldo NA, Gosman GG, Nestler JE, Giudice LC, Leppert PC, Myers ER; Cooperative Multicenter Reproductive Network. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007; 356(6):551-66.
  • Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Hum Reprod 2008;23:462-77 (also in Fertil Steril 2008;89:505-22.)
  • Azziz R, Carmina E, Dewailly D, Diamanti-Kandarakis E, Escobar-Morreale HF, Futterweit W, Janssen OE, Legro RS, Norman RJ, Taylor AE, Witchel SF; Task Force on the Phenotype of the Polycystic Ovary Syndrome of The Androgen Excess and PCOS Society. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril 2009; 91:456-88.
  • Goldzieher JW, Axelrod LR. Clinical and biochemical features of polycystic ovarian disease. Fertil Steril 1963; 14:631-53.

More on Polycystic Ovaries

Please start off by going back to the archived blogs from 7/06/06 and 7/22/06. These will update you with the basics of cysts and polycystic ovaries.
So let’s say you were told you have PCO, or Polycystic Ovaries, and you want to get pregnant. What are your next steps?
The first steps have to do with further diagnostics. You don’t ovulate and getting you to ovulate is probably all you need to get pregnant. Clomid may be all you need. Do you need to do any other tests before you start the Clomid? Probably not but you may. It is common for women to have more than one fertility problem. Some women with PCO also have blocked tubes (totally unrelated to having PCO) or a low sperm count. And some have other hormonal issues.
The basic things to check are your prolactin, thyroid and 17 hydroxyprogesterone. The last is a test for congenital adrenal hyperplasia, a rare disorder that can create a picture like PCO. If the blood tests are all ok, then you can consider the hysterogram and semen analysis. It is OK to start Clomid without these 2 tests, may patients do. Just understand that these tests need to be performed eventually. It’s really bad if you get a Clomid prescription for 6-12 months. A few months are fine and if you’re not pregnant, then check the tubes and sperm.
How do you know if the Clomid is working? If the time in between cycle is greater than 35 days and Clomid gives you cycle that are around 28 days, it’s working. If you still rarely get a period, it is not working. There are more accurate ways to check. If you take your temperature (temperature charting is too much work, but I know some of you are regular temperature takers) there is usually no clear rise mid cycle, but there is when Clomid is working. Progesterone causes the rise and progesterone is only present after ovulation. No ovulation, no progesterone, no temperature rise. The ovulation predictor kits are another option. These are hard for women who get cycles far apart because it’s difficult to know when to start testing, and testing can go on for weeks if ovulation is not happening. But if you were getting 50 day cycles and now they are 29 days, you are ovulating. It becomes easier to use the kits and time intercourse if your cycles become more regular. The best way to prove that you have ovulated is a blood test for progesterone. The problem with this is people get hung up about the level. This is not important. If your level is 6, 9 or 21 it does not matter. Progesterone levels vary throughout the day anyway. As long as it is elevated above baseline (2-3 depending on the lab) you are OK. More next time and please read the disclaimer 5/17/96.
Dr. Licciardi

References:

  • Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, Steinkampf MP, Coutifaris C, McGovern PG, Cataldo NA, Gosman GG, Nestler JE, Giudice LC, Leppert PC, Myers ER; Cooperative Multicenter Reproductive Network. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007; 356(6):551-66.
  • Misso ML, Costello MF, Garrubba M, Wong J, Hart R, Rombauts L, Melder AM, Norman RJ, Teede HJ. Metformin versus clomiphene citrate for infertility in non-obese women with polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2012 Sep 6. [Epub ahead of print].
  • Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2009 Oct 7 ;(4):CD003053.

The doctor said I can’t start because I have a cyst.

These are usually just “leftovers”. The normal cysts of ovulation dissolve away just before the period. An ultrasound on day 2 or day 3 usually shows no cysts. There may be small follicles (normal follicular cysts) but nothing over about 10 mm. However, sometimes the scan shows larger cysts. They can be black looking on the scan, these are filled with clear fluid. Sometimes they are grey in appearance, these are filled with blood. Whether or not you start is related to your estrogen level and the philosophy of your doctor.
If the cyst is producing estrogen (can’t tell by looking, need to wait for blood results), the cycle can’t start. Taking fertility drugs will do nothing more than make the big cyst bigger. If the estrogen is low, starting would be fine. An exception would be if the doctor is concerned about the consistency of the cyst and wants to follow the cyst over 1-2 months to be sure it shouldn’t be removed.
Some doctors don’t like starting the drugs even if the estrogen is low. They will tell you to wait a month. I don’t have a problem with that, it’s their call.
Cysts are much more common in women doing “back to back” cycles. The drugs cause multiple follicles to grow, and there may not be enough time for them to all dissolve before the period.

References:

  • Penzias AS, Jones EE, Seifer DB, Grifo JA, Thatcher SS, DeCherney AH. Baseline ovarian cysts do not affect clinical response to controlled ovarian hyperstimulation for in vitro fertilization. Fertil Steril. 1992 May; 57(5):1017-21.
  • Qublan HS, Amarin Z, Tahat YA, Smadi AZ, Kilani M. Ovarian cyst formation following GnRH agonist administration in IVF cycles: incidence and impact. Hum Reprod. 2006 Mar; 21(3):640-4.
  • Keltz MD, Jones EE, Duleba AJ, Polcz T, Kennedy K, Olive DL. Baseline cyst formation after luteal phase gonadotropin-releasing hormone agonist administration is linked to poor in vitro fertilization outcome. Fertil Steril. 1995 Sep; 64(3):568-72.
  • Hornstein MD, Barbieri RL, Ravnikar VA, McShane PM. The effects of baseline ovarian cysts on the clinical response to controlled ovarian hyperstimulation in an in vitro fertilization program. Fertil Steril. 1989 Sep; 52(3):437-40.

Ovarian Cysts Part One: Normal Ovulation

I need to write a few about cysts. I eventually want to get to Polycystic Ovaries, but I need to clarify the basics first. I will start with the cysts of normal ovulation.
The word “cyst” requires a long explanation. Cyst can mean a million things. A cyst is any fluid filled round thing growing on the ovary. They can be good, neutral or bad. In a woman who ovulates regularly there is one normal cyst produced every month. In the days leading up to ovulation, there is a cyst called the follicular cyst, or the follicle. It grows from a very small cyst of less than 10 mm in size to about 25 mm in size (2.5 cms or about an inch). The size can vary a bit, but most follicular cysts look the same on ultrasound from woman to woman. It’s filled with mostly fluid, but has some cells and one important cell: the egg. At ovulation the egg pops out, but the cyst stays around. The same cyst now takes on a different name: the corpus luteum (sometimes written as CL). The job of the follicular cyst is to make estrogen and develop the egg, the job of the corpus luteum is to make progesterone. The estrogen makes the lining of the uterus grow, and the progesterone makes the lining able to accept the embryo. The corpus luteum is a cyst, and it can vary in size, from small and difficult to see, to very large 2-4 inches, and easy to see. They are usually filled with blood. When they are large they can be painful, and they can sometime rupture, causing the sudden onset of pain. The corpus luteum dissolves away as the cycle goes along until there is nothing left. Therefore the source of progesterone goes away and this causes the period. This is all normal. It happens with every ovulation in every woman. So here we have a case of “cysts” that are good and normal. Sometimes these cysts are larger or look a little different than usual. In these cases we sometimes have women come back for a repeat ultrasound after their period, because this is when the ovaries should have only small follicular cycst(or follicles). In women who are pregnant, the early pregnancy makes the hormone hCG, which keeps the corpus luteum from dissolving, therefore there is no loss of progesterone and there is no period.

References:

  • Fritz MA, Speroff L. The endocrinology of the menstrual cycle: the interaction of folliculogenesis and neuroendocrine mechanisms. Fertil Steril. 1982 Nov; 38(5):509-29.
  • Baerwald AR, Adams GP, Pierson RA. Ovarian antral folliculogenesis during the human menstrual cycle: a review. Hum Reprod Update. 2012 Jan; 18(1):73-91.
  • Son WY, Das M, Shalom-Paz E, Holzer H. Mechanisms of follicle selection and development. Minerva Ginecol. 2011 Apr; 63(2):89-102.