Patient: “My OBGYN did blood work and said everything looks good. So why can’t I get pregnant?”
Patient: “My RE (reproductive endocrinologist/fertility doctor) did blood work and said that I have to do IVF because my numbers are bad.”
And when they tell me the numbers, I can’t decide if I want to face-palm or bang my head on the table. Because in one situation, the testing is all wrong, and in the other, the interpretation of the tests is too limited.
Here’s the upshot: “Good” and “Bad” are relative, and change depending on your situation!
Neither of the statements the doctors tell my patients is necessarily true. In both cases, the conclusion depends on the framework of the ordering doctor. The type of blood work the OBGYN ordered and the diagnosing/interpretive framework the RE used, significantly affect their interpretation of the results.
In the first case, what I’ve found is that often, when an OBGYN does “fertility” blood work, they aren’t actually testing fertility hormones. uhm, what? Yes, it’s true. (More on that soon). Or they are testing it on the wrong day. In the second case, when a reproductive endocrinologist does fertility blood work, they interpret the results ONLY in terms of suitability for IVF; but that doesn’t mean things are actually bad for natural fertility, or can’t be improved.
In either case, the statement from your doctor that the blood work is “good” or “bad” can mislead you, creating frustration, incorrect conclusions, and unsuitable decisions. Here’s an easy guide to figure out what your doc means, or what they really need to do.
Everything Looks “Good”
The first question is, did the OBGYN just run a routine blood work panel? Routine blood work looks at red and white blood cells, liver function, maybe thyroid function, some other blood values. Yes, it’s important to make sure these are all good, but they are NOT fertility hormone panels. For blood work to be a fertility panel, it has to be done on the second or third day of your cycle, and it has to include FSH/LH and E2 at a minimum, and it’s good to have it include free testosterone and DHEAS. (FSH= Follicle stimulating hormone, LH=luteinizing hormone, E2=estradiol, DHEAS=no need to remember what this stands for, it’s a loooong chemical name).
An Easy Intro to Fertility Blood Work: Interpreting the Alphabet Soup
So what are the basics of fertility hormone blood work?
FSH (follicle stimulating hormone) indicates how well your ovaries are responding to the hormonal message to develop a follicle.
You want LH (luteinizing hormone) to be almost equal to FSH on cycle day 2 or 3 (imbalances in the ration of FSH/LH can indicate a hormonal problem).
E2 (estradiol) is the type of estrogen that follicles secrete to tell the brain to keep sending FSH and help with follicle growth.
Free testosterone and DHEAS are responsible for stimulating proto-follicles into developing.
And, one more that you might see: AFC (antral follicle count) is an ultrasound test; it’s unlikely that your OBGYN will order it. But your RE might: it’s a count of the number of eggs/follicle that you have available that month for retrieval.
These are the hormones that roughly tell you how your fertility is doing. (There are other tests. I’ll talk about AMH, in particular, in a future post). But you can’t do these tests on any ol’ day of your cycle. FSH/LH must to be done on cycle day 2 or 3, because they are constantly in flux, and so we know what “normal” looks like ONLY on these days. You need these tests, on these particular days. Routine blood work, or these tests done on the wrong day, really don’t tell you anything at all. That leads us into the second question, which is what do the values tell you, anyway?
What the Blood Work is Measuring
The blood work that an RE does is meant to be a rough guide to what is going on with your fertility, and how well you will respond to stimulation medications. That is the framework that the RE uses to evaluate the results. Let’s look at the numbers the way an RE would.
High FSH levels means that your follicles/ovaries are not responding to the message to develop. In general, you want FSH below 10 for a good IVF. Really low FSH means…..? We don’t really know what it means. High E2 can suppress FSH, meaning if your E2 is high, your follicles are responding worse than the numbers say they are. It can also be an indicator of endometriosis (along with other signs and symptoms). High testosterone or DHEAS levels can indicate PCOS, which interferes with egg quality. Low testosterone/DHEAS can mean that your proto-follicles aren’t getting stimulated into development, so you will have a lower number available for retrieval, which is a concern for an RE. None of these are good indicators for PCOS, but more importantly for the interpretation issue, your RE’s training says they can’t be improved.
Furthermore, if your RE tests the number of eggs/follicles you have available (AFC= antral follicle count, the number of follicles that might be available for a retrieval), and there are only a limited number of eggs, then the success rate of IVF decreases.
It’s important to realize that IVF is a numbers game. In fact, REs know that in general, 5 out of 6 eggs will die from retrieval to day 5. If you have a small number of available follicles, or you aren’t going to respond to stimulation medications well, the odds are not in your favor. And in the Western medicine paradigm, blood work numbers only deteriorate. So based on this interpretation, the RE will tell you that you need to do IVF immediately because of the small number of eggs, or “bad” blood work.
What The Blood Work Results are “Bad” Means…….to an RE
If an RE tells you that the testing results are “bad” you have to understand how they are looking at the results. The RE assumes that these levels will only get worse in the future. From a Western medicine point of view this makes sense. In fact, there is almost nothing a Western doctor or Western medicine can do to make your blood work/fertility better. Therefore, the thinking goes, if your body’s fertility cannot be improved, blood work that says things are bad indicate that from a Western medicine framework, your best bet for a baby is to do IVF NOW.
- Interpreting the Blood Work: There’s More Than One Way to Look at It
Notice (it’s hard to miss) the emphasis on Western medicine as the framework. The Western medicine interpretation is only ONE way of looking at what is going on. Your blood work is just a snapshot of what is, in this moment. That is all. How that information gets interpreted depends on what tools the person looking at the blood work has.
Your RE is not wrong: from their point of view, with their training and expertise, IVF may be the only option based on your blood work. They are giving you their expert opinion based on what they know. Unfortunately, they have been taught that fertility only decreases.
Fertility is Dynamic, So Numbers Can Change
This is not necessarily the case. Fertility is a dynamic state. Fertility improves with care and cultivation. “Bad” fertility is the result of multiple factors: stress, nutrient-poor lousy diets, toxin exposure, hormone imbalance, etc, etc, etc. The beautiful, hopeful news is that FERTILITY CHANGES, given the right care and commitment.
The judgement of “bad” blood work also ignores that the numbers necessary for IVF are not the same as the numbers needed to conceive naturally. IVF needs LOTS of eggs, because so many don’t make it to Day 5 embryo state. In contrast, natural conception only needs one good egg a month. So blood work results that are “bad” for IVF tell you very little about what is going on in terms of natural conception. Furthermore, you can also make changes that will improve the outcomes of IVF or natural fertility. Fertility is dynamic, for both IVF and natural fertility.
The blood work is not a conclusion: it is a starting point for improving fertility. This is a huge topic, and I’ll explore it in future posts. I’ve been teaching women how to improve their fertility for a decade: it can be done. (I’ve even got courses available online to teach you how: www.fertilityresetonline.
The point of this post, however, is to remind you that the interpretation of the results of your blood work, as “good” or “bad” are not the final word. Too often, women assume that their doctors know everything (they don’t), and assume the doctor’s assessment of the blood work results is infallible (it’s not).
So, What’s the Takeaway?
- Check and make sure the right basic fertility tests have been ordered. At a minimum, cycle day 2 or 3 FSH/LH and estradiol values, DHEAS/free testosterone. Don’t be afraid to question your doctor’s blood work order if you don’t think it’s correct. (And, yes, get the general blood work done too.)
- Get your fertility blood work results and do some homework to figure out what they mean.
- Educate yourself. Learn what you can do to improve your fertility.
- Challenge the interpretation of the results, or the conclusion to do IVF now, IF you are willing to put in the effort to improve your fertility. If you can’t/don’t want to make changes, then go with what your doc says, it’s likely your best chance.
- Find a non-Western fertility specialist who can help you unlock your body’s ability to improve your fertility. Even if you do IVF, you can improve the quality of your eggs and improve your blood work so that your IVF cycle will be more successful.
Have you had an issue with your blood work? Share your experience if you have.