by Fiona McCulloch, ND
Top Fertility tests : A Quick Reference for Women from an Integrative Medicine Perspective
FSH – Follicle Stimulating Hormone
Day 3 FSH can indicate how hard the pituitary is working to stimulate the ovaries. Though traditionally a higher FSH is given a poor prognosis, I don’t always see it this way clinically. The FSH can very much change depending on the quality of the antral follicles, which depends on ovarian health over the previous months as well as ovarian reserve. The poorer the quality of the eggs, the more free radical damage they have accumulated and the poorer ovarian blood flow is, the more FSH the pituitary will have to put out in order to stimulate the antral follicles. Healthy follicles are responsive to lower amounts of FSH. If treatments are started to enhance ovarian health over 120 days of folliculogenesis prior to ovulation, the lowered FSH that can result can indeed indicate that the quality of the eggs in the ovaries has increased. Please keep in mind that I have seen many women with high FSH become pregnant when egg quality and ovarian health is worked on so having a high FSH is not untreatable.
|FSH Levels (Day 3)
||less than 6 mIU/mL
||above 13 mIU/mL
LH – Luteinizing Hormone
This is a test which is often done on day 3 of the cycle. If higher than the FSH, especially if higher than a 2:1 ratio, it can indicate polycystic ovarian syndrome. Having a high LH level will result in increased ovarian testosterone production, altered estrogen production, and abnormalities with ovulation. Normal day 3 range : <7 mIU/mL
Measured on day 3 of the cycle. If elevated, estradiol can lower the fsh, thereby masking elevated fsh levels. This can happen in cases of low ovarian reserve or functional cysts. Estradiol can be low in conditions of low ovarian reserve. Women who have estradiol over 294 pmol/L (or 80 pg/ml) have a lower chance of success with an IVF cycle since they will not respond to stimulation as well.
This is often measured on day 21. This is used to determine whether ovulation has occurred as a healthy corpus luteum produces progesterone. It is important to measure progesterone 7 days after your ovulation, measuring on day 21 only applies to women who ovulate on day 14. Levels higher than 16 nmol/L strongly suggest an ovulatory cycle.
Often measured in the morning can indicate the impact of stress on the reproductive system. Elevated cortisol can affect ovarian circulation and function. Normal levels : 250 – 850 nmol/L taken between 6-8am. Low cortisol can be found in congenital adrenal hyperplasia. Normal levels for am cortisol 101-536 nmol/L
The total level of testosterone in the system. If elevated this can indicate polycystic ovarian syndrome. High testosterone can interfere with normal ovulation often causing delayed ovulation or anovulation. Levels can also be low around which can negatively affect ovarian function. Normal levels for females 0.3- 4.0 nmol/L
The amount of testosterone that is not bound to carriers and is available to stimulate tissues. The higher this is, the more androgenic effect on the tissues. This can be elevated in PCOS and specific adrenal conditions such as non-classical congenital adrenal hyperplasia (non classical CAH). Normal levels for females 0.1-8.9 pmol/L
A hormone normally elevated in nursing and pregnancy. If elevated in other situations it can interfere with ovulation and fertility. It can be elevated due to stress, medications such as antidepressants or painkillers, thyroid disease, or pituitary conditions such as microadenomas. normal levels in women 3.3 – 26.7 ug/l.
DHT – Dihydrotestosterone
A form of testosterone which is very potent. DHT Can be elevated in pcos or enzyme conversion disorders resulting in androgen excess signs and symptoms. Serum testing for DHT is often unreliable.
Sex hormone binding globulin
Can be low in patients with androgen excess conditions such as pcos or in hypothyroidism. Can be high in non classical CAH, hyperthyroidism. Normal levels : Follicular phase 24 – 200 nmol/L, Luteal phase 48 – 185 nmol/L
A long termarker of insulin resistance and blood glucose control. Can be elevated in pcos. Marks the previous 3 months of blood glucose control. Normal levels 0.040 – 0.060
DHEA – S
A precursor to hormones, most especially androgens. DHEA is made by the adrenal gland. Levels tend to reduce with age and can be reduced in low ovarian reserve. Levels can be elevated in PCOS. Normal range for women 0-11 µmol/liter
A marker for stored iron. Levels can be low in patients with infertility. I recommend patients to achieve ferritin levels of above 50.
TSH - thyroid stimulating hormone
I like to achieve levels of approximately 2 – 2.5. Levels above this can put the patient at risk for early miscarriage. Normal Ranges are : 0.4 – 4 mIU/L. If levels are above 3, and especially if thyroid antibodies such as antithyroglobulin and anti-thyroid peroxidase are present with signs and symptoms of hypothyroidism, this and may present risks for fertility.
Important for overall health, hormone balance, and stress levels. Normal levels of 1, 25 Hydroxy Vitamin D 40 -150 pmol/L
A marker of inflammation and circulatory health. This test is only recently being found to be important for ovarian health. Elevated levels can be found in autoimmune conditions, ovarian aging and endometriosis. Normal range : 4.7 – 14.1 umol/L
A measure of blood clotting. Blood which clots excessively may interfere with implantation. Can also elevated in endometriosis or fibroids. Normal value for INR 0.9 – 1.2
Anti sperm antibodies
The presence of anti- sperm antibodies in women can destroy or damage the sperm before they have the chance to fertilize the egg. Around 5% of infertile women have these antibodies in their bloodstreams.
Anti thyroid antibodies
These include antithyroid peroxidase and antithyroglobulin. These antibodies, if present will reduce fertility by 13%, even if thyroid function is normal. These antibodies can cause alterations in thyroid function and also can be cross reactive with ovarian tissue. Women with PCOS who don’t respond to clomid have a higher liklihood of having antithyroid antibodies.
Anti nuclear antibodies
These antibodies are present in autoimmune disease such as Lupus and Sjogrens syndrome.
Special Ovarian Reserve Markers:
Antimullerian hormone is produced by growing follicles and prevents premature recruitment of primordial follicles. This value generally correlates with the number of functional primordial and antral follicles remaining in the ovary. Generally, the higher the AMH, the more healthy follicles are in the ovary. Antimullerian hormone can predict the age of onset of menopause with some degree of accuracy. Low AMH often does not give a good prognosis for IVF because IVF is based on the stimulation of multiple follicles – women with lower AMH tend to get fewer follicles during IVF stimulation. However, even if AMH is low, conception is possible. Even if there are not many follicles remaining in the ovary, their quality can be improved with treatments including antioxidants and circulatory enhancing therapies. Natural conception with low AMH can and does happen. Normal ranges :
||28.6 pmol/L – 48.5 pmol/L or over 1.0 ng/ml
||15.7 pmol/L – 28.6 pmol/L or over 1.0 ng/ml
||2.2 pmol/L – 15.7 pmol/L or 0.3 – 0.9 ng/ml
||0.0 pmol/L – 2.2 pmol/L or less than 0.3 ng/ml
|High Level found in PCOS
||> 48.5 pmol/L or over 3 ng/ml
A marker of ovarian function and reserve, this protein is secreted by small developing follicles and works to inhibit FSH levels, hence the name inhibin. This test is completed on day 3 of the cycle. As inhibin is secreted by the follicles, it can indicate the number of and function of the remaining folliciles. This test is not widely available. Normal = above 45 pg/ml Low = below 45 pg/mL Inhibin B is a spectrum however, and this line is a general guideline not a strict cutoff. Like with AMH even if inhibin B is low, conception is possible if the health of the remaining follicles is enhanced.
Mosby’s Manual of Diagnostic and Laboratory Tests. 4th Ed. 2010
Speroff, Clinical Gynecologic Endocrinology and Infertility. 7th Edition 2005.