Can the level of hCG in blood tell me whether my pregnancy is a healthy one or not?

Yes – but only to a certain extent.  The hCG (human chorionic gonadotropin) hormone is a remarkable molecule, which is very unusual because it is produced only by the cells that will become the placenta of the developing embryo (trophoblast cells). Once the embryo implants in the uterine lining, these cells start producing hCG . It takes a few days for the hCG hormone to build up in the body to a level, which is high enough for it be detected in the blood or urine of pregnant women. Normally, you do your first pregnancy test (hCG blood test) 14 days after embryo transfer.  At this point, if the embryo has implanted, you will also get a positive urine pregnancy test. The hCG hormone level in the blood doubles every 48-72 h. If the hCG level doubles well, this indicates that the cells of the embryo are dividing well, suggesting that the pregnancy is progressing normally and is healthy.  This is why monitoring the hCG blood levels during the first few weeks helps to make sure that the pregnancy is advancing as expected. A drop in hCG level during this time is a sign that the pregnancy is not healthy.  Make sure that you measure your hCG level in the same lab each time to avoid discrepancy in the results.

However, do remember that because the trophoblastic cells of the embryo produce the hCG, a rising level does not always mean that the pregnancy is healthy. Thus, while a drop in hCG confirms the pregnancy is doomed, a rising hCG level provides limited information.

Also, once the hCG level crosses 1000 mIU/ml, a vaginal ultrasound scan provides much more useful information than just the hCG levels, because it allows us to actually visualize the development of the growing embryo.

What is a chemical pregnancy? 

Sometimes, the joy of being pregnant can be very short lived. You might get a positive urine pregnancy test, or a positive blood pregnancy test, two weeks after (or even earlier!) your embryo transfer. But, to your agony, the subsequent pregnancy tests you take might reveal a dropping hCG value; or your urine pregnancy test may become negative. This is a very hard situation to face because you feel disheartened and cheated. Such a pregnancy, which dissolves quickly, is termed a chemical pregnancy. This means your embryo implanted in your uterine lining, but failed to develop further. This is quite common and occurs because the embryo is not competent enough to grow further. Please do not blame your life-style or other activities for this!  A chemical pregnancy cannot be prevented by any means what so ever – taking extra progesterone, avoiding certain foods, avoiding intercourse or taking strict bed rest cannot prevent a chemical pregnancy, so please do not beat up on yourself!

This is an excerpt from our forthcoming, book, The Expert Patient’s Guide to IVF. This being authored by our expert patient, Manju and me.

Egg freezing and hollywood

‘At 46, those 37-year-old eggs will start to look pretty good’: Egg freezing is a hot topic in Hollywood – and it’s never too late to put yours on ice, says Ashley Pearson

Read more: http://www.dailymail.co.uk/femail/article-2324382/Egg-freezing-hot-topic-Hollywood—expensive-risky-baby-plan-warns-Ashley-Pearson.html#ixzz2ThkBoF00 

WHEN EGG DONATION IS RECOMMENDED: Are You Talking to Us?

As a couple, you have most probably been on the emotional roller coaster ride that comes with infertility treatment for any length of time. Going through the sequence of treatments from fertility drugs, to IUI, to possibly several IVF attempts has made you no stranger to the painful emotional cycle of allowing your hopes to grow, dealing with the uncertainty of waiting for the results, only to come emotionally crashing down when the attempt proves unsuccessful. Just when you thought it couldn’t be worse, your doctor introduces the recommendation that you consider a donor egg recipient cycle. Why are these words so hard to hear and absorb? After all, you are no stranger to bad news.

The recommendation for a donor egg cycle represents moving from still being able to have your own genetic child to the unchartered territory of egg donation. You are experiencing the loss of the dream of looking into your child’s eyes and seeing yourself. The impact can be the same as experiencing the death of a loved one. But to further complicate matters, instead of being able to openly rely on the comfort of family and friends, you bear your feelings of loss privately. To the rest of the world, it is business as usual, even though nothing could be further from the truth. The danger in this is that you might “get stuck” in grief and not be able to move ahead in whatever direction you might take.

Mental health professionals have identified a sequence of stages that characterize the process of grieving. The initial stage is denial, which may show itself in feelings of numbness or shock. Typically, the thought process is “this can’t be happening to us” and “we’ll just keep trying with our own eggs, we’ll beat the odds”. However, practical considerations present themselves as it is not financially feasible or medically indicated to keep trying indefinitely. Denial is a temporary response that carries you through the first wave of pain.

Denial then gives way to anger which springs from feelings of vulnerability and helplessness. You have done everything possible to conceive with your own eggs. Generally, when you work this hard at something, the goal is achieved. You feel you have no control, that you are a victim where you can no longer count on anything good happening. Anger emerges, but there is no one to blame. Often, anger combines with the next stage, Bargaining. Bargaining revels itself in thoughts of “what if?”.  “What if we had sought help sooner, what if I hadn’t put my career first, what if we had gotten that second opinion sooner?’.  Privately, in an attempt to regain control you make a deal with God or a higher power in an attempt to protect yourself from the painful reality of not being able to have your own genetic child.

Eventually, the bargaining dissipates and feelings of guilt and shame may emerge. These feelings manifest themselves with thoughts that “I am a failure” or “I am defective”. Self -esteem ebbs and a sense of inadequacy and fear of the negative judgment of others pervades and you begin to lose hold of all the things you value most about yourself.  Ultimately, you arrive at a place of feeling intensely sad about your loss. Allowing yourself to experience this feeling and being able to accept yourself and the comfort of trusted others will help you to arrive at the final stage: Acceptance.  Accepting your loss means that you accept yourself as an imperfect human being who continues to move forward in spite of the obstacles before you.

Coping with loss is ultimately a deeply personal experience – no one can understand all the emotions that you are experiencing. It is also important to know that everyone goes through these stages at their own pace and may even go back a stage or two when a particularly painful wave of grief is experienced. The most important thing you can do is to allow yourself to feel the grief as it comes over you. Resisting it will only prolong the natural process of healing. Accepting the comfort of your spouse, talking about your feelings aloud, no matter how irrational they might be, is essential to resolving the loss and moving forward in life.

In spite of all you might know about the process of grieving, it is still possible to “get stuck” there. If this is the case, consult a mental health professional experienced in working with issues of infertility and fertility treatments.

Mary V. Speno PhD is a Licensed Clinical Psychologist serving as a consultant to InVia Fertility in all matters related to ART. She can be reached at 847.577.1155 x 239.

AMH level and menopause. Does AMH level predict age at menopause?

Anti-mullerian hormone (AMH) level is now routinely used to evaluate ovarian reserve.  AMH levels decrease with age and are a more consistent predictor of “ovarian age” than antral follicle count on ultrasound, inhibin b, or FSH levels.  The ovary produces AMH and this is confirmed by the fact that AMH levels are undetectable after surgical removal of ovaries as well as menopause.  It is therefore reasonable to ask, “Does AMH level predict age at menopause?”

The answer is a qualified yes!  But this is true only in older women.  Freeman et al. from the University of Pennsylvania, Philadelphia, studied this very question as part of the Penn Ovarian Aging Study (Freeman et al., J Clin Endocrinol Metab 2012;97:1673-80).   They studied 401 older women (mean age 41.47 y) with a median AMH level of 0.68 ng/mL over a 14-year period.  AMH strongly predicted time to menopause; age further improved predictions. Among women with a baseline AMH level below 0.20 ng/ml, the median time to menopause was 5.99 yr [95% confidence interval (CI), 4.20–6.33] in the 45- to 48-yr age group and 9.94 yr (95% CI, 3.31–12.73) in the 35- to 39-yr age group. With higher baseline AMH levels above 1.50 ng/ml, the median time to menopause was 6.23 yr in the oldest age group and more than 13.01 yr in the youngest age group. Smoking significantly reduced the time to menopause (hazard ratio, 1.61; 95% CI, 1.19 –2.19; P = 0.002).

These data may not be applicable to younger women.  I have addressed this in another blog where a recent study showed young women with low AMH levels had a good chance of natural conception.  The authors emphasize that these are findings from generally healthy women and may not be applicable to women with ovulatory infertility, menstrual cycle irregularities, or other health problems. Women who had disease conditions such as endometriosis or polycystic ovary syndrome were not included in this study.  Another limitation of their findings is that AMH levels can vary from lab to lab and their numbers should not be taken literally.  This data should not be used to counsel individual with a precise estimate as to when they will go through the menopause.

Low AMH level is NOT predictive of decreased chance of pregnancy in young healthy women.

A previous blog regarding AMH levels was greeted by more than 150 questions from interested readers.   A common question was regarding the clinical significance of a low AMH level.  I am young and my AMH level is low.  What does this mean?  Does a low AMH level mean I will never get pregnant?

Hagen et al.  addressed this very question in a recent issue of the journal Fertility and Sterility (Low concentration of circulating antimullerian hormone is not predictive of reduced fecundability in young healthy women: a prospective cohort study Fertil Steril 2012; 98:1602-8).   They followed a total of 186 young Danish couples that intended to discontinue contraception to become pregnant until they conceived or for six menstrual cycles. They calculated the fecundability ratio (FR) (i.e., the monthly probability of conceiving) and time to pregnancy (TTP) was measured as the number of cycles from stopping birth control to pregnancy.  They measured AMH levels and anticipated that those with low AMH levels would have a low FR and take longer to conceive.  AMH levels were measured and were divided into 3 groups low (quintile 1), medium (quintile 2 -4) and high (quintile 5).  The results are interesting.

59% of couples conceived during the study period.  There was no difference in the FR in women with low or medium AMH levels (FR 0.81; 95% CI 0.44 – 1.40)!  In contrast women with high AMH levels had reduced FR (FR 0.62; 95% CI 0.39 – 0.99).  High AMH levels are often seen in women with polycystic ovary syndrome (PCOS) and have irregular cycles.  This decrease in FR was significant even when women with irregular menses were excluded from the analysis.

Very few of these women had very low AMH levels (<0.16 ng/mL).  So the study cannot be used to reassure this group of patients.  It is possible that even in young patients, very low AMH levels may indeed be associated with premature menopause.

In IVF-related literature, a low AMH level is useful as a marker of follicle quantity than egg quality.  This study demonstrates that in the context of natural conception in young women, where only one egg is involved, low AMH level also does not reflect egg quality.

Women with high AMH levels and regular cycles had lower chance of conception.  These women may be similar to the group often termed ovulatory PCOS.  They have other hormonal imbalances (elevated circulating levels of testosterone) that may be responsible for the lower FR.

They conclude that low AMH levels in young healthy women do not seem to be a predictor of reduced fecundability.  This is consistent with high egg quality in these young women, despite a reduced ovarian reserve.  Conversely, women with high AMH levels had a 40% reduction in the FR, and this persisted even after exclusion of women with irregular cycles.

So what does all this mean?  At present, routine measurement of AMH level as a “fertility check up” in young women is not useful.  This study clearly shows that young women with low AMH levels did not have a decreased chance of conception compared to women with normal AMH levels.