Linda is a very confident woman in her early 30's who has a very successful career in sales in a science-related field. She and her husband have been married for six years but didn’t want kids right away. So, she had been diligent about taking birth control pills up until a year ago, when they first made the decision to start trying. She was originally started on the pill back in college to help regulate her erratic cycles. After going off the pill, her period had returned although sometimes coming in 26 days and other times as long as 34 days.
When she first came to see me for consultation, she brought
in a stack of color-coded temperature charts that she had created with the help
of some ovulation-tracking websites and dropped them on my desk in frustration.
She told me her story with sadness. She and her husband had put off having
children until now because they both loved their jobs. They also both had a
great love of traveling, each year typically going on two major vacations and
countless minor ones. They had moved into their dream home two years ago and
realized it would be an ideal time to start their family. Everything had been
perfect up to that point. Now she is convinced that she waited too long and
greatly regretted her decision. I told her that it’s very common to feel this
way, but in reality, she most likely had not done anything wrong to permanently harm to
her fertility. She continued her story.
When they went off the pill, they were expecting their life of perfection to continue so that they would get pregnant right away. However after eight months of nothing, Linda began being more proactive with diligently charting her cycles. The frustrating part was that some months, the temperature curve looked classic, like in the textbooks, with a clear increase in temperature during the second half of her cycle. However, there were also months in which it looked like a jagged set of random numbers. Her urine ovulation prediction kits had turned clearly positive in some months, with the test line definitely darker than the control line. However, there had also been months where she had a light line that stayed light for 5 days (never darker than the control) and then went negative. And then each month, there was the excruciatingly long wait to see if she was pregnant or not. She said she and her husband wanted to forego all vacations this year and put that money towards doing an IVF cycle to see if they can pregnant instantly.
I reviewed her charts with her and agreed that it was likely that she was ovulating some months and not ovulating on other months. I also confirmed that she had been off the birth control for eight months prior to embarking on the massive charting, and that she had been charting for a year now. Since she was on day 13 of her cycle on the day she first saw me, we had the opportunity to check with ultrasound to see how her follicles here doing. We found that her right ovary had a 14mm follicle. Nothing else was present on either ovary. Her lining was good at 8mm thickness with a triple layer. I explained to her that the follicle would have to grow to at least 17mm or better before it could ovulate. After talking for an hour total about other potential fertility factors, we came up with the plan of following this cycle using ultrasound and seeing how it correlated with her ovulating testing.
Two days later, she called the office excitedly saying she tested positive on her ovulation stick! We brought her in the next day for a repeat ultrasound and saw a single 18mm follicle on the right. So far, so good. She and her husband got busy for the next few nights. She then came back two days later for an ovulation check. To our slight surprise, the follicle was still there and had now grown to 25mm. She also reported vague abdominal pain on that side and even some mild spotting. The follicle had a clear appearance and did not have cloudiness inside as is sometimes seen when a follicle DOES ovulate, but somehow just fills with blood giving rise to what is called a corpus luteum. So even though her ovulation kits detected a surge, she had not physically ruptured the follicle. She had not physically ovulated. After another three days of intercourse, she returned for a final ultrasound. This time, there was a 31mm follicle on the right, still not ovulated. Almost two weeks after the positive surge, her period came. Optimistically, I advised her to hold off on IVF and start with something much simpler first.
In the next few weeks, we did many things, the most notable being diagnosing her with insulin resistance and starting her on metformin as well as confirming her husband to have a normal semen analysis. She had no apparent risk factors for tubal disease, so we held off on getting an HSG yet. With her next cycle, she was started on clomiphene citrate and monitored using ultrasound. By day #12, she had a lovely follicle on each side, each measuring 16mm. Three days later, her ovulation testing turned positive and she came back for another ultrasound, which showed one follicle to be 22mm and the other to be 20mm. She and her husband got together a lot in the subsequent days. Three days later, she returned. This time, ultrasound confirmed that both follicles were no longer there. They were gone for certain, presumably ovulated! She was scheduled for a blood pregnancy test in two weeks, but she “cheated” two days early and did a urine test, calling us immediately with the good news. She went on to have a healthy baby (just one). She beamed about how she had only spent a few hundred dollars and was thus able to take the money they saved for IVF and take a vacation to Tokyo during her second trimester. =)
KEY POINTS TO CONSIDER:
- An ovulation test does not actually detect ovulation. It detects a hormonal surge that is SUPPOSED to trigger ovulation in the majority of cases. However, it does not guarantee ovulation, as we learned in this specific example. So it’s very much OK to start out doing ovulation tests on your own, especially if it gives you something to do and if it gives you peace of mind that you are having the proper surges. However, if enough time passes and you are still not getting pregnant, then it’s time to take advantage of professional guidance.
- Women don’t ALWAYS ovulate or NEVER ovulate. There are many who will ovulate in some months and not in others.
- Some people may mistakenly equate going to see a reproductive endocrinologist with leaping into IVF or injectable fertility drugs. More often, there are simpler options to start with.
- If a particular strategy has not worked for six months, it's a good idea to consider trying something more effective, even if it's only a little more effective.