Tuesday, April 27, 2010

30 Yr Old With Very High FSH Levels Getting Poor Advice From Her Doctor: Has Ovarian Resistance & Possible Future POF


Dear Dr. Ramirez,

I am 30 years old and recently started trying to conceive. My periods have always been regular and I always been ovulating on day 13. But I still could not succeed after 2 /3 attempt. I did all the blood tests, pelvic ultrasound. My husband did his semen analysis and everything came out OK. I had an FSH 28.5 and LH 81.9 on day 13 (ovulation time) and then again I did the test on Day 1 with an FSH 10.48 and LH 4.72 and again i did on day 4 FSH 8.72 and LH 14.42. Recently my day 3 FSH was 11.54 and LH 4.18. My doctor has prescribed me to take tablet Duoluton L for 3 months.

What is surprising to me is that all my FSH and LH ranges are within the reference range given in the lab test report and more over I have regular periods which start on every 26th day and I am ovulating (which i check through ovulation test kit). I have a normal height and weight, no excessive body hair etc. Why is my doctor considering me a patient of PCOD?

Is my LH and FSH proportion so bad that I have to take these tablets for 03 months?

Please advise, thanking you, Sarika from India.


Hello Sarika from India,

I'm afraid to say that based on your description, your doctor does not know what she is doing. Sorry to be so blunt. FSH and LH levels only make sense if drawn on cycle day # 2 or 3. We do not draw them at other times in the cycle because the levels can vary. Therefore, the standard is CD# 2 or 3 only.What they tell you, if interpreted by someone who knows what they are doing, is how the ovaries are functioning. The FSH and LH are hormones that the pituitary sends to stimulate the ovary. If the ovary is picking up the hormones correctly, then the levels are low. If not, the levels are high. This is on cycle day # 2 or 3 only.

Your ovaries are functioning correctly as evidenced by regular menstrual cycles. This means that you are ovulating, and based on your cycle day # 3 FSH/LH levels, your ovary is NOT menopausal nor PCOD. However, the worrisome thing is that your FSH level is high (11.54). This is a sign of "ovarian resistance" which means that the ovaries are tending toward menopause, although they have not reached that level yet (> 20). We interpret it as shortening the amount of time you have for ovarian function, therefore we approach this situation more aggressively. I recommend IVF in these patients because we don't want to waste time. There is a disorder called "premature ovarian failure" or POF, whereby a young woman (less than 40) enters menopause early. That is what I would fear with you. So don't waste time. Go see a fertility specialist!!

Follow-Up Question:

Thanks a lot for picking my question! It helped me a lot to understand what's been going wrong for a long time. In the mean time I did my follicular study today (i.e. Day 5) and it showed two follicles in the left ovary : F1 - 18.5mm (dominant follicle) and F2 5.0 mm. So I thought of giving one more try this month also. Is that OK? Or this also indicate that I am moving towards "premature ovarian failure"? Also in the report it is written "Minimal free fluid in Pouch of Douglas". What does this mean? Please help me more with this.

I will be always grateful to you Dr. Ramirez for giving so much information. Regards, Sarika

Follow-Up Answer:


If your ovary is functioning, then you should continue to try to get pregnant. Don't give up. You are not in premature ovarian failure yet. Also, the fluid found on ultrasound is a normal finding.

You are wise to question what is going on, please consider switching over to a fertility specialist as I mentioned above! Good luck with your procedures!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, USA


  1. Dr. Rameriz,

    Thank you for your response on my blog. It is great to see a fertility specialist interested in reading what we, the patients, have to say. Please feel free to use anything that I have posted on your Facebook page.


  2. Thanks for your comment on my blog. I think the doctor makes all the difference. I adore my RE, and plan to go back to him for my FET. (Because I have PCO, I produced a lot of eggs, and we also have several embies frozen.)

    Glad you are out here providing information.

  3. PCOD and tubal blockage and used for irregular cycles. first he just start doing ovulation monitoring. if ovulation occurs then u can have intercourse on the same day of ovulation and for next 4-5 days. u can repeat the same process for 3 months. still if u are not concieving then there should be some block in uterine tubes for which histerosalpingography is advised. if your cycles are unovulatory then u will have to take some tablets to induce ovulation and repeat above process .

  4. I am not quite in agreement with Herbalife. The approach being described, which is used by many general Ob/Gyn's, is a "trial and error" method. In others words, let's try this, if it doesn't work do this, if that doesn't work try something else. It is very haphazard and wastes lots of time, money and emotional effort. My recommendation, if you have been unable to become pregnant, is to do an infertility evaluation first. Just as with most other diseases, we do not prescribe a treatment without knowing what it is we are treating. The same is with infertility. You have to find out what the problem or problems are so that you can prescribe an appropriate treatment. For example, if a patient is just started on ovulation induction, and it turns out the tubes were blocked, the ovulation induction would never have worked and so all that time was wasted. On the other hand, if the patient underwent an infertility and it was found that the tubes were blocked from the beginning, ovulation induction would never have been prescribed. That patient would have been recommended to go straight to IVF.

  5. Hi Doctor,

    I would like to know whether the number of follicles ruptured will be the number of kids if i get pregnant ? My doctor had performed the follicular study and found out that 2 follicles had ruptured from my left ovary. And one more follicle is becoming big in the right ovary .

    Is there something like only one ovary will release egg in a month ? or will the follicle from the right ovary will also rupture once it reaches the required size?

    I'm a 27 year old lady, had clomid50mg for 5 days this month, as my period was irregular for last two months.I'm trying to have my first baby.

    Since 2 follicles had ruptured this month,If everything works fine , how much will be the chance to get twins ? Is there any chance to conceive triplets as the right follicle is also getting bigger ?

    Please reply

  6. Hi. You have to keep in mind that an IUI is a "Natural" procedure requiring the natural process to function completly in order to become pregnant. That means that the chances of pregnancy are less than with IVF and it is not a guarantee that every egg ovulated will find the tube, get picked up by the tube, be fertilized, grow into a normal embryo, get into the uterus or implant. So your maximum chances of pregnancy, given 3 eggs ovulated, is 24% at your age. For this reason, if you were to ovulate 3 eggs, your chances of a twin would only be 12% and the chances of all 3 (triplet) is less than 10%.

    If the follicles reach ovulatory size (>16 mms), then there is a chance that they will ovulate, but again it is not an absolute. Once the trigger is given, or the LH surge occurs, the remaining follicle will not progress to ovulation.

    Good Luck.



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