The Clomid challenge test (CCCT) provides an indication of how the patient will respond to ovulation induction with FSH for an IVF cycle and is usually the best predictor of ovarian reserve. A significantly elevated FSH level on day 3 suggests a poor prognosis for pregnancy success. There are many fertility programs that will not allow a patient who has an abnormal CCCT undergo IVF treatment.
The CCCT is performed by measuring the day 3 FSH and estradiol levels, the patient takes 100 mg of Clomid on cycle days 5-9, and her FSH is measured again on day 10. The test is abnormal if either the day 3 or day 10 FSH values are elevated (above 12) or if the day 3 estradiol is greater than 65 pg/ml. Marginal values for FSH are between 10 and 12. The prognosis is less predictable with marginal values but most patients will require high doses of FSH for adequate stimulation during an IUI or IVF cycle.
An abnormal Clomid challenge test, regardless of the patient's age, indicates that there will be a decreased response to injectable FSH, that pregnancy success rates will be low, that there may be an increased chance of miscarriage and that there may be an increased chance for chromosomal abnormalities in an ongoing pregnancy.
Patients with poor Clomid challenge test results are encouraged to consider our donor egg program where success rates are much higher. In our infertility clinic program, after appropriate discussions, patients with a poor CCCT result are not usually barred from attempting IVF unless the FSH level is above 20. However, we emphasize that the pregnancy prognosis is usually poor (5% delivered pregnancy rate or less).
The lining of the uterus, the endometrium, must thicken and become more vascular during the ovulatory cycle. Otherwise, it will not be able to provide sufficient support and nourishment to a developing embryo. The "thickening" occurs under the influence of two hormones, progesterone and estrogen. An underdeveloped endometrium can also lead to early miscarriage.
A small sample of the endometrium can be taken during the luteal phase of the menstrual cycle approximately twelve days after the LH surge and ovulation and 1-2 days before menstruation. The biopsy can be examined to see if the cellular structure and development of the endometrium “matches” the cycle day or is “in phase”. If a sample taken at this time shows little development, a luteal phase defect may be present. This test was commonly performed in the past but is used infrequently currently due to the discomfort, high cost and marginal value. In addition, the results determining whether the endometrium is “in phase” are often inaccurate. Currently blood tests for progesterone, in conjunction with determining the length of the luteal phase, are used to help evaluate this potential problem.
Medications to enhance ovulation, or progesterone, may be administered in the next treatment cycle to correct the luteal phase defect if it is suspected. Typically ovulation enhancement is often the next line of therapy for many patients. This is a good treatment for many patients who in the past may have been diagnosed with a luteal phase defect by biopsy.
Endometrial biopsy may be considered in certain circumstances such as for performing the E-tegrity test to evaluate the endometrium for the presence of certain substances (beta 3 integrins) that are felt to be necessary for implantation. It can also be used to evaluate the patient for chronic endometritis (endometrial infection) or endometrial hyperplasia (thought to be a precursor to endometrial cancer). Endometrial hyperplasia is more common in women with PCOS who have not used medication to induce regular cycles.
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