Luteal defect, prolactin and OPK questions

[dot1]

Been TTC for about a year and a half. Secondary infertility. Biological clock rapidly ticking away (pushing 40 and dh is pushing 50). HSG was normal and so were the LH/FSH/thyroid, etc. bloodwork done on day 3 of my cycle. (I hemorrhaged badly after dd so the OB wanted the hsg done right away in case there was scarring/clotting). Haven't had any other tests. We're still waiting for semen analysis results...

Cycles vary in length from 30-36 days on average....but a couple times a year I either miss one or have a very long one (45-50 days). It seems I'm still ovulating (mucus ok and OPK showed LH surge).

RE. Luteal phase: I haven't used many OPK's...but when I have, the LH surge occured on Day 21. I assume that means ovulation is Day 22. Started spotting Day 32 and full bleeding Day 33. Could this be a luteal phase defect, and if so, how is it treated and formally diagnosed?

RE: Prolactin: My OB doesn't test prolactin levels when the Day 3 bloodwork comes back normal. However, dd weaned a couple months ago at age 3.5 (she had only nursed a bit at bedtime for the past year)...and since then I still can squeeze out a bit of milk/colostrum. Could excess prolactin be preventing conception, and if so, how is this diagnosed/treated?

I also experienced some PPD which resolved when my cycles returned at 9 months pp. Now I just have gnarly mood swings once a month instead of all month Since completely weaning, these mood swings are quite a bit worse.

Could any of these things be related?

Any advice?

Any questions I should be asking my OB next visit?

Thanks so much, wise women!

[no5no5]

I can't answer all of your questions, but I think I can help with some of it.

First, if you O on CD 22 and AF arrives on CD 33, that's a full 10 days. So it's short, but not super short. It could be a problem. I'd recommend a progesterone test about 7 days after ovulation, and progesterone supplementation during your LP if you're low.

Second, increased prolactin could very well be the cause of a slightly-short LP. It'll do that. If you've just recently weaned, that could be the cause, and you might see improvement as time goes on.

Third, you mentioned that your thyroid levels came back normal, but since you have some symptoms that could be thyroid related, it's worth rethinking. There is a lot of misinformation about thyroid labwork, and OBs are not immune. If you didn't get your thyroid antibodies tested, you should. And if you have your TSH number, you should make sure that it is less than 2 or 3.

Fourth, it sounds like you're dealing with your regular OB. I'd switch to a reproductive endocrinologist at this point if that is an option in your area.

I hope that helps.

[dot1]

Thanks so much for responding!

I'll ask the OB at next app't about all those things you suggested. I'm not even sure where I'd start to look for a RE...we're a rural area. The OB said they could try to do as much preliminary investigation here as possible, and then refer me to some others in larger centres when the time comes.

Where we are (Canada) the TSH test is covered, and the other thyroid test (antibodies?) will only be done when the TSH comes back as abnormal...but maybe I could ask for it anyway?

Is prolactin tested via bloodwork? Are you aware if there's a best time to test this?

Thanks again!

[no5no5]

I am happy to help.

The "other" thyroid test could be antibodies, or it could be T4. Many doctors aren't aware of this, but you can have antibodies present, indicating an autoimmune thyroid condition, but have totally normal levels of TSH & T4. Autoimmune thyroiditis is pretty common, and it can cause fluctuating levels of TSH/T4, such that you might have normal levels the day of the test, high levels two weeks later, and low levels a month after that. It can also definitely cause problems with conception, including a short luteal phase. You might want to check out these lists of symptoms and see whether some of them sound familiar (keeping in mind that you won't have them all even if you have thyroiditis) and go from there.

Prolactin is a blood test, and I think it is usually tested on CD3, but I'm not sure there's any particular reason for that. It wouldn't be too unusual for someone to still have elevated prolactin a few months after weaning, though, so I'm not sure what you'll learn from a blood test. But I really don't know too much about it.

[LessTraveledBy]

About Thyroid tests: T3free should be taken also, as some people are not able convert T4 into T3. Thus the TSH and T4 can look good, even if one has hypothyroidism.

[dot1]

Thanks everyone for all the info on the thyroid tests - I hadn't thought of that. I've got all the symptoms except for weight gain (luckily that's pretty stable ). I'll ask about getting the other tests done. If they say no, then are you aware of any research/evidence (that would be considered credible to the mainstream medical establishment) that would help support my advocacy for further thyroid bloodword?

[no5no5]

I don't know about T3, but there's a LOT of evidence that thyroid antibodies complicate pregnancy. There's so much I don't really know where to start. There's not as much evidence about fertility, at least as far as I am aware.

You can do your own search on Pubmed, if you like. I get sucked in there for hours at a time.

[dot1]

Update - script for Clomid

Hi again,
Just got back from OB appointment and thought I'd share an update:

SA - all within "normal" limits but the motility was 60% (lowest end of normal) and volume 2 ml (lowest end or normal). The count was a little on the low side (92, with reference range being 40-250. 20 is considered the minimum adequate level).

Luteal Phase: OB feels that since my cycles are longish, and occasionally irregular, that the problem probably lies with my eggs and that I might not be ovulating that often. My OPK results (2 I've done so far) have been meekly positive (half the line went dark, which the company First Response considers still being a positive). I asked if progesterone has any benefit to lengthen the luteal phase to help one get pregnant. She felt it doesn't, and won't generally prescribe it unless there's a history or miscarriage.

She was pretty clear that the best medical intervention to try would be clomid (starting at 50 mg) and monitoring my progesterone levels on Day 21, 24 and 28 (she made it a standing order so I can have it tested anytime). She'll only prescribe 1 month at a time, as she wants to ensure cycle is monitored....up to a max of 3 months, at which point she'd then refer to infertility clinics (which are 7-8 hours drive away). She gave me the option of a referral now also.

She didn't feel vitamins/supplements (e.g. B6) would be any benefit. Interestingly, she did suggest that acupuncture has shown promising results.

My TSH (thyroid stim. hormone) result was 1.26 (the normal range is .35 - 5)...so I'm not really sure what that means. Guess I'll have to research that a little more.

So....I have the script for clomid. Time is rapidly ticking away (will turn 39 this year). The longer it takes for conception, the greater the risk of miscarriage, birth defects, etc. The OB feels the only significant risk is the twins/multiples risk (10% chance of twins), and that it would be the twins factor that could increase miscarriage/birth defects rates.

Thanks for reading this far....
To clomid or not to clomid.... Feel free to share any thoughts on what you might do.
Thanks again