Hormone Testing in a Female Fertility Work Up



If you have been struggling with fertility you know that there are a myriad of tests that are run on both the male and female partner or gamete contributor. Like much of the fertility experience, fertility testing can all be overwhelming. I would like to break down the hormone testing that is often recommended for women specifically when a couple is struggling with fertility. This is by no means a comprehensive review just a quick, down-to-the-point, summary of some of the key points about each hormone you might see in your fertility hormone panel. Please also note that not every test below is indicated for every person. I have done my best to run through the conditions associated with high or low levels that are related to infertility. Please know that diagnosis of any of the conditions listed here is much more involved and will require the involvement of your ND and/ or MD. If you have questions, please bring them up with your health care provider.


Let’s start with the most common hormones we look at:


Estrogen


Estrogen is one of the primary female hormones and the one that dominates the first part of a women’s cycle (the follicular/ proliferative phase). There are different species of estrogen, for testing purposes, estradiol is the form that is investigated most often. Estrogen should always be tested on day 2 or 3 of a women’s cycle (this is very important).

Estrogen is important to both the growth and maintenance of the endometrium (uterine lining). If estrogen is low, it could lead to a failure in implantation, due to insufficient development of the endometrium. Estrogen levels naturally fall during menopause and could be a sign of diminished ovarian reserve (DOR) **. High levels of estrogen can be problematic for fertility also; both polycystic ovarian syndrome (PCOS) and endometriosis may lead to higher-than-normal estrogen levels and both are associated with infertility. This could also indicate the presence of an ovarian or adrenal tumor (this is much less common). Low levels can occur with Turner’s syndrome, under-fueling, hypogonadism (ovarian dysfunction), or hypopituitarism (low pituitary hormones) all of which are known to be associated with infertility.


Progesterone


The other primary female hormone and the hormone that dominates the later ½ of a women’s cycle (luteal/ secretory phase) is progesterone. It is often referred to as the “pregnancy hormone” as it plays an integral role before and during pregnancy. Like estrogen, it is important to test this hormone at the correct time in a woman's cycle. For women with a normal 28-day cycle, progesterone should be tested on cycle day 21 and adjusted accordingly for women with different cycle lengths.

Two of the primary roles of progesterone are to maintain a pregnancy and to thicken the endometrium. Low levels of progesterone can lead to a luteal phase defect in which the luteal phase of a woman’s cycle is shortened, this can prevent implantation. The simplest way to describe this is that the signal for the endometrial lining to shed (a women’s flow to start) is not stopped in time. This means that even if sperm does meet ovum, it would not have sufficient time to implant and prevent that month’s menstrual flow. Low levels of progesterone in the blood may also indicate an ectopic pregnancy or DOR.

Another important note about progesterone is that it is often prescribed to women who are struggling to conceive. Progesterone therapy might be prescribed for many reasons, 2 of the most common reasons are if you are not producing sufficient amounts, or if you are undergoing an assisted reproductive technology (ART) procedure such as in-vitro fertilization (IVF), in part because the medications used in these procedures can suppress your progesterone production.


Follicle Stimulating Hormone (FSH)


Just like its name describes, FSH is involved in the maturation of the follicle(s) each month. It plays a part in an interesting feedback loop with estrogen. As FSH increases and the follicle matures, the follicle will produce more estrogen which in turn reduces FSH levels.

This hormone is inversely related to fertility; meaning that as FSH levels increase in the blood, chances of conception decrease. High blood FSH can be a sign of menopause, PCOS, DOR, or Turner’s syndrome. Low blood levels of FSH are linked to under-fueling, and pituitary dysfunction. Like estrogen and progesterone, FSH testing should also be timed to cycle day 2-3.


Testosterone


I know what you are thinking, isn’t testosterone a male hormone?? You are right; it is also an important part of what we test in men. It can, however, also be helpful for women. High levels of testosterone can occur in PCOS, pituitary dysfunction, or cancer of the ovary or adrenal. Low levels can occur in menopause and can lead to decreases in libido.


Anti-Mullerian Hormone (AMH)


This hormone is commonly tested in couples who have been struggling to conceive for some time. It is important to know that it is age-specific, meaning that the “normal” range changes depending on your age. High levels may indicate DOR and it can be used as a predictor of success for ART procedures (Broer et al., 2011).



Now for a super quick review of some tests that you might be less familiar with:


Luteinizing Hormone (LH)


Luteinizing hormone is involved primarily in triggering ovulation and plays a role in the production of hormones important to maintaining a pregnancy. High blood levels of LH can be a sign of PCOS or Turner’s Syndrome, or ovarian injury (chemotherapy, radiation, autoimmune disease). Low levels can indicate under-fueling or malnutrition, or a pituitary, adrenal, or thyroid disorder.


Thyroid Stimulating Hormone (TSH)/ T3/T4


Thyroid conditions are becoming more and more prevalent and are a common cause of infertility. Both hyper- and hypo-thyroid states can lead to infertility. It is thought that autoimmune thyroiditis is the most common cause of thyroid dysfunction in women of childbearing age, a common cause of infertility, and can be used as a predictor of ART outcomes (Busnelli et al., 2022; Li et al., 2022). I generally recommend a full thyroid panel to my fertility patients including TSH, T3, T4, anti-TPO antibodies, and anti-thyroglobulin antibodies.


Insulin


Metabolic disease is common in PCOS, which as we know can cause infertility (Lim et al., 2019). Insulin is one way of testing this. Understanding a women’s blood sugar metabolism is also critical during pregnancy. Early testing can help identify women who we want to monitor more closely.


Prolactin


This hormone increases when a woman is nursing a child. High levels at another period in a woman’s life can be a sign of other health concerns that should be investigated. High blood prolactin levels can prevent ovulation; this is thought to be the primary reason that women do not have a period when they are nursing.




Ok, so that is a lot of information I know… and it’s only a small portion of what we generally test in fertility!


If I can summarize all of the above, it would be to say that with hormones we are looking for the “goldilocks zone”. You don’t want too much or too little, we want just the right amount of each so that they can work together harmoniously to create the perfect environment for an embryo to grow.


Sorting through labs in a fertility workup is not straightforward. Looking at each value in isolation only gives a limited view and can miss important details. Any health care professional in the fertility space will review all of the values from all of your lab work (well beyond the hormones listed here), together in a comprehensive way to pull together all of the details of your fertility story. This information should not be used as medical advice; please always seek out professional care when making decisions about your health. I hope that now you have more clarity on which labs your care provider might run and why. If you would like a personalized look at your fertility struggles, we would love to provide this for you, just reach out.


Now gentlemen, I know I left you out of this conversation, and I apologize if you are interested in learning more about the hormones tested in male fertility workup. Let me know and I would be happy to write you your very own blog on the topic 😉 Further if you are interested in exploring other fertility tests let me know, I would love to tailor information to what you are most curious about.


** Please note that for the purposes of this article I will refer only to DOR; it is important to understand that this is part of a spectrum of related conditions that also includes premature ovarian failure, primary ovarian insufficiency, poor ovarian response, and functional ovarian reserve. Outlining the differences between these conditions is beyond the scope of this article.


References

  1. Broer, S. L., Dólleman, M., Opmeer, B. C., Fauser, B. C., Mol, B. W., & Broekmans, F. J. M. (2011). AMH and AFC as predictors of excessive response in controlled ovarian hyperstimulation: A meta-analysis. Human Reproduction Update, 17(1), 46–54. https://doi.org/10.1093/humupd/dmq034

  2. Busnelli, A., Beltratti, C., Cirillo, F., Bulfoni, A., Lania, A., & Levi-Setti, P. E. (2022). IMPACT OF THYROID AUTOIMMUNITY ON ASSISTED REPRODUCTIVE TECHNOLOGY OUTCOMES AND OVARIAN RESERVE MARKERS: AN UPDATED SYSTEMATIC REVIEW AND META-ANALYSIS. Thyroid: Official Journal of the American Thyroid Association. https://doi.org/10.1089/thy.2021.0656

  3. Li, F., Lu, H., Huang, Y., Wang, X., Zhang, Q., Li, X., Qiang, L., & Yang, Q. (2022). A systematic review and meta-analysis of the association between Hashimoto’s thyroiditis and ovarian reserve. International Immunopharmacology, 108, 108670. https://doi.org/10.1016/j.intimp.2022.108670

  4. Lim, S. S., Kakoly, N. S., Tan, J. W. J., Fitzgerald, G., Bahri Khomami, M., Joham, A. E., Cooray, S. D., Misso, M. L., Norman, R. J., Harrison, C. L., Ranasinha, S., Teede, H. J., & Moran, L. J. (2019). Metabolic syndrome in polycystic ovary syndrome: A systematic review, meta-analysis and meta-regression. Obesity Reviews: An Official Journal of the International Association for the Study of Obesity, 20(2), 339–352. https://doi.org/10.1111/obr.12762


*Disclaimer: This article is for information purposes only, it is not medical advice. When making any decisions about your health please consult with your health care provider.

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