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Fertility Hormones

It is very useful to have your hormones tested to give an insight into what’s going on inside your body. Here western medicine hormones tests are invaluable. Some can be performed by your GP, whilst others may need to be done privately. Hormone tests are valid for around 4 months depending on the fertility clinic. After that, new tests should be taken as the body is always changing. Some IVF clinics will insist on taking new hormone tests even though existing tests are still valid. The range of a normal hormone level actually varies from one clinic to another. Therefore, you might find the ranges here different to yours.

Going along your fertility journey can be stressful, emotional and draining. Stress and other factors can cause hormonal imbalances that can negatively impact your fertility. Research has shown that acupuncture reduces stress by affecting hormone levels. It does this by promoting the release of beta-endorphin in the brain, which affects the release of gonadotrophin releasing hormone by the hypothalamus, FSH from the pituitary gland, and oestrogens and progesterone levels from the ovary.

Oral contraceptive pills (OCP)

Taking contraceptives is common amongst women today. They are often prescribed to teenage girls to alleviate their menstrual pain, moods and prevent unwanted teenage pregnancies and are continued without a break for over a decade until they meet someone and settle down. In my clinic, I’ve found that women who have been on contraceptives for more than several years find it hard to fall pregnant when they stop taking them.

I believe this is because the body has been told to for so long that it’s pregnant, that it finds it hard to simply switch on production and normalise sex hormones needed for active fertility. The body is not a machine that you can simply flick a switch and turn something on or off. Research has shown that woman who had taken the combined pill took significantly longer to fall pregnant after coming off the pill. The situation was worse for women who were over 35, obese or had irregular periods.

Today, most oral contraceptive pills use a combination of hormones, oestrogens and progestins, hence their name; the combined pill. They work by suppressing FSH and LH thereby preventing ovulation. They also thicken cervical mucus making it more difficult for the sperm to use it as a ladder to enter into the uterus. Progestin only contraceptive pills (the mini pill) do not inhibit ovulation and just block sperm from entering the uterus by making the cervical mucus too thick for the sperm to enter and use it as a ladder.

The use of the combined pill should mean that AMH levels remain high as generally no eggs are released. However, in my experience, long-term use of the combined pill literally shuts down the ovaries causing infertility. Research has shown that women who use the combined pill take longer to conceive after stopping it.

The use of progestins is less problematic to the ovaries and therefore to fertility as it only thickens the cervical mucus making it inhospitable to sperm. However, again, long-term use of the mini pill can cause problems with cervical mucus and therefore fertility. In such cases, acupuncture can help to restore cervical mucus function and if necessary a substitute to the cervical mucus can be used allowing the sperm to enter the cervix, i.e. pre-seed.

In my experience, the use of contraceptive skin implants causes great hormonal imbalances, with weight gain and emotional disturbances. The patch can also become dislodged and lost in the body.

Oestrogens

Oestrogens are vital in a variety of bodily functions. In fertility their main effects are to maintain female reproductive glands and organs including cervical mucous discharge, increase libido as well as repair and regenerate the uterus (endometrial) lining. Oestrogens are made up of three hormones; oestradiol, oestrone and oestriol. The most abundant and therefore the most important one for fertility is oestradiol (E2).

The normal level of oestradiol is between 45-610pmol in the follicular/yin phase. During IVF, most fertility clinics will want oestradiol to be as low as possible, ideally between 25-75pmol for younger women or below 200pmol in older women on day 2 of their menstrual cycle. If it’s higher than this, then an IVF cycle will be put on hold and it will be tested the following month until it drops. Higher than normal levels can affect a fertilised embryo implanting into the endometrial wall. Once an IVF cycle begins and the woman starts taking the IVF drugs, levels of oestradiol will increase dramatically. This is normal. However, they shouldn’t increase too high, otherwise it can lead to ovarian hyperstimulation syndrome (OHSS).

A major cause of excessive oestrogens is exposure to xenoestrogens. Xenoestrogens are a type of xenohormone that imitates oestrogens. They can be either synthetic or natural chemical compounds. Synthetic xenoestrogens are widely used in industry, such as PCBs, BPA and phthalates, whilst growth hormones and pesticides used in agriculture are stored inside the fat cells of poultry and fish. Certain plants are also sources of xenoestrogens and are known as phytoestrogenic plants.

During an IVF cycle, clinics like to tightly control hormone levels to reduce any potential problems. One of the main reasons IVF clinics give to their patients for not taking Chinese herbs is that some of the herbs can contain naturally occurring oestrogens (phytoestrogens), which may slightly elevate the level of oestrogens beyond the normal range thereby affecting the IVF cycle. It’s then ironic that some IVF clinics will then tell their patients to drink 1 pint of cow’s milk a day, which contain animal oestrogens and not to take Chinese herbs that may contain weak levels of oestrogens. There is no other reason not to take Chinese herbs in the run up and during an IVF cycle.

If you are taking Chinese herbs, make sure your herbalist hasn’t included any herbs that contain naturally occurring oestrogens (phytoestrogens), just in case. There are also some foods that are sold in health food shops, which contain naturally occurring phytoestrogens, see below. It is best to avoid these foods whilst trying to fall pregnant naturally and during an IVF cycle, unless you are knowingly trying to influence higher oestrogen levels. I would avoid drinking cow’s milk in large quantities so as to not increase oestrogen levels as well as strain the digestive system from consuming such large amounts of diary.

Foods that contain phytoestrogens include:

American ginseng
Angelica sinensis (dong quai/dang gui)
Chinese raspberry
Cistanche
Fennel seeds
Flaxseed
Ginseng
Liquorice
Red clover
Sea cucumber
Siberian ginseng
Soya
Thyme

Testosterone

Testosterone is the primary androgen that causes increased hair growth, acne and virilisation (male characteristics). It is secreted by the adrenal glands (25%), ovaries (25%) and produced in adipose (fat) tissue (50%). Its production is dependant upon LH. There are two types of testosterone: one that is bound to sex hormone-binding globulin (SHBG) and therefore inactive or one that is not bound and is therefore free. The latter type is the one that has an effect on the body. The normal level of active testosterone on day 3 of the menstrual cycle is between 0.5-3.6pgmL or nmol/L. In men, it helps with sperm production. In females, is helps with follicle growth, but too much testosterone can cause PCOS.

GnRH

GnRH is an abbreviation for gonadotropin-releasing hormone. It is secreted from the hypothalamus and causes the secretion of FSH and LH from the pituitary gland. Changes in the levels of GnRH are controlled by the amount of oestrogens (oestradiol) and progestins (progesterone) in the blood. Oestrogens increase GnRH whilst progesterone decreases it. In a ‘long’ IVF cycle, the hypothalamus is shut down to stop it producing GnRH and therefore the sex hormones FSH and LH from the pituitary gland.

Follicle Stimulating Hormone (FSH)

Follicle stimulating hormone (FSH) is regulated by the pituitary gland under influence from the hypothalamus. It is an important indicator of fertility. FSH stimulates sex hormone secretion, mainly oestradiol, from the maturing ovarian follicle. Generally, a follicle contains one egg although it can contain more than one or none at all. The normal level of FSH is between 3.5-12.5pmol in the follicular/yin phase around day 2-3 of the menstrual cycle. The level of FSH varies with age, see below.

Age FSH Level (pmol)
25-29 5-6
30-35 7-8
36-40 9-12
41-43 12-15

FSH is very much related to yin in Chinese medicine. It nourishes and grows the egg, helping it to ripen. A deficiency of yin and blood will cause problems with FSH and the growth of the follicles. The normal size of a matured follicle is between 18-25mm. If there is a deficiency of yin and blood and/or high FSH levels, then it will take longer if at all for the follicle to reach this size. It takes 120 days for a follicle to mature from start to finish. Any physical deficiencies that exist during this time will affect the growth of the follicles. Acupuncture has been shown to regulate FSH levels.

IVF drugs contain FSH to increase levels of FSH in the body and thereby the production of multiple follicles. The dosage of FSH given during IVF will depend on the woman’s FSH level. A lower FSH range can mean FSH drugs can be given at a higher level to produce more eggs. However, if FSH levels are too high, over 12-15pmol, then the dosage of FSH will be less effective and may take longer to produce multiple follicles or won’t produce any at all.

Luteal Hormone (LH)

Luteal hormone (LH) is produced by the pituitary gland under influence from the hypothalamus. The hypothalamus is like management telling the workers, the pituitary gland, to produce a certain hormone on the factory floor. Luteal hormone, when it surges, triggers the final maturation of the follicle, the rupture of the follicle wall and the consequential release of the egg. The normal level of LH is between 2.1-12.6pmol. After ovulation, it helps to maintain the empty follicle sack (corpus luteum), which in turn produces progesterone.

Progestins

Progestins (also known as progestogens) are a group of steroid hormones produced by the corpus luteum after ovulation has occurred. The most important progestin is progesterone (P4). Progesterone has several important functions including: thickens the endometrial lining, propels the egg along the fallopian tube, enlarges the mammary glands (breasts) and maintains pregnancy. The normal level of progesterone on days 3 of the menstrual cycle is less than 1.5ngml. Progesterone is very much yang in its nature.

Progesterone production begins roughly 24 hours after ovulation and rises rapidly to a maximum 3-4 days after ovulation. The progesterone level at this time should be greater than 15ngml. If conception does not occur, the corpus luteum disintegrates and progesterone levels fall causing the start of the menstrual cycle, FSH production and the development of new follicles. If conception does take place, the corpus luteum continues to produce progesterone until the placenta is grown and takes over from 8-12 weeks.

Prolactin

Prolactin is made by the pituitary gland. It stimulates a woman’s breasts to develop and maintains the release of milk, hence ‘lactin’ relates to lactation. Mothers’ breastfeeding have high levels of prolactin, which stops the ovulation cycle to prevent another pregnancy. A new mother is busy looking after her baby and does not have enough energy and blood to produce both breast milk and grow another baby. Prolactin is often measured in an initial hormone test along with oestrogen, FSH and TSH. The normal range is less than 24ngml on day 3 of the menstrual cycle. High levels of prolactin can cause infertility and are sometimes seen in women with PCOS and hypothyroidism.

TSH

Thyroid stimulating hormone (TSH) is the hormone that triggers the secretion of thyroid hormones by the thyroid gland. The thyroid hormones it produces are T4, T3 and CT. TSH, T4 and T3 levels on day 3 of the menstrual cycle and in pregnancy are shown below. They are not directly related to fertility. However, irregular levels of these hormones can affect the pituitary gland and the increased production of TSH, which when high increases the production of prolactin and decreases the production of FSH and LH.

Anti-Müllerian Hormone

Anti-müllerian hormone (AMH) has become a more accurate indicator of fertility in recent years. It is a measure of ovarian potential; how many eggs a women has left as well as egg quality. It helps to give perspective on a woman’s fertility, like looking inside the body to see what time the biological clock says. It therefore helps to make better decisions when it comes to the changes that maybe needed in order to have a baby and the treatment options available. Not currently available on the NHS, it can be measured anywhere in the cycle from a blood test. It is measured in either ng (nanogram) or pmol (picomole). Both levels are shown below.

Level Ng Pmol
Optimal fertility 12.7-21.6 28.6-48.5
Satisfactory fertility 7-12.7 15.7-28.5
Low fertility 1-6.9 2.2-15.6
Very low fertility <1 <2.2

AMH decreases with age. Below shows age in relation to AMH levels.

Age AMH (ng) AMH (pmol)
20-29 years 5.8-23.9 13.1-53.8
30-34 years 3-21.3 6.8-47.8
35-39 years 2.4-16-6 5.5-37.4
40-44 years 0.3-9.4 0.7-21.2
45-50 years 0.1-6.5 0.3-14.7

Low AMH levels generally affect egg quality. AMH can be seen as a measure of underlying fertility, what’s left in the tank after years of living. In Chinese medicine terms, AMH is related to jing (essence), which has become exhausted from an excessive life, where the candle has been burnt at both ends. However, by refuelling the body, egg quality can be influenced enough over the 120 days it takes for them to develop to restore enough fertility even in women with a low AMH level. This is because egg quality is also influenced by a woman’s underlying health at the time.

High AMH levels are sometimes seen in women with PCOS. The increase in the number of follicles on the ovaries increases the levels of AMH. Recent research has shown that acupuncture can reduce and normalise high AMH levels in women with PCOS.

DHEA

DHEA is short for dehydroepiandrosterone. It is a naturally occurring hormone in females that is converted mainly into testosterone. In women with a lack of yang, DHEA might be useful. However, in those that feel hot and sweat at night, DHEA might create more heat and worsen fertility. Women with PCOS should not take DHEA. In small studies, taking DHEA two months prior to starting an IVF cycle increased the quantity of eggs collected, increased egg quality and improved the live birth rate.

Human chorionic gonadotropin (hCG)

Production of hCG begins shortly after the fertilised egg (zygote) has implanted into the endometrial wall. hCG sustains the corpus luteum (the sack that contained the egg before ovulation) for a further 6-7 weeks, thereby maintaining the production of progesterone. From roughly week 8, the newly grown placenta takes over the production of progesterone. hCG is often prescribed to trigger ovulation during an IVF cycle. Further hCG support is sometimes given during IVF but increases the rise of a woman developing OHSS. The testing of hCG levels in a woman’s urine is how a home pregnancy test works. Levels of hCG rise dramatically in early pregnancy.

Sex hormone-binding globulin (SHBG)

Sex hormone-binding globulin is a carrier protein and binds to testosterone. The normal range of SHBG is 18-114nmol/L on day 3 of the menstrual cycle. Testosterone that is bound to SHGB is unable to bind to testosterone receptors and is therefore inactive. Only a small fraction (1-3%) of testosterone is unbound and free. It’s this small per cent of free testosterone that exerts the effects on the body and fertility. The liver makes SHBG after receiving the message from oestrogen. The higher the oestrogen level, the more SHBG is produced and the less free testosterone there is. Hence why higher levels of oestrogen in the environment affect male sperm levels.

High insulin levels will reduce the production of SHBG by the liver causing higher levels of testosterone and the free androgen level (FAI). FAI is calculated by Tx100/SHBG. The normal level of FAI should be below 5.

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