Episode 22: Sex & the City and How to Know if You are Ovulating

Dr. Klimczak and Dr. Reed talk about how to know on your own if you are ovulating. What is ovulation? What are the natural ways to tell if you are ovulating? What the clues your body is giving you? Should you get a hormone monitoring kit? How can we medically tell if you are ovulating? If you aren’t ovulating, what are the possible causes? And what are the available treatments?

Transcript

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I am Dr. Beverly Reed. And I'm Dr. Amber Klemczak. And we are Two Peaks in a Pod. Well, Happy New Year, everybody. We are back from the holidays. Did you have a good New Year's Eve? I did. We were, um, pretty lame. We were in bed by 930. Oh, I was going to ask you, you didn't stay up until midnight? No. Oh my gosh, you're so lame. My husband was working and I had two little kids and both of them were like, Can we go to bed? And I'm like, yes, let's go to bed. What a great idea! That actually sounds like a great way to start the year. Do you have any New Year's resolutions? I do. Nothing, nothing professional. I'm sorry. You're going to be a slacker this year. I have lots of goals for us in general. But I did make a New Year's resolution to Reach out to new, to old friends and make new friends because I moved here and I keep telling myself. Oh, I just moved back home Yeah, it's been like over a year and I just really haven't made a big effort to make friends Yeah, and things like that. So yeah, that's my goal. What's yours? That's good. You know, I'm still trying to come up with exactly what I do Have a lot of things I need to be better about mainly taking care of my health Like I want to exercise and eat healthier and everything I just don't really have a plan to back that up yet. One of my patients is actually a coach, so I'm like, maybe she can coach me through this. But, um, but I guess I'm just, I'm working on it. But I did stay up till midnight, which I'm pretty impressed with myself. That's really impressive. And, but only because we were watching a movie. I finally saw the Barbie movie. So did you like it? It was a little weird, but I mean, it just wasn't what I expected. I thought it was very thought promoting. Did you see it? No, I always sit down and watch it, but like, I feel like I only have like 15 minute intervals. I like want to sit down and watch a whole movie, but I haven't been able to do it. Yeah. Yeah. I want to see it. Um, okay. So I think you've got something to show me today, right? Okay. So as our listeners know, I'm not cool and hip. I don't watch any reality shows. I watch like old school shows. So. Probably, if anyone's like around our age, you know, they've probably watched this show before, maybe you'll recognize this. Oh, I love that you said our age. Yeah, I'm not way older. Thank you. I think this show is from your time too. Yeah. Um, and so you'll probably recognize this voice, but this is a funny scene from one of my favorite shows. It's not on anymore. Let me play it again for you. It's a little bit aggressive. My ovaries, I'm opulent. Very cute. So, do you know whose voice that is? Yes, Charlotte, right? Yes, from Sex and the City. Such a great show. So many great scenes. We know Charlotte struggled with fertility and went through a lot. I think, until ultimately, I think she adopted and then got pregnant later on her own. But this particular scene, she seems to have some sort of Watch that is telling her that she's ovulating, which I don't even know if that's on the market. Do we know if there's an ovulation on the watch? You know, I actually remember when I was in residency a long time ago, we were doing a study on this watch. Um, I mean, I don't remember it alarming like that exactly. That might have been added for cinematic effect or something like that. I want to say it was called like the Ovu watch or something like that. So I know there was a watch. I don't know if it's still available, but we did studies on it in residency. That's a good idea. That's definitely a good idea. Yeah. Who is your favorite Sex and the City character? Oh, you know, that's a good one. I mean, I think probably Sarah Jessica Parker, right? The main one. Yeah, she's so cute with her little outfits and her shoes and all of that. But, yeah. I always like Miranda, which I feel like she's everyone's least favorite. Oh, I'm surprised you like Miranda. I know, I don't know anybody who likes Miranda. I know, but she's like this, like, power woman warrior. Okay. I usually thought she was so cool. Yeah. And she, like, really, like, did whatever she wanted. Yeah. I don't know. Yes. Okay. And do you like Big or Aiden? Big. Okay. I'm an Aiden guy. Yeah. Okay. Okay. Gotcha. Um, do you, anyways. Too much about sexuality. Yes. Back to our topic. Okay. So. I could go on a whole. I know. Um, so, Charlotte has her watch. It's telling her to ovulate. So what we wanted to talk about today is, you know, how do you know you're ovulating? What are signs that you're ovulating? What are signs that maybe you're not ovulating? And what do you do about it? How can you pick up on it? Yes, sounds good. Well, I think kind of one of the main things to point out is when somebody says ovulation Sometimes I think there's a misconception that you're talking about just one event that is happening, but really ovulation is three different things that are happening. So the first thing, um, that I kind of think of when I think of ovulation is the characteristic of the follicle where your egg came from will change so that it starts making a hormone called progesterone. And progesterone is a hormone that's really important for uterine receptivity and pregnancy implantation and pregnancy support. So that's the first thing that happens. The second thing that happens is the follicle will pop. It'll pop so that the fluid and the egg can come out of the follicle. And then the third thing is that the egg inside of it actually undergoes the final stage of maturation. And that's very important because only a mature egg should be able to fertilize. So I think that's kind of complicated actually. When people say, are you ovulating or not? Some of those things you may not be able to figure out on your own at home, right? Absolutely. Yeah. So the tests that are available to you are really not looking for all three of those things, which are all necessary in order for you to actually conceive. And so certainly a little bit more to dive in there and what, you know, so what are some of the tests that you have available to you and what are they actually testing for? So probably the most common one that people use, uh, they shouldn't predict her kids. Sometimes they're called OPKs, um, LH detector kits. What else can you call them? Well, I mean, monitors now, I mean, they've just gotten so fancy these days. There's a lot of them that test a lot of your hormones all the way. Yes. Yeah. So, um, I remember in the very beginning it was just these little strips and they would check your lh, that's a hormone that goes from your brain to, um, tell your ovaries to start the ovulation process. And you would, it's just two lines. You would have a control line and then your test line. And when that control line was. Um, as, or sorry, when the test line was as dark or darker than the control line, then you know that your brain is giving off the LH surge and that you should be about to ovulate the next day, usually. Um, and, but I think sometimes those tests were hard because patients would get confused when they would read the test. They would see a line, but they weren't sure if it was as dark or darker than the other line. And so then they came out with the electronic version that just tells you yes or no. Right. Smiley face. Yeah. Blinky smiley face. Um, so I can understand that. And then, over time, they've started adding more hormones that some of these tests can detect. So instead of just looking for the LH surge, sometimes they'll also be looking for a Estrogen metabolite that can show up in the urine and then also after ovulation they can look for progesterone metabolites that show up So they've gotten really really fancy. Um, have you ever used any of those? I Yes, I did. Uh huh. Yeah. Or my, like, are you talking about from me or from a patient? Yeah, for you, yeah. Okay, for me, yes. I definitely did. They didn't work for me because I don't obviate. Ah. Yes, okay. That's, and that's exactly the point, right? Yes. So that's perfect. Yeah. I thought I was positive all the time. Yeah. Yes. You know, and I was very young when I was doing this. Yeah. So I was, you know, really excited. Yes. Well, can you explain to us why somebody might be coming up positive all the time and how we know usually if it's all the time it's a false positive? Yes. So, okay. So, ovulation predictor hits. standard ones. Like Dr. Reed said, they're checking for L. H. And traditionally, you're going to have a nice rise in your L. H. That gets a certain, you know, to a certain point and it triggers ovulation. Well, certain populations of women can have a baseline high level of L. H. that will unfortunately kind of trigger or look like a positive ovulation predictor kit. Um, I think the level that most of them detect is about a level of 25 is what I'm told, but I think they're getting more and more sensitive is probably why, you know, even more people have, um, you know, more and more false positives because really what's that point at which it's just a normal level versus starting ovulation. So patients with PCOS or polycystic ovarian syndrome, um, traditionally are not ovulating on a regular basis, rarely can be ovulating, but they're the patients that will often have high resting LH. LH is just kind of high all the time. And when you take an ovulation predictor kit, it can look like your mind is as dark, or maybe kind of the same darkness as the control line. So very difficult to interpret in the setting of PCOS, or if you know there's something else going on, you know that you're not ovulating. Yes, absolutely. So I think if I hear a patient who's telling me, okay, I had negative, negative, negative, then positive for a day or two and then negative again, to me, I'm like, okay, that sounds like you legitimately ovulated, whereas somebody is telling me I'm getting positive, positive, positive day after day. Then I'm like, no, no, no, that's just, we know that that it shouldn't happen that way. It should be a brief surge up and down. Um, and if it's positive all the time, that is it. likely false positives that have occurred. Um, another important thing is sometimes I'll have patients that even they, even though they may not need to, sometimes they're monitoring their LH surge while they're doing fertility treatment. So you know how when we're monitoring with ultrasound, Most of the time you don't have to monitor at home. Sometimes I'll ask a patient to for a specific circumstance, but most of the time they don't need to. And what do you think sometimes I'll get people who say I was testing and it never turned positive. Um, and then I have to explain, well, that's because we gave you a trigger injection to make you opulate. So, um, the, those little ovulation tests are, are checking for LH, okay, but when we are forcing somebody's body to ovulate, instead of LH, we're actually giving pregnancy hormone, which binds to the same receptor that LH does. And so actually, if you took a pregnancy test, it would be positive from the trigger injection. Um, but, but you could potentially. Stay negative that whole time, yet still have ovulated. Um, and so that would be another circumstance in which sometimes they're just not as accurate as you would think. Yes, absolutely. Mm-Hmm, And the other thing we should mention about maybe not giving positive the opposite. Mm-Hmm. maybe you're missing your LH surge, which can potentially happen. I think the kit's instructions usually say to take it first thing in the morning when your urine is most concentrated and more likely to pick it up. Um, what the studies show is that your beginning of your LH surge typically starts around 2 to 3 a. m. for most women. and typically the best time to actually look for a positive surge is the late afternoon because then it's going to be high enough to trigger that positive. If you started your surge at two to three a. m and you test first thing in the morning, you actually might miss it. It may not be high enough to trigger a positive. So I always recommend people, you can always test twice a day if you're kind of neurotic about it, but you know, let's be honest, we all are, or you can try testing in the late afternoon to see. see if you get better results. So, you know, just I just never seem to get a positive. So yeah, I think this was an issue that was a little confusing for me because you will see from the manufacturers. The instructions will say different things that will tell you test first thing in the morning. Some will. Say in the afternoon for those exact reasons that you said, whereas usually when we're talking about pregnancy testing, it's pretty uniform that they say test on your first morning urine. But yeah, for the ovulation test, it can be confusing. So I usually say just follow what the manufacturer said, or like you said, just test twice a day and then you know you're not going to miss it. Yeah. Yeah. Yeah. Um, so interestingly, I've had some patients that are using some of the really fancy monitors that do all of the hormones and they have brought the curves to me. And I will say sometimes I have found them to be useful because when the patient brings it to me, I look at it and I can see, okay, they didn't have their LH surge, their progesterone didn't go up, they're not ovulating. Um, so that can be helpful. Although I probably could have figured that out based on their history too. But I will say there's been some other patients that have brought in their curves and I'm like, this is. It's medically impossible for, for this result. So what it would show, for example, so I had a patient who thought, she said, my body doesn't make estrogen. Okay. And indeed her curve showed that her estrogen level was completely low. She had an LH surge and she made progesterone, but her estrogen never went up the entire time. And I said, that's impossible. I've never seen that. Have you ever seen that? I'm like, that's impossible. In order to, grow a follicle that's going to ovulate an egg, that follicle will make estradiol. It always happens. And, you know, of course it's hard because she's like, well, do I believe my monitor or do I believe you? And I'm like, let's check blood test, right? And so we checked it with blood test and indeed her estrogen went up just like it should. She did not have low estrogen. And so that fertility monitor had led her, um, astray on that. Um, and then I had another patient who did an, um, a fertility monitor and it kept telling her her estrogen was high and that she was about to ovulate at any minute. And I checked the blood test, and no, her estradiol is very low. She wasn't about to ovulate. And so I don't know, you know, What's the metabolite in the urine? Do you know which estradiol type it is? I don't, I can't remember off the top of my head. It's definitely not estradiol. It's a conjugated version of estradiol. But, but what I'm learning just from a couple of patients, is that part does not always seem to be accurate. So I, you know, I'd like to learn more about it to kind of understand. Um, you know, how they're able to sell and market the test if it's maybe not always accurate. And in those cases, I feel like it created more stress for my patients. So I, I, I guess I'm not a big fan of the real fancy ones. I, I think if somebody was asking me, like, what would you do? I would say, you know what, I'd probably do just standard ovulation tests and probably not anything more than that. Just based on what I've seen so far, because those monitors are expensive. Expensive too. I think they're very confusing. Yeah. For example, I mentioned blinky, smiley face versus solid smiley face. Oh yes. Okay. So like sometimes, sometimes to my patients and I'm like, I don't even know what that means. Yeah. Truly. Like if I think that logically and I'm like, okay. What would this machine trying to be testing where it just has a blinky versus a solid? I don't know. Is the solid once they actually think you're on the day of ovulation and so the blinky is actually the LH surge? I don't know. I know about this one. This one confuses everybody. So you're talking about the clear blue digital advanced. Yes. So when it's blinking, it's supposedly detecting an estrogen metabolite. So that's true. Yeah. Cause they're trying to be like, you're growing a dominant follicle. You're probably getting close to ovulation. And when it turns solid, that's when you're having your LH surge. But it confuses everybody because sometimes we'll have patients who, for example, are doing a natural, you know, donor sperm insemination and we'll say call with a positive ovulation test and they will call when it's a blinking smiley. That is not what we mean by a positive. It needs to be the solid smiling. So actually, if I can catch people before they buy the test, I'm like, don't buy the fancy one. I'm like, just look at it. I'm a fertility doctor. I misinterpreted it. Yeah. I don't know if my patients use those anyways. Yeah, yeah. So some, fancier is not always better, I guess, is what I would say. And actually, one of them too is a step up above that, which it has Bluetooth. That goes to your phone or something. Oh, wow. So it's a population test. Your watch? I don't know. Yeah, I guess, yeah, exactly. I guess it could be what I watch. Yeah, but I mean, I remember, see, it was like 50 or something. Actually, we need to go on a field trip one day and go to CVS and look at all the options. Yeah. We should not be paying that much. Yeah. I'm a big fan of, if you go to Amazon, you get the Wanfos, they're just the little strips. You get a huge bag of them for like 20. They're ovulation tests and pregnancy tests. It's just so much cheaper and, and I think very accurate and everything too. Yeah. Um, but I also just wanted to talk about how to know if you're ovulating even separate from the kit. So there are signs in your own body that I actually think are so important. So much more reliable. Mm-Hmm, So the first being the pattern of your cycle. So I will say almost everybody these days, they're tracking their periods on apps and I'm very supportive of that. That has been super helpful to me. Very helpful because sometimes women will. tell me, Oh yeah, I get a regular period every month. And then they give me their app. And I'm like, well, this period was 25 days and this period was 32 days. So to me, I would not call that a regular pattern of your periods. I wouldn't say that's an irregular pattern in the periods. And so being able to track and show me, I think has been, um, really helpful. When I'm asking somebody if they're having regular periods, I'm meaning like, is it every 28 days on the dot? Is it every 30 days on the dot? When I see a very regular pattern like that, then I know the vast majority of the time, that woman is ovulating every single month. And in fact, you can figure out what day you're ovulating by taking the day of your period and subtracting usually 12 to 14 days. And that is going to be your fertile time and very reliable, right? Absolutely. Totally agree. And I would say the other common thing that I see people sort of just a misconception is someone might say, yeah, I have really regular cycles, but they're really long. So they may be. every 45 days. I think once you're kind of that far out, people kind of lose track too sometimes. But they are tracking them and they're very, very long, long cycles like that, also very much associated with not ovulating and ovulation PCOS, things like that. Yeah, yeah. So whenever I'm reviewing a new patient's history, that's probably the very first thing I look at is what's going on with their periods. How often are they coming and how many days apart? part are there? And if they're irregular or if they're very far apart, I'm always kind of happy because that is our easiest problem to fix. I'm like, Oh, she's going to be an easy fix. It's probably the first or no, it's the second question that comes out of my mouth when I see people's notifications. I'm like, are your cycles regular? Cause I get it. I love that. I love fixing your irregular cycle much easier. Yeah. And so this is something that, you know, if you're at home and let's say you've been tracking your periods and let's say they're 45 days apart. Don't buy an ovulation test, don't buy a fertility monitor, just go see your doctor. They just need to help you ovulate. It's really as simple as that and you're just wasting your time and energy trying to do anything else besides that. Um, and then if you're having very regular periods. Honestly, you probably don't need an ovulation monitor either, because you can just count and know when you're likely to be ovulating. Or even if you just want to verify for one month, fine, you know, just double check it. But, but I don't think you need to spend a lot of money on fertility tests or fertility monitors in those cases. Absolutely, totally agree. Yeah. And then, okay, what about some other ways of somebody knowing that they are about to ovulate? Do you have any that you talk to your patients about? So I don't always have my patients check these things. Because often my patients will come to me with these. So cervical mucus, I think, or discharge is a really common one that I think women take notice of. And they just kind of learn their own bodies over time. A lot of them maybe have done their research and are, you know, are like, Okay, I know that my My cervical mucus is supposed to be like this when I'm close to ovulation and other people just have realized that that happens for them and they know, um, and you know, it is kind of interesting because what really causes the change in cervical mucus as Dr. Reed and I know is really getting a high estrogen level. Um, and so it definitely means that you could be getting really, really close to ovulation, but. sort of same concept with fertility treatments and things that we do. It's just often a lot more complicated. Yeah. So we've had patients who are going through treatment and are really worried that they're going to ovulate because they notice changes in their cervical mucus. And we're like, don't worry, you're getting a medication to prevent you from ovulating too early. So things like that, not always reliable, but when you're at home on your own, you may take notice of your cervical mucus. So what are some of the signs that they can look at for their? Yes. So, um, increased cervical mucus. Usually clear, maybe a little bit white, very stretchy. And so a lot of times they compare it to egg whites, but not cooked egg white, like raw egg whites is, is kind of the best way that they describe it. But you know, what you were saying about IVF kind of reminded me, I wanted to bring this up with you. Um, we did have a patient the other day who was concerned because she was doing her stimulation. She had lots of. Clear vaginal discharge, which we had warned her about. That is normal when you're doing IVF, you're taking your injections, you're stimulating lots of follicles to grow. They're making estrogen. You're going to have tons of discharge. But then her discharge suddenly disappeared. And she said, Oh my gosh, I'm ovulated. And I realized she's one of my first patients that really has noticed this since I stopped using. Ganyrelix and Cetrazide to keep somebody from ovulating. And instead I use what Dr. K has taught me to use, Medroxyprogesterone. So, um, so previously I just used a shot to keep people from ovulating. Now I'm using oral progesterone, which is so nice. It decreases an injection my patients take every day. Much more tolerable. It's cheaper and everything. But then I realized, well, what does progesterone do? Yeah, it dries up your discharge, right? And so I thought this is interesting. It's probably something I need to be warning my patients about. As we see that pattern because when you take anorexia centrotide, the mechanism of action is different. So my patients in that case would just keep getting all that on discharge. But this was a very stark difference when she started them with doxyprogesterone. So really good point. Yeah. Yeah. Yeah. Um, Okay, so, um, Some other things that sometimes we can associate with ovulation would be breast tenderness. Now I will say a lot of times I'm not seeing this until after they've ovulated, so it's almost more of a confirmation that somebody is, um, has ovulated. We call these malignant symptoms and somebody who's having breast tenderness, um, 95 percent of the time they are actually ovulatory, they're ovulating. And so again, these are all signs that you can notice in yourself to say, okay. Is my body functioning like it's supposed to? Is it ovulating every month even without doing any of those, um, fancy fertility monitors? So, um, but okay, let's say we have a patient who comes in to see us and they're just not sure. Okay. Let's say they just don't even track their periods. They, they're, you say, when you're, I don't know, I don't really keep track. So what, what are some ways that we medically can decide if they've ovulated or not? One other thing we should mention about symptoms of ovulation, sometimes people can feel when they actually are ovulating. Um, so there's a funny term for this pain. It's called needle hurts, named after the guy who, I wouldn't say he discovered it, but he named it, right? Okay, so sometimes my patients will tell me, yeah, I ovulated from my right side. I felt it exactly when it's happening. And that really is probably that follicular rupture that Dr. Reed was talking about. The follicle, you know, opening, bursting, releasing, hopefully your mature egg from it. And it's sort of a pain on one side or the other. I don't have it. Have you ever had it? I don't ever have it, and I feel like I'm missing out. So many times my patients will come in and they'll be like, I'm growing follicles on the left, or I ovulate on the right. And they're right. And I'm like, how do you know? Like, I guess I'm just not in touch with my body at all. Okay, so back to your question, the patient comes in, not sure if she's ovulating. Yes. Um, so, first of all, first question we always ask. Are you having regular cycles with, let's say she's not tracking her cycles? Mm-Hmm. Um, so things that we would commonly do, ultrasounds. Mm-Hmm. So a really simple way to figure out if you are growing a follicle, at least or not. So we can do an ultrasound sort of mid cycle like Dr. Reed was saying, you're probably gonna ovulate about two weeks before you're expected next period. Bring you in around that time. see if there's a big follicle there, a big dominant follicle growing. We can check hormone levels around that time, see if your estrogen level is nice and high. And then we could even proceed to do an ultrasound a few days later. And look, is the follicle collapsed? Um, and we could check your progesterone level around day 21, kind of halfway through that second part of your menstrual cycle and see if your progesterone level has come up. So that's another part of ovulation. Um, so I would say blood work. Ultrasounds, um, are the common ways that I'll investigate. Yeah, and I think there's maybe a couple scenarios too that can be confusing on the patient's side depending on what type of fertility treatment they may be doing. So let's say we take a patient who's not ovulating and let's say she goes to see her OB GYN, her OB GYN gives her Clomid, okay? Now I will say, and there's nothing wrong with this, some OB GYNs when they give Clomid may not do ultrasound monitoring. Okay. So how are they going to check to see did you respond and ovulate to the medication? They're going to just check a blood test. This is called a progesterone level because again, we know that if you've ovulated that, um, follicle should start to make progesterone. And so sometimes they're doing what's called a day 21 progesterone. However, we know sometimes that may actually miss it because that, a day 21 progesterone, will pick up if somebody's ovulated the week before. But if you were a late ovulator, sometimes it can come back as negative when it maybe just needed to be checked at a different time or something like that. So I do feel like on the fertility doctor level, we just, we do like to really watch things I would say a lot closer than maybe kind of just an average, uh, unmonitored clementine cycle. Right? Absolutely. You reminded me of another thing because with the rise in progesterone that we get after you ovulate, you also can have an increase in your body temperature. Oh yes. Yeah. And so something that sometimes people will do at home to investigate whether or not they're ovulating and tracking their cycles is basal body temperature measuring. Um, I feel like it's kind of out of date now. Not a lot of people do it. But something really important to know about that is when does your body temperature actually rise? Well, it's usually after ovulation. Often you sort of miss that window. So it's something that you have to do pretty routinely. Yeah. Every morning, know exactly when it's going to happen. What I was told by my mentor is that you have to be laying flat in your bed, can't get up, can't eat, can't drink water or anything, get your thermometer, put it in, take it, and that's a basal body temperature. I'm like, what woman can do that? I know. I've had some patients try. They almost always tell me it's just too work intensive. They just don't. Yeah, it's intense. But yeah, so progesterone does cause that rise in body temperature. Yes, absolutely. So, um, so I will say by the time a patient maybe has come to see me if I'm doing, you know, You know, Clomid or Letrozole medication or something. I love to do ultrasounds, um, ultrasound monitoring that, I mean, you, uh, just the ultrasound can tell you everything. Mm-Hmm, Okay. So let's say somebody's taking medication. They come in to see me. I look at their ovaries. They don't have any follicles that are responding yet. Okay. So in that case, I end up just giving them more medication. I bring them back later. Okay. But sometimes the patient who may not know a lot about fertility might say, well, you know, have, why aren't you checking for ovulation? And in my mind, it's like, okay, well I don't need to check for ovulation because in order to ovulate, you first need to grow a big dominant follicle. Since that hasn't happened yet, then we know we need to go back to get. more fertility medication, usually at a higher dose. The only exception to that is if we were too late, if we maybe, you know, sometimes patients will go out of town for the holidays or something like that. They come back later than, um, we would have liked. Maybe we come in and do the ultrasound. We don't see any follicles, but that's because the follicles have already popped. But usually you can see some signs of that on ultrasound too. You'll see some free fluid in the pelvis. You might see their corpus luteum, which is where they ovulated from. Um, so I think sometimes you'll see Um, less blood work if you're able to clearly see on sonogram what is going on as well. Yeah, blood work is sort of our answer too. I'm not really sure. Let's do a little bit more investigation. Yeah, but sometimes things are super obvious just by doing ultrasounds. Right, right. And I will say I think this might be a little bit different from how you practice, but I'm progesterone levels actually, um, after I do fertility treatment. And the reason why is I know if I'm tracking a follicle. And I trigger that follicle at the proper time, it's the progesterone is always going to be high. I have literally never seen somebody not respond to a trigger injection. And so I tend just not to check it because it's always high. Um, but if I have concerns about whether those other parts of ovulation occurred, like did the follicle actually pop, actually pop or something like that, then sometimes I will say, Hey. you know, I know we just for example, let's have y or four days to make sure did actually pop like the so I think that's maybe j customized according to j it over the years. But I do it? I not, I don't kno I certainly have So I have seen really, um, older patients, um, who have diminished ovarian reserve, whose follicles do not luteinize and they do not have arisin progesterone. So I have seen that, um, despite getting a proper trigger injection. So definitely have seen that. More rare. Yeah. And typically not really in the patients that were doing ovulation induction. Um, and And we're kind of talking about, you know, time, dinner, core, or some insemination cycles, typically not that patient. But yes, I agree. Usually we'll do ultrasound timing, based it off the size of the follicle. If I have a patient who we've had a couple of cycles that haven't been. going well. I'm going to get more blood work kind of leading up. I want to see what's their estrogen peaking at. You know, some of the medications we give them affect all of these things. So it's just, it's interesting to see what's going on in their, their cycles. Right, right. And I will say, um, I really kind of make the assumption that ovulation has occurred in a patient where I'm giving them fertility medications. I saw them make a dominant follicle. I triggered them. I, I assume it worked. But then if they don't get pregnant, then that is, I usually start trying to look deeper and say, okay, what are we missing here? And that may be totally unrelated testing, looking at other issues. But also if everything else is perfect, then that's. when I'm sometimes like, Hey, let's just see if you're one of these really rare people who has what's called luteinized, unruptured follicle syndrome, which means we give you the trigger injection, or maybe you even surge on your own, but your follicle doesn't pop. And I will say this, I've seen this happen before. And then you say, Oh my gosh, this is what's going on. And the treatment could be a couple of things. One is you could always try to be more aggressive with the trigger injection, maybe give two trigger injections, for example, instead of just one. Or ultimately, what I found most people end up needing is IVF because look, if that follicle won't pop, you can go inside that follicle and get the egg by doing IVF as well. And sometimes it's just helpful to have that answer as to what's going on. I just recently had a patient like that who I came and asked Dr. Reid about, um, and we discussed, and it was fairly obvious that this was probably what was going on because we were doing incineration cycles. We would get through the whole thing. She would get her dominant follicle and she would come in for her baseline ultrasound for the next cycle. And she would have this resting follicle there. And I'm like. It's the same side that the follicle was on, I'm suspecting that it's an arching, and sure enough we did an ultrasound after what I would have expected that follicle to collapse and it was still there. She did beautifully with IVF. Good! Great! Yes! And, I mean, I think too that can maybe be a hint as somebody who says, look, I always get cysts, you know. And maybe even when she wasn't trying to get pregnant, maybe she had a cyst and it was causing her pain and she had to go to the ER and things like that. And they say, I've had cysts all my life, you know. Sometimes that can be a sign that you are having some dysfunction with your ovulation and that can be helpful for us history wise, but also just something that we can potentially look for and then, and treat with either, again, trying a more aggressive trigger or doing IVF. I, I feel like IVF is probably really the mainstay of it. I, um, I don't know that necessarily there's lots of success with, um, going higher on the trigger, but always something somebody can try. Yeah, I did try it. Yeah. Yeah. Yeah. Yeah. Um, yeah. Yeah. Yeah. Um, okay. So let's talk about some causes of women who are not ovulating. Um, so I know you've been pretty open with one of the causes in the past cause you haven't. Yes. So PCOS, polycystic ovarian syndrome, essentially what's going on, what's making it hard for you to get pregnant is that you're usually not ovulating an egg. So there's just no ability to get pregnant in general. So I would say that's the most common reason why someone might not be ovulating. symptoms of that would be things like having your regular cycles, having some symptoms of higher than normal male hormone levels. Maybe you struggle with acne, maybe have a little peach fuzz hairs that you have to pluck on your face, things like that. And then we can do an ultrasound and look at your ovaries and see if your ovaries have a particular appearance to them as well. So PCOS. Pretty common, I think, for patients who are not ovulating. Other things that we'll often investigate that you may not know are going on are things like problems with your thyroid, and can cause you to not ovulate. So we're going to check your TSH, hormones like that, to investigate your thyroid. There's another hormone that's released from your brain called prolactin. Typically, this should just be elevated when you're breastfeeding, but sometimes your brain can kind of turn on and release it on its own, and when that's high, it can prevent you from ovulating, because your body kind of goes into this state of I'm supposed to be breastfeeding a baby. I shouldn't be trying to conceive and ovulating an egg. So if you do have a higher than normal prolactin level, which is something we always check for, it could also cause you to have no ovulation in sort of your regular cycles. Yeah. And then just a couple of other causes, and these are not as common or as likely, is that sometimes your ovaries are not receiving the correct signals from your brain. So your brain should be making, FSH and LH hormone to stimulate your ovaries. Your ovaries should produce hormones that then feed back to the brain. So you have that two-way communication going. But sometimes if that signal is broken, you could have what's called hypogonadotropic. Hypogonadism. We just call it hypo. Hypo. Mm-Hmm. Because it's easier to say Um, and with hypo, that is something that. requires some thorough investigation to try to help you figure out why that may be, and that, but in terms of treatment, we're certainly able to treat that as well, even though it's not. Other things that could be happening, also, you know, we see it, but not as common is that your brain could be working. but your ovaries are not working. Um, and that is a challenging position to be in. We think of that as ovarian insufficiency for one reason or another, your brain's on overdrive trying to get you to ovulate, but your ovary is just not responding. Um, and typically that means, you know, there's really not a lot of eggs left in your reserve and just not able to release any eggs to ovulate. Um, and then I think after that you really get into more rare genetic disorders. Yeah, right. That could be causing you to not ovulate. Yes, yes. Um, okay, and so, you know, let's say we are doing an evaluation on our patient. We've done the lab testing. We've confirmed that she's not ovulating. Let's just talk about some of the basic treatments that we can, um, offer as well to fix that. Mm hmm. So patients who are just, simply not ovulating. We think you fit into maybe, um, PCOS, a sort of, um, situation. Then we can typically give you an oral medication to help you to ovulate because your brain is working. We're just going to try and make your brain respond a little bit more strongly. And so our two common medications, I think a lot of people have heard. clomid before. Um, and t another one that we use b help you to essentially g fuel to grow a follicle, Now, I think one point that's interesting is for patients that have that more rare cause, uh, hypo, hypo, or sometimes hypothalamic amenorrhea would be another word for it, is those medications tend not to work on patients in that case because Both clomid and letrozole are essentially ways of hacking the brain, almost tricking the brain into stimulating the ovaries. But with hypo hypo, because that two way communication, that link is broken. Giving those medications tends to be completely ineffective and instead the treatments usually involve number one, trying to fix the underlying cause if possible or number two, actually just giving fertility injections of Um, FSH and, and LH type, um, medication. And so usually if you're talking about that, you're talking about moving on to more aggressive treatment like IVF as well. For some of the other things that we talked about, if we find something that we're relying, like your thyroid, it may be the problem. It's giving you thyroid hormone and correcting that, um, or prolactin. We do a little bit of an investigation to make sure everything's okay. And then we can give you a medication just by mouth that helps you to lower that prolactin level. And often that can regulate your cycles. And, you know, we didn't mention this, but oftentimes, um, having an elevated body mass index, so just being a little heavier, maybe than you should, can also affect ovulation. And by losing weight, and we had a whole different episode, um, on this recently, um, by losing weight, that may actually restore ovulation as well, which is great. Yes. And then, um, in terms of women that you brought up that their ovaries are just not responding like they should in, in a sense that maybe, you know, approaching menopause, premature menopause, something like that, I know we're definitely in the fertility field trying to explore other treatments that may be helpful. Um, I'm really excited you have a treatment that, or a patient that's going to be trying PRP treatment, um, coming up. Um, it's hard because we have so, so So just limited options in those cases. But I love that, um, we have late and breaking things that we can at least try to see if we can help patients like that. Yeah. So PRP, many of you have probably heard about it. Everyone's putting it on their skin and everything, their joints, people are using in all different medical fields, stands for platelet rich plasma. Um, it's something that you get your blood drawn and you actually create it from your own blood. And so we can actually inject that into the ovary. And sometimes people call this ovary rejuvenation, the idea is we're trying to get Give your ovaries all of these really, um, you know, high nutrients, trying to feed it to see if we can get it to kind of perform a little bit better for us. I will say, um, that my co fellow in fellowship did a really nice randomized control trial on this. Um, just recently got published. Mm-Hmm. And really we were trying to see do, does this affect, um, IVF outcomes? Mm-Hmm. If someone did an IVF cycle before, didn't do well, gets PRP and then does IVF again? Mm-Hmm. is it gonna improve their outcomes? And what she found is it doesn't Mm-Hmm. But there was a lot of things that I've just. Discuss with her that I'm really interested to see. Mm-Hmm. And maybe if we could study it a little bit differently. So for example, they did the PRP and then the very next month they had to do their IVF cycle. Mm-Hmm. That's a problem with research. Mm-Hmm. But really we have to move quickly. Yeah. We have better answers. We don't have time. Yeah. To wait. So I think one hypothesis that both she and I had Mm-Hmm. was does it need to sit. Yeah. Does it need to have time, maybe three months to take effect? Yeah. Um, and interesting, a lot, interestingly, a lot of the patients in her study got pregnant on their own. Oh, interesting. So even though patients didn't have a great response, yeah, usually improved response to IVF, we really think it might've been doing something. And then they have better pregnancy, you know, outcomes in the future. So it's hard because that wasn't the outcome of the study. Yeah. So I think there's a lot more to investigate with. Yeah, absolutely. Well, I think it's hard to, I love to follow studies, but sometimes it's hard to do studies on populations where there's not many people to look at all the, you know, so this is a problem that's pretty rare. Of course, as fertility doctors, we see it quite a bit, but it's hard to get thousands of women with that exact. be able to do studies on always good when you're o course we counsel, hey, t data, but also sometimes tries, if you've tried ev else is working, then it reasonable option too. So we wrap it up for the wee