High FSH

Q & A with Dr. Jerome Check – Treating patients no matter their numbers

When I first consulted an RE, I was under the impression that most who took the insurance I was so lucky to have would make me pay up front and file claims myself so I chose my clinic based on how they approached billing. I didn’t know I had DOR. I had never heard of AMH or FSH, so I didn’t stop to think that I may need a specialized clinic. I don’t think I am alone in this. Many women just starting this journey have no idea how to choose the right doctor. Eventually we figure out if we are in the right hands and hopefully find the right fit if we are not.

I never saw Dr. Check but over time in groups and reading research I learned of him. I have suggested him to those that have very high FSH and those that are in the PA and NJ area. He is known for taking tough cases and for an individualized approach for trying to get follicles to grow in women whose ovaries have struggled or failed. In the questions below he touches on many important points, from how his protocols work to the what supplements he believes in and the business of fertility.

Dealing with women who have a small likelihood of responding to meds very much limits the tricks in the bag of any RE. Some may refuse these patients because they don’t know how to help, or because they are worried about their stats, or because they feel ethically challenged for taking money for cycle after cycle with a poor prognosis. I don’t fault any RE who treats DOR primarily with donor eggs, but I do deeply appreciate REs that will give everyone a chance at their own. I have seen a lot of hope from women in groups who go to Dr. Check and I know he works tirelessly to help those in even the worse shape.

Dr. Check is at the Cooper Institute for Reproductive Hormonal Disorders and has offices in NJ and PA. https://ccivf.com/ His nurses run a great facebook group found here https://www.facebook.com/groups/DrCheckInfertilitySupportGroup/?ref=group_header You an also like their facebook page at  https://www.facebook.com/cooperinstituteforreproductive/?rf=1708524172727649

Dr. Jerome Check

In Facebook groups people discuss their experiences and report what they are told by nurses and doctors. Often they get it right, but sometimes they don’t fully understand what was said in an appointment, especially when emotions run so high. I know it is easy when you hear something like donor egg to leave that appointment not fully recalling everything else that was said and hearing donor egg over and over in your head. So since I never consulted with Dr. Check and had actually sent many women to him, and gotten some mixed information about his approach, I reached out to the clinic to see if he would explain it for me to print here.

I think its important to follow your own path with your doctor. Everyone has an opinion and your care is best managed by the person monitoring you. For example, Dr. Check details below why he doesn’t want people taking DHEA with his protocol, but your doctor may prescribe it to you based on your labs and/or your protocol. I am hopeful for those of you that are not able to see Dr. Check but are interested in his approach, this will help you formulate questions for your own RE. The good news is that Dr. Check will take patients from all over, and remote monitoring is possible.

1. Can you describe your protocol with ethinyl estradiol?  Why do you use that form of estradiol?  How does it work?

First, I am going to also send you some articles that will deal with this in more detail. I am going to send you first article #632 entitled “The Multiple Uses of Ethinyl Estradiol for Treating Infertility.”  We use ethinyl estradiol to lower FSH, but the reason that we use that as opposed to standard estradiol preparations is because it does not measure in the assay for 17-betaestradiol in the blood test. So we can evaluate people by the bloods because even if you see a follicle on ultrasound, it does not necessarily mean it is mature enough, or it may even be what we call an airhead.  Sometimes it looks like a follicle but it is not making estrogen, so it is not a follicle.  So it lowers the FSH, but it is not that we use it for everybody.

2. Do you feel that ethinyl estradiol is the right path for all women who have elevated FSH or would you reserve that for women whose levels are above a certain threshold? 

We do not reserve it for women above a certain threshold but, for example, if we have a woman who is actually in premature ovarian failure where they have high FSH, low AMH but have an estradiol level that is less than 20 that does not rise, then they probably have down-regulation of their FSH receptor by the high serum FSH level. If you lower the FSH, you can have receptor restoration and then they can even respond to their own endogenous gonadotropins, or they can respond to a little boost of FSH at that point.  

We also use ethinyl estradiol for women who have diminished ovarian reserve who wind up having short cycles related to a short follicular phase.  I am actually going to enclose an interesting article, article #97 entitled “Successful Pregnancy in a Forty-Five-Year-Old Woman with Elevated Day 3 FSH and a Short Follicular Phase.”  You need a certain number of days of estrogen exposure to develop progesterone receptors and although some people can conceive with a short follicular phase, it is much better to have a little bit of a length to it, even if you eventually get to an estradiol above 200.  A lot of times we will use it to hold back the follicular development and then let it go and let the person respond to their own endogenous FSH or sometimes we will give them a tiny boost of FSH.  We tend to give the boost when the FSH is closer to the normal range.  If it is elevated, we do not want to add more FSH because that will shut down the receptors by raising the serum FSH level.

 3. One thing I have noticed anecdotally is that some of us whose FSH is 50 or below tend to be able to get it down to a better level with supplements, diet, acupuncture, etc.  When it has succeeded in doing this with a better FSH and a normal estradiol with baseline, they tend to respond better in stimulated cycles.  Do you feel there is a place for trying to reduce FSH naturally?

Yes, the higher the FSH, the less tendency a woman has of making a mature follicle.  We do not have a hard fast rule on that.  If someone has regular cycles and they have an estradiol level of 45, if they are making a mature follicle I am not looking to suppress their FSH and then give them stimulation, I am looking at their own endogenous FSH to stimulate their follicle.  If they are nowhere close to a mature follicle, then many times we will use the ethinyl estradiol, bring down the FSH, stay on it but then give a small boost of FSH to push the follicle to the right point. I am not so sure though that there is enough estrogen in supplements like wheatgrass or soy to lower FSH and I have no experience to say yes or no that acupuncture can help lower it or not.

4. Some doctors say you are good as your highest FSH, yet they will cycle a woman when her FSH drops.  Do you feel that statement is false?

Absolutely it is false if I am reading it right.  The highest FSH we ever had a pregnancy in is 185.  We have had pregnancies at 163 and many people above 140.  To me, there is no absolute level of FSH where a person cannot get pregnant.  In fact, a woman who had a 185 actually is a woman who failed, I think, four cycles to get pregnant with donor eggs and she got pregnant with her own egg.  Article #103 is entitled “Successful Pregnancy with Spontaneous Ovulation in a Woman with Apparent Premature Ovarian Failure Who Failed to Conceive Despite Four Transfers of Embryos Derived from Donated Oocytes.”  We published that in 2006. Later she told me that when she was in California her level had been as high as 185 but I have it lower in the article.

5. Some doctors say that having high FSH is a sign of having bad egg quality.  It seems from the experience of my group that egg quality is largely based on age, not lab values.  Do you feel high FSH is a sign of bad egg quality?

No, not necessarily.  I think you are right on point with that.  I am enclosing article #702 which is entitled “The Younger the Patients, the Less Adverse Effect of Diminished Oocyte Reserve on Outcome Following IVF as Long as the Proper Ovarian Stimulation Protocol is Used.”  If you look at the data and the table on that, you will find that women when they are 35 and under, when the proper low-dose stimulation was used, they had 80% as likely chance of getting pregnant as a woman 35 and under who has normal egg reserve.  In the group that was 36 to 39, they were 70% as good.  In the women who were 40 to 42, they were 50% as good.  Interestingly, if you look at the data, it looks like the women who were 35 and under who have diminished egg reserve behaved the same way with pregnancy rates and live delivered pregnancy rates as women 36 to 39 with normal egg reserve and women 36 to 39 with diminished egg reserve seemed to do just as well as women 40 to 42 with normal egg reserve.  Although we have written some papers on women 45 and 46 getting pregnant, there is no question age is a much more important determinant than the FSH, but the FSH becomes more important the older you are as far as the elevation is concerned.  Eighty percent does not mean as much when you are  young and a little more important but not tremendously important when you are 36 to 39, but you are only half as good when you are 40 to 42, so some of that answer is right and some of it is a little bit…There is some effect, but age is definitely much more important. 

6. Often I see women with low AMH being pointed to IVF right away when they have unexplained infertility.  Do you feel that is the best course of action for DOR? Why or why not?
            Indeed, many people will fail IVF and then get pregnant on natural cycles.  The drugs have an adverse effect.  I am also enclosing summary articles #706  and #690 about using the proper stimulation protocol.  There is no one right answer to that question.  IVF if done the right way will give a person a two and a half fold higher pregnancy rate per cycle than non-IVF, both in women with normal ovulation, normal fertile women and women with DOR.  If you have a 35-year-old woman who has a 50/50 chance of being pregnant in three cycles with just good, old-fashioned sex if everything is normal, if she did IVF she would have a 50/50 chance of getting pregnant in one cycle.  Obviously, for that woman it is not a lot greater benefit than having sex. 

            The way that most doctors will do IVF is using too high of a dose of FSH drugs, it is probably more detrimental than helpful.  Done the right way, if a woman’s husband had borderline low sperm but not really enough that she really needs IVF or let’s say a morphology issue where morphology does not really matter much,  but we can get the insurance company to pay for it, do you think there would be any advantage to doing IVF? The answer would be yes.  We can’t guarantee that if we use drugs to make a few more eggs that they are all going to release, but at least with IVF we can go in and get them.  The key is that it has to be done the right way. 

7. Do you believe in supplements to enhance egg quality like CoQ10, DHEA, melatonin and others?  Why or why not?

I see no harm in CoQ10.  I see no harm in melatonin.  I do not really know if it works or not, but I do not stop people.  On the other hand, for a follicle to be a dominant follicle, what happens in normal ovulation is you have to convert these antral follicles into a dominant follicle and to do that, these antral follicles are androgen dominant and the follicle that can be converted to an estrogen-dominant follicle, that follicle is now controlling its own destiny. Once it does that, there are all kinds of interactions that occur that allow that follicle to reach complete maturation.  The way some people treat, DHEA supplementation could help them because DHEA is converted to estradiol and the estradiol can lower the FSH and they may be benefitted.  When you do it the right way, however, it is actually harmful because the DHEA will make the follicular fluid more androgenic and it is less likely to form a good dominant follicle. 

We tried that and we looked at serum DHEA levels and it is article #661 called “No Evidence to Support the Concept that Low Serum DHEA Sulfate Levels are Associated with Less Oocyte Production or Lower Pregnancy Rates.”  The original article came out of a Dr. Casson from Tennessee.  Actually, it is interesting.  His group were poor responders who did not have elevated FSH but had low DHEA levels and he found in some cases giving them DHEA made them make more follicles.  Norbert Gleicher was a naysayer in the beginning, then became a follower when one woman apparently went from like three follicles to eighteen, but that is extremely rare.  So the thought was if you have low DHEA levels, you should have less egg production and have a lower pregnancy rate.  Though we did not see a statistical difference, there was a definite trend toward a higher number of eggs produced in an IVF cycle with low DHEA levels and also higher pregnancy rates.  I forget what New York group did it because they all blend together, I think it was NYU, but a year later they looked at it better than we did.  They looked at the follicular fluid level of DHEA to see whether or not…again them thinking that the higher the DHEA, the better the number of eggs and the better the pregnancy rate.  There they found a significant difference in lower pregnancy rates and less egg production the higher the DHEA.  So we say nay to using DHEA.

Wheatgrass has some estrogen in it, but it is like dumping a glass of water in a big lake.  It does not really contribute much to the total estrogen production.

 8. For those readers in other parts of the country and world, what advice would you give them to finding an RE that is willing to work with them?

That is a tough one because as you may or may not know, a lot of people do not want to be bothered with it because they like to do a type of cookie cutter shotgun approach because it is easier. Everybody gets put on the same regimen and it is too many different phone calls and nuances and it also takes an understanding of the concept because it is not one protocol for everybody because the protocols vary from person to person.  It depends if the woman has adequate egg reserve, at least five to six follicles but her FSH is only 13 or if she had not had a period in four months or has not had a period in two years.  It all changes.  Some people need a boost and some people can take 150 IU FSH earlier.  I have them all listed.  In fact, I have another article that we wrote that talks about women who only had a single embryo transfer depending on their egg quality, but it talks about some of the protocols.  That is article #105 that I am sending.  

Also, from a business standpoint, people worry about the fact that the CDC publishes their statistics, and if they wind up taking people with diminished egg reserve, and even I admit done the right way that women 35 and under will have only 80% as good of a chance of getting pregnant and women 36 to 39 only 70% as good and women 40 to 42 only 50% as good. If you have a lot of those patients, they are going to lower your success rate and other people who have normal reserve are going to spend their money with the other center that seems to have higher live delivered pregnancy rates.  The IVF center is getting paid for 1 IVF cycle but losing 10 other “customers”.  If you can get them into a donor egg cycle, that is win-win.  Do not lower your pregnancy rate and at the same time even make more money from a donor egg cycle than you do from a regular IVF cycle.  So not too many people are that interested.  

We are willing to take cases from around the world. I am a little short right now with associates.  I had been doing it right now while we are down, but from a survival standpoint, I may not be able to do as many long-distance phone consults for survival to get enough people locally that I have enough work for my staff to see.  I do them.  I am happy to help them that way.  I am adding another associate in January, but at the moment I am a little short.  I lost one and one is on sabbatical.

9. Is there anything else you would like to share?

We have to face the reality of life that medicine is a business and that difficult problems take too much time and they do not pay more money.  They are not going to get a large number of REI’s interested in this.  There are some of us who care, like I do.  It is part of what I do.  In fact, MY WHOLE STAFF REALLY CARES. I would be happy to help out as best I can.

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