We weren’t completely satisfied with the consult at the first fertility clinic we visited in our new area so we had a consult with another fertility clinic. I’m so glad we decided to do this, because it turns out that the second clinic is much more like where we used to go before the move across the country.
We met with a reproductive endocrinologist, and he was extremely nice, wasn’t phased by me being a female-to-male transsexual at all (at least he didn’t show it if he was). We discussed our history of doing four natural IUI cycles and two Clomid cycles, with no positive pregnancy tests yet, and her diagnosis of Unexplained Fertility. He also did a baseline ultrasound, and found that Molly’s ovaries are polycystic in appearance, meaning there were more than a normal number of cysts along the outside of the ovary. He also looked at Molly’s bloodwork, which has all been normal, and explained to us that even with her normal bloodwork, she technically still meets the diagnostic criteria for Polycystic Ovarian Syndrome (PCOS).
It’s important to note that simply having polycystic-appearing ovaries is not necessarily diagnostic for Polycystic Ovarian Syndrome (PCOS) as the ovaries of normal women can also be polycystic-appearing. But according to Rotterdam Consensus1, the diagnosis of PCOS is made when at least two of the three following conditions occur simultaneously:
- Polycystic-appearing ovaries on ultrasound or direct inspection
- Clinical or biochemical signs of hyperandrogenism (high androgens such as testosterone)
- Oligoovulation (infrequent, irregular ovulation) or anovulation (lack of ovulation)
Most people associate PCOS with the first two criteria – polycystic-appearing ovaries with high levels of androgens. All of Molly’s bloodwork, including androgen, glucose, insulin, and thyroid hormone levels, were all normal. Therefore, a diagnosis of Unexplained Infertility was first made after the 6 intrauterine inseminations failed to produce a pregnancy. However, even though her hormone levels are normal, because Molly had polycystic-appearing ovaries as well as infrequent/irregular menstruation, she technically meets the diagnostic criteria for PCOS.
Our doctor listened to our interest in pursuing injectable fertility medications (gonadotropins) as the next step, instead of continuing on with more Clomid cycles. He also told us that injectable gonadotropins have been shown to have the highest success rate in those with Unexplained Fertility (besides IVF, which has the highest success rate regardless of diagnosis). This pretty much made up our mind that we wanted to try at least one, probably two, cycles of injectable gonadotropins before moving on to the more expensive, and more invasive, IVF procedure.
1 The Rotterdam ESHRE/ASRM-sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome (PCOS). Hum Reprod (2004) 19(1):41-47.