Dear Dr. ,
I love your blog. I have been up for hours, blurry-eyed, reading and reading. 
I am 23 years old and my husband has cancer. We have only 2 vials of sperm taken from before he had chemo.
I have been off the pill for 5 months, but have not had normal periods return. I had menarche at 10 and normal, though extremely painful periods, until I went on the pill at 14. A period was induced with provera for CD3 testing. My FSH was 8.2, LH was 8.5, and estradiol was 91. My doctor said the levels were a bit high for my age. An ultrasound showed a bicornuate uterus, many follicles, and a fairly recent ovulation out of the left ovary (The ultrasound was done this morning May 14 on day 28, though I haven’t actually started yet) He recommended using letrozole and HcG trigger shot with IUI for the first try.
My question is, do I need to be concerned about my levels? Further reading on the internet says that these levels may be worse than he let on. Even if I achieve pregnancy this time am I at higher risk of premature menopause later on?
Thank you for your time,
ELIZABETH
Johnson City, TN
Dear Elizabeth,
I certainly hope your husband is OK and continues to stay healthy after his chemotherapy. It was so wise of you to freeze his sperm ahead of time. Those two vials are precious and should be used very wisely. Bear in mind the possibility that his sperm could naturally return to normal or at least to some detectable levels. If so, then it’s not quite as worrisome. I’ve known patients whose husbands froze their sperm before chemo. Then before we could plan out their treatment, they end up getting pregnant on their own. So it might be worthwhile to do a semen analysis, say four months or so after the final treatment to see what we’re dealing with. There might be a pleasant surprise.
It’s expected that five months after going off BCPs, the periods should return to the pattern they showed prior to starting the BCPs. A day 3 FSH of 8.2 with a E2 of 91 is a little higher than expected in someone so young, but it’s not something that would send me into a panic. However, short of a grizzly bear rapidly headed my way, there is not much that sends me into a panic nowadays. You should look into OTHER possibilities that your periods have not returned. Instead of just looking at the hardware (the ovaries themselves) investigate the software (hormonal programming of the ovaries). Without knowing more about you, such as your BMI and medical history, I can’t tell you directly what to investigate, but some potential testing would include your thyroid function, prolactin level and the possibility of PCOS.
If it turns out that all these are normal and we are left only with the FSH and E2 as suspects, then realize that there are many other ways to estimate someone’s ovarian age. I wrote it all up last year on a post for my old blog.
Taken literally, your question of "Do I need to be concerned about my levels?" is one I can’t answer, because nobody can judge whether someone should worry about something or not. That is a personal choice. A better way to focus our energy is to ask "Given my D3 FSH and estradiol and all my other relevant clinical information, how should that guide my actions?". I know it’s picky of me to say things this way, but I hope you see my point. 
One suggestion is to get the truth about your husband’s CURRENT sperm status. As I said earlier, a good time to test is four months after the final chemo treatment. Remember that sperm takes 74 days to develop, so any toxic injury could leave its mark for as long as that time. If there is sperm detected, that is cause for celebration. If there is none, then I would think twice about wasting one of two vials on just a simple IUI cycle, even with Letrozole. By the way, while there was a time in the past where I tried Leterozole as an alternative to Clomid, I now have almost stopped using Letrozole all together. The data is limited, but there have been reports of at least 12 women who took Letrozole DURING PREGNANCY inadvertently. Out of those, two delivered their children with birth defects and two lost their pregnancies. A larger study looked at Letrozole use prior to pregnancy and the birth defect risk was found to be similar to baseline, so opinions are mixed. Since Clomid has been in use for a much longer time, I feel safer using it, mainly out of fear of giving it to someone who is already pregnant. There might be some specific cases in patients who don’t respond as well to Clomid where Letrozole is worth the risk, but in general, I now stick with Clomid. You might want to discuss with your RE why the choice of Letrozole. An even bigger question is this. If the two remaining vials of sperm are so precious, why even risk them on IUI as opposed to saving them for IVF? (Especially if one vial is used in an unsuccessful IUI and only one vial remains)
Back to the issue of your ovarian aging, the most revealing information about your ovaries will surface once you begin stimulation. If you make a lot of eggs and get pregnant, then the whole FSH issue would be put to rest. So if you are physically, emotionally and financially ready to be parents, then get started now. Your FSH level of 8.2 cannot reliably predict what will happen. You could be fine and not go into menopause until age 49, or you could be menopausal within a year. The test does not say for sure one way or another, although my first guess is that you’ll be fine even for another 10 years. I hope this information helps guide you in your next conversation with your RE. Good luck and thanks for your question!
