Last updated: Dec 3, 2007
You can write to me at my email address.

High FSH Info

If you've ever been told you have high FSH, bad eggs, or diminished/poor ovarian reserve, then you'll want to read this!

Preface: I compiled the information in these pages as a patient – not as a doctor or a specialist. I am sharing this information with you to help you on your quest for fertility. Nothing in this document should be substituted for medical advice. I hope you find it useful and I wish you Godspeed in overcoming infertility.

What is FSH?
If I Have High FSH, Am I In Menopause?
So If I'm Not In Menopause, Why Can't I Get Pregnant?
Can FSH Be Lowered?
Some Additional Facts About FSH
So, I have High FSH - What Are My Options?
An Overview of Meds used in ART
More Info on Protocols that RE’s Use For Overcoming High FSH
High FSH-Friendly RE's
An Overview of the Components of Traditional Chinese Medicine (TCM)
Finding a TCM Practitioner
Other Factors to Evaluate Besides FSH
Some Special Research Topics
What's On The Horizon for Treating High FSH
Interesting Links
Recommended Reading

What is FSH?

Here is an oversimplified and unscientific definition of FSH: FSH stands for follicle-stimulating hormone. It is a hormone that is produced by the pituitary gland that, in the female, stimulates the ovaries to develop a follicle (the housing that accompanies the egg prior to ovulation) – each month. It can be thought of metaphorically as the gas pedal which causes the ovaries to ovulate each month. As women age, it becomes more difficult for the ovaries to ovulate as the supply of eggs gets reduced and so the level of FSH rises (in order to push down the gas pedal further) over time. When a woman enters menopause, her ovaries are depleted and the gas pedal stays depressed permanently; that is to say the FSH level remains high. It is also possible for young women to have prematurely high FSH.

If I Have High FSH, Am I In Menopause?

Some doctors indicate that a patient is "in menopause" solely based on their FSH. In actuality, the entry to menopause is much more complex and subtle than any one test can indicate. There is an excellent article on menopause that you should begin by reviewing. Some of the highlights are as follows:

The phases of fertility are referred to as "reproductive years", "menopausal transition" and "menopause".
The reproductive years are subdivided into "early", "peak" and "late". The early and peak reproductive years are characterized by high fertility and regular cycles. The late reproductive years are characterized by somewhat declining fertility and regular cycles. FSH levels can either be normal or elevated during the late reproductive years. Sometime in the late reproductive years - generally ten to fifteen years before menopause, the length of the menstrual cycle decreases (due to a shortened follicular phase).
Menopausal transition lasts on average around 4 to 5 years, but can be 0 years or up to 10 years in duration. Menopausal transition is also known as perimenopause, although perimenopause is technically different from menopausal transition in that perimenopause also includes the first year after menses have ceased. Menopausal transition has two phases known as "early" and "late". The early menopausal transition is characterized by variable cycle length (variation of more than 7 days from normal cycle length) and late menopausal transition is characterized by two or more skipped cycles and an interval of amenorrhea (of 60 days or longer). The average cycle length and the standard deviation of cycle length begin to increase and ovulation occurs less frequently. Fertility begins to decline in the late reproductive years, declines further in the early menopausal transition and further still in the late menopausal transition.
Menopause is defined as the permanent cessation of menses. Menopause occurs at a mean age of around 51, with a standard deviation of around 2 years. Menopause is said to be "natural" if it occurs at or after the age of 40 and is said to be "premature" if it occurs prior to the age of 40. Premature menopause is also known as premature ovarian failure (POF). FSH is constantly elevated in menopause, although studies that have attempted to define a specific cutoff on FSH to define menopause are inconclusive.

So If I'm Not In Menopause, Why Can't I Get Pregnant?

As outlined in the section above, fertility begins to decline in the late reproductive years and continues to decline until menopause occurs and a woman is considered to be infertile. The point at which pregnancy becomes difficult, but not impossible, is referred to as either diminished ovarian reserve ("DOR") or poor ovarian reserve. DOR is a natural phase that all women pass through on their way to menopause. Here is an excellent article that further explains what happens in DOR.
It's important to note that the reproductive phases outlined above and the entry into DOR do not occur on a fixed timetable. Although the majority of women will fall into the timeframes outlined above, some women are exceptions and their fertility may be reduced prematurely, even in the absence of premature ovarian failure. The causes for this early decline in fertility are generally unknown.

High FSH is one factor that can point to DOR. When FSH approaches and exceeds the cutoff in most clinics (ranges from around 12 to 15), and if other indications are present, then a woman may be diagnosed with DOR. Women with DOR have an increased likelihood of having difficulty conceiving and being a “poor responder” – i.e., responding poorly or not at all to fertility drugs which are meant to improve a woman's chances at pregnancy.
Having multiple factors pointing to a diagnosis of DOR increases the likelihood of DOR. This is particularly important in younger women with prematurely high FSH because the FSH can be elevated but if other factors are good, then the odds of conception are better. Below is a list of other factors besides high FSH that can point to a diagnosis of DOR:
- Low antral follicle count. Antral follicles are follicles that are "in the running", so to speak, to be the ovulated follicle for a particular month. In a natural cycle, generally one follicle gets chosen and ovulated and the other ones that aren't chosen die off. In an ART cycle, the medications attempt to recruit multiple follicles from the antral pool, thus improving the chances of conception. If there are fewer antral follicles, this is an indication that the number of remaining eggs in the ovaries is reducing - i.e., it points to DOR. The number of antral follicles can be determined via ultrasound.
- Low Inhibin B. Inhibin B is produced by the antral follicles and so if there are fewer antral follicles then the Inhibin B level will be lower. Inhibin B is tested via a blood test.
- Smaller ovarian volume. The ovaries reduce in size as the reserve of eggs diminishes over a woman's lifetime. Ovarian volume can be measured via ultrasound.
- Low Anti-Mullerian Hormone (AMH). AMH can be measured via a bloodtest.
- Clomiphene-Citrate Challenge Test (CCCT aka Clomid Challenge Test). The CCCT measures how well the ovaries respond to Clomiphene-Citrate - a stimulating medication.
High FSH does not preclude pregnancy. High FSH indicates that a woman is likely to be a poor responder to fertility medications. It does not necessarily mean that there aren’t any high quality eggs remaining and that pregnancy is impossible. It MAY mean that it will take a long time for her to become pregnant and that IUI/IVF may or may not increase her chances of pregnancy. If a young woman has prematurely high FSH, this woman MAY or MAY NOT suffer from premature ovarian failure or premature menopause.
High FSH can be caused by other factors besides DOR. Your RE should rule out other potential causes for high FSH before diagnosing you with DOR. Other causes are unusual but should be investigated nonetheless. FSH can rise due to autoimmune disorders, adrenal gland impairment, hereditary dizygotic twinning, discontinuing the use of oral contraceptives (FSH can rise temporarily after extended use of contraceptives), lactation, unilateral ovariectomy, recovery from hypothalmic amenorrhea and excessive smoking.

Can FSH Be Lowered?

FSH can be artificially suppressed exogenously (from outside the body). FSH can be artificially suppressed – for example, by taking birth control pills or synthetic estrogen. Exogenous suppression of FSH does not necessarily improve DOR and the research as to whether FSH suppression improves conception rates and IVF outcomes is mixed. However, the “estrogen priming” protocol does seem to have some positive affects (see below).
FSH can be artificially suppressed endogenously (from inside the body). Some women are in a situation with low/normal FSH but high estrogen levels. As the FSH trends upward, estrogen can trend upward and has the affect of artificially suppressing the FSH. So a high estrogen level (e.g., day 3 estrodial greater than 75) can mean that the FSH is actually high. So although the FSH is low, the high estrogen level can be indicative of DOR.
Claims of being able to truly lower FSH (and improve ovarian reserve) are controversial. Practitioners of TCM (traditional Chinese medicine) claim to have had some success in truly lowering FSH levels (with a resulting increase in fertility) and some studies indicate there may be some merit to these therapies (some links are included below).

Some Additional Facts About FSH

FSH varies throughout a woman’s cycle. For fertility testing, FSH is typically tested somewhere on days 2 through 5. This is because the early fertility research used readings from days 2 through 5 for consistency. If you have an FSH reading from other days of your cycle, your doctor will need to interpret it for you. For purposes of this document, FSH refers to a reading taken from days 2 through 5. Note that some RE’s only do FSH testing on particular cycle days – e.g., day 3.
FSH fluctuates from cycle to cycle. In young women, the FSH is nearly always low and the fluctuation is minimal. As a woman ages, the fluctuation becomes greater and the maximum readings get higher and higher until finally a woman enters perimenopause and, subsequently, menopause. Most RE’s believe (and there is some evidence in clinical studies to support this) that a woman’s ovarian reserve is only as good as her worst (highest) FSH reading. In other words, if a woman has an FSH of 25 one month and 5 the next month, then her ovarian reserve did not improve during the course of the month - diminished ovarian reserve is indicated by the reading of 25. Some RE’s, however, take this rule with a grain of salt and depending on the other indicators of ovarian reserve may accept a woman for an IUI or IVF cycle if a woman’s FSH is below the cutoff even if she has had other readings above the cutoff. Note that after a woman enters menopause, the FSH is elevated and stays elevated. So as long as the FSH is fluctuating, the odds of conception are higher than if it remains elevated.
Age is a more important predictor of fertility than FSH. The most important factor that RE’s use to determine whether a woman has DOR is age. Age is considered a much more important factor than FSH, although most clinics have both age and FSH cutoffs. High FSH is viewed as less of an obstacle in younger women.
FSH levels vary across laboratories. FSH is a complex hormone to measure and there is a lot of variation in its measurement across different laboratories. In the same cycle, a woman could go to three different laboratories and get three different FSH readings. This is important to keep in mind when discussing your case with a new RE. It’s best to retest the FSH in the new RE’s lab so that there is no confusion.

So, I Have High FSH – What Are My Options?

The first thing you need to do is to learn as much as you can so that you can be your own advocate. Then, you can do any or all of these options – separately or together:

Pursue fertility treatments – IUI/IVF. Work with your RE and follow his recommendations for your situation. Or go to a different RE for another opinion. You'll want to review the sections below - An Overview of Meds used in ART, More Info on Protocols that RE's Use for Overcoming High FSH and High FSH-Friendly RE's.
Monitor your own cycles and attempt natural conception. Use a fertility monitor and chart your temperatures. See Fertility Friend for information on charting temperatures and improving your chances for conception.
Pursue alternative approaches. See Randine Lewis’ book “The Infertility Cure” (listed below) for information on supplements, herbs and acupuncture. Also, here are two links to an alternative practitioner’s view on high FSH: Randine Lewis and the Berkley Center. Also, you'll want to review the section below - Finding a TCM Practitioner.
Choose an alternative such as receiving donor eggs or adoption. Both of these paths are wonderful avenues to parenthood. If you're considering either of these options, keep in mind that there may be long waiting lists so you should plan ahead.
Regardless of the path you choose, get support along the way. Go to any of the following discussion boards for peer support: New High FSH Forum, Women Over 40 With High FSH, Secondary Infertility and High FSH. And if you're looking for inspiration, the following board provides peer support for women who have become pregnant in spite of high FSH: New Pregnant despite IF Forum

An Overview of Meds Used in ART (Assisted Reproductive Technology)

Note: Much of the information in this section was derived from “How to Get Pregnant” by Sherman Silber c 2005
There are generally four main types of medications utilized in ART: 1) medication to stimulate the ovaries into producing more eggs than normal – “stims”, 2) medication to suppress ovulation so that ovulation doesn’t happen too early, 3) medication to trigger ovulation at the appropriate time, and 4) medications to promote implantation and support pregnancy. Typical protocols involve using at least one medication from each of the first three categories and medications from the fourth category as needed.

Stim medications: There are two main types of stims – Mild Stimulation Medications and Gonadotropins.
- Mild Stimulation Medications. There are two primary medications that fall into this category - Clomiphene Citrate (brand names are Serophene and Clomid) and Letrozole (brand name Femara).
  - These medications provide mild ovarian stimulation, generally producing a small increase in the number of follicles ovulated.
  - Are safe to use with timed intercourse or IUI because of the mild stimulation involved.
  - Can be used in conjunction with Gonadotropins (see below) and they may allow a smaller dose of Gonadotropins to be required.
  - Clomiphene Citrate can have an adverse affect on the uterine lining and cervical mucous in some women and this affect can last for six to eight weeks.
  - Letrozole does not appear to have adverse affects on the lining and mucous and is cleared from the body more quickly.
  - Clomiphene Citrate and Letrozole are similar but operate in somewhat different manners and RE's will choose a particular medication on a case by case basis.
- Gonadotropins. Purified preparations of FSH – they work as an additive affect to the FSH your body is already producing (endogenous FSH) and further stimulate the ovaries. There are two types of gonadotropins: Human Menopausal Gonadotropin (HMG) and recombinant FSH products (r-FSH). The two types of gonadotropin can be used individually or can be mixed together – in a so-called “mixed protocol” – to result in an optimal level of LH.
  - Human Memopausal Gonadotropin(HMG)(aka menopausal gonadotropins)
    - Derived from the urine of menopausal women which is high in FSH and contains a small amount of LH which is necessary for follicle development
    - Some brand names – Pergonal, Humegon, Menogon, Repronex, Menopur, and Bravelle.
  - Recombinant FSH (r-FSH)
    - Created using DNA technology
    - Original products contained no LH which was detrimental to follicular development. Some products now have added LH, but the amount of LH can be too much because it is an additive to endogenous LH.
    - Some brand names – Gonal-F, Follistim
    - A low dosage of r-FSH would be 1 or 2 ampules, a high dose would be 6 ampules
    - Costs more than HMG
Medication to suppress ovulation: There are two main types: GnRH agonists and GnRH antagonists. It should also be noted that the mild stimulation medications can also be used to suppress ovulation if they are taken up until the time of desired ovulation.
- GnRH Agonists
  - GnRH is a hormone produced by the brain that triggers the pituitary to release FSH and LH. Lupron (brand name) is a GnRH agonist which means that it stimulates the pituitary to release lots of FSH and LH, then the pituitary is depleted so it can then no longer release FSH and LH. This process of depleting the pituitary is referred to as “down regulation”. Down regulation takes about five days after Lupron is started.
  - In the US, Lupron can be known as leuprolide, in Europe, Lupron can be known as buserelin, lucrin or suprefact.
  - There are several protocols for using Lupron – Long phase, Short phase and Mini-dose
    - Long-phase
      - Lupron is started during the luteal phase of the preceding cycle.
      - The normal dosage is .2ml / 1mg
      - This approach means that by the time the IVF cycle is started there will be no endogenous LH or FSH to interfere with the stims.
      - Long phase results in better pregnancy rates for patients with normal FSH.
    - Short-phase
      - Lupron is started on CD3, then 2 days later HMG or FSH is started.
      - The Lupron provides an early stimulating affect (before down regulation kicks in) which allows the usage of less HMG/FSH.
      - The normal dosage is .2ml / 1mg
      - Short phase is often used for patients w/ DOR because some patients w/ DOR do not respond well to Lupron.
    - Mini-dose (aka Micro-dose or Flare protocol)
      - Same as the short phase protocol but 1/4 to 1/10 of the normal dosage is used.
      - Mini-dose is often used for patients w/ DOR because some patients w/ DOR do not respond well to Lupron
      - The theory is that it is meant to suppress endogenous FSH and LH less vigorously, thus allowing endogenous FSH and LH to work in combination with the stims to affect the ovary. Sometimes, however, it can result in too much LH which is bad.
- GnRH antagonists
  - Makes the pituitary think that there is no GnRH which is its trigger to produce LH and FSH, so the pituitary immediately ceases production of LH and FSH
  - LH and FSH drops instantly so there’s no need for a long phase to “prime the system”.
  - There are a few disadvantages: 1) it’s expensive, 2) it drops the LH even lower than Lupron, 3) 1 missed dose of medication can cause a premature LH surge and early ovulation.
  - One way to overcome the extremely low LH is to start it later – when the lead follicle is 13-14mm
  - GnRH antagonists are preferable for DOR because some patients w/ DOR do not respond well to Lupron
  - Two brand names are Cetrotide and Antagon
Medication to trigger ovulation: There are two main types: Human Chorionic Gonadotropin (HCG) and Lupron
- Human Chorionic Gonadotropin (HCG) - Is the equivalent of LH and when applied will mimic the natural LH surge which triggers ovulation. Some brand names are Pregnyl, Profasi, and Novarel.
- Lupron - When used in conjunction with an ovulation suppression protocol that does not involve Lupron, Lupron can actually be used to trigger ovulation because of its action as a GnRH agonist.
Medication to promote implantation and support pregnancy: In an IVF cycle, the body's natural ability to produce hormones such as progesterone and estrogen is compromised due to the aspiration of the corpus luteum (mature follicle). For this reason, hormones are taken to supplement or replace the body's natural hormones. In some cases, hormones are also taken with cycles involving either timed intercourse or IUI if the RE feels that the hormones need to be supplemented.

More Info on Protocols that RE’s Use For Overcoming High FSH

The approaches outlined below are based on a limited survey – there may be other protocols of which the author is not aware. Note that the literature below focuses on IVF. The vast majority of the studies specifically addressing protocols for DOR focus on IVF rather than IUI. In terms of protocol, one of the primary differences between IUI and IVF is that with IUI the goal is to stimulate the ovaries, but not too much - otherwise there is a high risk of multiples. With IVF, the RE and the couple work together to determine how many embryos to transfer in order to control the risk of multiples. So with IVF, maximal stimulation is desired while avoiding hyperstimulation. Some RE's will cancel IVF cycles that don't create enough follicles, whereas other RE's will pursue retrieval and transfer with few or only one follicle. This can be a very important issue for patients with high FSH because of the likelihood of producing a lower number of follicles.

High-Stim Protocols.
- Some RE’s theorize that patients who have demonstrated that they are poor responders (common with DOR, as explained above), may respond better to an extra-high dose of stim medications (e.g., 6 ampules).
Minimal or Low Stim Protocols.
- Some RE’s theorize that poor responders may respond better to an approach using minimal stimulation medications. Some RE’s even go so far as to say that minimal stimulation protocols are not only favored for poor responders but can provide a lower-cost, effective option for “normal” responders which is easier on the body than higher stimulation protocols. Although this approach results in fewer oocytes at retrieval, some RE’s contend that the pregnancy rates are comparable to a standard stimulation protocol.
- Minimal-Stim protocols can utilize any of the stim medications described above – alone or in combination.
- Some RE’s favor minimal-stim protocols primarily for those patients with “borderline” FSH – i.e., those patients close to (either just under or just over) the FSH cutoff for their clinic.
Natural Cycle with Controlled Ovulation Protocols.
- Since patients with DOR often do not respond to stim’s (regardless of protocol used), some RE’s will perform “natural cycle IVF”. Most RE’s do not favor it because of the low probability of success since generally only one egg is produced.
- The concept behind a natural cycle IVF is that in women who will probably not respond to stimulation medications, the actual procedure of an IVF – even if only one follicle is present – could potentially improve the chances for conception due to reduction of the steps in the conception process which are left to chance (and therefore subject to failure) in a cycle using intercourse only. A true natural cycle is very difficult, however, due to the need to know precisely when ovulation occurs in order to time the egg retrieval. Therefore, the few RE’s who attempt “natural cycle IVF’s” typically introduce some medication into the cycle in order to control the timing of ovulation (and to prevent a premature LH surge).
- The few RE’s who do natural cycle IVF’s do so typically with those patients with very high FSH who have a proven track record of not responding to stimulation medications.
Synthetic Estrogen.
- Synthetic estrogen (including ethinyl estradiol (oral contraceptive), femtrace, estrace, gynodiol, etc.) can be used in two different ways for fertility. Note that RE's will prescribe a specific type and dosage of synthetic estrogen based on where it is being used in your cycle - they are not all interchangeable.
- The two different ways that synthetic estrogen is used are:
  - In women w/ high fsh, the problem is not only that the fsh is high but that it starts rising before cd1. By having an fsh "head start", it makes it difficult for stim meds to be effective because often one lead follicle takes the lead too early - possibly even before stims are started. By taking synthetic estrogen for some time prior to cd1 (e.g., 2 weeks), it keeps your fsh down and therefore "suppresses" your ovaries so that no follie gets an early head start. The objective is to keep the antrals at relatively the same size so that they all grow together in response to the stims.
  - The other related problem in women w/ high fsh is that sometimes ovulation happens too early (because of the head start) - before the egg has matured properly. Dr. Check says that ovulation before cd11 is bad. So in early ovulators, synthetic estrogen can be used in the first part of the cycle in order to slow down the maturation process so that the egg(s) has/have enough time to fully develop.

High FSH-friendly RE’s

There are not many RE’s who specialize in treating patients with high FSH. In most clinics, reproductive endocrinologists (“RE’s”) reject patients with FSH levels above their cutoff. The few who do treat patients with high FSH are focusing their treatment on specific protocols (combinations of fertility drugs) that they have researched and had some success with in the past. Note that if your RE isn’t “high FSH-friendly” – i.e., isn’t willing to pursue any treatment for you other than donor eggs – then you need to find a new RE if you want to have a chance of conceiving with your own eggs. The support board mentioned below is a great resource to find an RE in your area who can help you. Also, many of the “high FSH-friendly” RE’s will also do phone consults with out of town patients and typically have ways to treat out of town patients – often partnering with local laboratories for monitoring, thus minimizing travel time. Below is a very incomplete list of RE’s who are High FSH-friendly (in alphabetical order):
Note: The list below was compiled from discussion on the support board. The author makes no guarantees about the services provided by these practitioners and stands to gain nothing from referring patients to their practices. The purpose of including this list on this site is to assist patients in their quest to find medical practitioners who are at least open to the possibility that conception is possible in spite of high fsh.

U.S. - West

Arnold, Dr. Lori at La Jolla IVF in La Jolla, California.
Danzer, Dr. Hal at Southern California Reproductive Center in Los Angeles, California. Open to low stim approaches.
Letterie, Dr. Gerard at The Northwest Center for Reproductive Sciences in Seattle, Washington.
Milki, Dr. Amin at Stanford's Reproductive Endocrinology and Infertility Center in Palo Alto, California. Favors high stim approches and very open to high fsh and older patients.
Nelson, Dr. Jeffrey at Huntington Reproductive Center in Pasadena, California. Favors high stim approaches.
Nemiro, Dr. Jay at Arizona Center for Fertility Studies in Scottsdale, Arizona.
Patton, Dr. Phillip at Oregon Health & Science University in Portland, Oregon.
University of Utah Center for Reproductive Medicine in Salt Lake City, Utah. Favors high stim approaches.

U.S. - Midwest
Abuzeid, Dr. Mostafah at IVF Michigan in Detroit, MI.
Ahlering, Dr. Peter at SIRM in St. Louis, Missouri. Will treat some cases of high FSH. Prefers high stim but has done low stim in some situations.
Henry Ford Reproductive Center in Troy, Michigan. Drs. Hayter and Strickler are said to be high-fsh-friendly at least with borderline cases.
Kubik, Dr. Carolyn at Reproductive Health Specialists in Pittsburgh, Pennsylvania.
Lifchez, Dr. Aaron at Fertility Center of Illinois in Chicago, Illinois.

U.S. - South
Batres, Dr. Francisco at Arkansas Fertility and Gynecology in Little Rock, Arkansas.
Chuong, Dr. C. James at Cooper Institute for Advanced Reproductive Medicine in Houston, Texas. Uses various approaches depending on the FSH. Very receptive to high fsh and older patients.
Heard, Dr. Michael at Women's Specialists of Houston in Houston, Texas.
Isaacs, Dr. John at Mississippi Fertility Institute in Jackson, Mississippi.
Walmer, Dr. David at Duke Fertility Services in Durham, North Carolina. Favors MDL and high-stim protocols.

U.S. - Northeast
Cardone, Dr. Vito at Cardone Reproductive Medicine & Infertility in Stoneham, MA.
Check, Dr. Jerome at The Cooper Center in Marlton, NJ. Favors natural or low stim approaches, but uses various approaches depending on the FSH. Very receptive to high fsh and older patients.
Davis, Dr. Owen at Cornell in NY. Favors high stim approaches.
Frankfurter, Dr. David at George Washington University Fertility Associates in Washington DC.
Garrisi, Dr. Margaret at The Institute for Reproductive Medicine and Science (IRMS) in Livingston, New Jersey.
Hall, Dr. Janet at Massachusetts General in Boston, Mass. Dr. Hall does not do IVF but is open to treating high FSH patients with medications.
Jurema, Dr. Marcus at Women and Infants Hospital of Rhode Island in Providence, Rhode Island. Also said to practice in Boston, Massachusetts.
Maier, Dr. Donald at The Center for Advanced Reproductive Services at Uconn in Farmington, Connecticut. Favors high stim protocols.
Sher, Dr. Geoffrey at Sher Institute in NY. Favors high stim approaches.
Toth, Dr. Thomas at Vincent Obstetrics and Gynecological Services - Massachusetts General Hospital in Boston, Massachusetts. Will treat some cases of high fsh.
Zhang, Dr. John at New Hope Fertility Center in NY. Favors natural or low stim approaches, but uses various approaches depending on the FSH. Very receptive to high fsh and older patients.

International
Kato Ladies' Clinic in Tokyo, Japan. Pioneered the "Mini IVF", a low-stim protocol.
Kelly, Dr. Simon at Fertility Associates in Auckland, New Zealand. Open to mid/high or low stim/natural approaches.
Lister Clinic in London.
Ryan, Dr. Eddy at Toronto West Fertility Associates in Toronto, Canada.
Soliman, Dr. Samuel at NewLife Fertility Centre in Brampton and Mississauga, Ontario, Canada.

Editorial comment: Why are there not many RE's who specialize in treating patients with high FSH? The simple answer is that fertility clinics are evaluated based on their pregnancy rates. Women with high FSH pull down their pregnancy rates. Most RE's will cite dire statistics when relaying a diagnosis of DOR to a patient and use words like "impossible" and "never". The fact is that pregnancy with DOR is more difficult but it is *possible* and it *sometimes* happens!

An Overview of the Components of Traditional Chinese Medicine (TCM)

As mentioned above, some studies have indicated that TCM can lower FSH and improve fertility. Here are two links to an alternative practitioner’s view on high FSH: Randine Lewis and the Berkley Center. It is important to note that TCM is not an overnight solution. TCM takes time and patience in order to be effective. Different TCM practitioners – even those within the same discipline – often have different viewpoints about the details of a TCM diagnosis and treatment plan. The key is to find a practitioner – ideally one who specializes in infertility – who can work with you. Much of the information below is summarized from “The Infertility Cure” by Randine Lewis, Ph.D. (published by Little, Brown and Company, copyright 2004). I highly recommend purchasing this book and following the detailed recommendations if you choose to pursue TCM (see link in the Recommended Reading section). Ideally a TCM treatment plan will involve as many of the following aspects as possible:

Taking care of your overall health and well-being. This includes getting adequate exercise and sleep, reducing stress levels and maintaining a positive attitude.
Eating a more organic, whole-foods diet. Some specific recommendations include avoiding junk food, caffeine, tobacco and any food treated with growth hormones.
Receiving Acupuncture. Weekly treatments are recommended to enhance a variety of aspects of fertility. Acupuncture, along with other techniques such as acupressure and massage, can also serve to increase blood flow to the ovaries and uterus. Reduced blood flow to the reproductive organs is thought to be a key reason why fertility declines as we age.
Including herbal therapies either as a preparation for or instead of Assisted Reproductive Technologies (ART). Although some practitioners sell prepared formulas that are generic preparations to improve fertility, a better approach is to get a customized prescription from a licensed herbalist. Note that it is not recommended to take herbal formulas during a stimulated cycle – i.e., either an IUI or IVF cycle.
Taking appropriate supplements. Before taking any of the supplements listed below, do your own research on them and consult your doctor. Also check with your reproductive endocrinologist as to whether it is recommended to continue the supplements during an ART cycle.
- Royal jelly.
- Blue-green algae.
- Wheatgrass.
- Chlorella.
- Coenzyme Q-10 (Co Q-10).
- Antioxidant vitamins including C, E, A, zinc and selenium and superantioxidants (pycnogenol).
- Dehydroepiandrosterone (DHEA). Not recommended for women who have elevated levels of male hormones.
- L-arginine. Not recommended during an ART cycle.

Finding a Traditional Chinese Medicine (TCM) Practitioner

Before you start, here is a great document from Resolve that lists some key questions to ask a practitioner. And a few practitioners are listed below:
Note: The list below was compiled from discussion on the support board. The author makes no guarantees about the services provided by these practitioners and stands to gain nothing from referring patients to their practices. The purpose of including this list on this site is to assist patients in their quest to find alternative practitioners who are said to have some experience in working with clients with infertility.

Acupuncture for Women in Dallas, Texas.
Acupuncture in Michigan in Detroit, Michigan.
Axelrad Clinic in Houston, Texas. They do acupuncture, herbs and medical qigong.
Berkley Center in New York, New York.
Christine Kleinschmidt at Brentwood Center of Health in St. Louis, Missouri.
Hoboken Acupuncture in Hoboken, New Jersey.
Lifang Liang in San Francisco, California.
Mary Margaret Dobson at Ocean Acupuncture in Redondo Beach, California.
Pulling Down the Moon has three locations around Chicago, Illinois.
Rosemary Cody in Anchorage, Alaska.
Sadhna Singh at Eastern Harmony in Houston, Texas.
Southwest Center for Oriental Medicine in Phoenix, Arizona.
Vitalis Acupuncture in Aukland, New Zealand.
Yu Chen at Meridian Medical Group in New York, NY.

Other Factors to Evaluate Besides FSH

A group of women with DOR who had been trying to conceive for a long time (some were still trying, some were pursuing other options such as donor eggs and some were pregnant) were polled and asked the following question: Please list the things that you found out after wasting time and money that could have made a difference had you known them earlier. The items below reflect the items that the women listed. The motivation for the question is that too often RE's reach a diagnosis of DOR based on a measurement of high FSH and they automatically dismiss the possibility that there may be other factors also influencing fertility. If you have been trying to conceive for a long time and/or have had recurrent miscarriages, then make sure that all these areas have been tested:

Male Factors. A full semen analysis is necessary including testing for antisperm antibodies and SCSA (tests for DNA fragmentation).
Polyps and Fibroids. Uterine polyps and fibroids, even if they're small, can influence the menstrual cycle and can interfere with implantation. They can typically be seen via ultrasound and can be removed through a relatively simple surgical procedure.
Thyroid Issues. Thyroid issues can impact fertility and need to be ruled out as a contributing factor. A thorough thyroid test needs to include TSH, free T3/T4 and anti-thyroid antibodies.
Ureaplasma. Ureaplasma is an infection for which you should be tested. "Ureaplasma may cause the formation of sperm antibodies and an inflammation of the uterine lining, either of which may interfere with implantation of the embryo" (Source)
Factor V Leiden. Testing for Factor V Leiden is also important. "Factor V Leiden is the most common hereditary blood coagualtion disorder in the United States and can lead to stillbirth or unexplained recurrent miscarriage" (Source)
Hysterosalpingogram (HSG). An HSG is a test to determine whether the fallopian tubes are open. (More info)
Recurrent miscarriage testing panel. There are many more tests that are recommended in the case of recurrent miscarriage in addition to those listed above. Refer to this website for a list of the recommended tests. Also, check out Dr. Alan Beer's book, listed in the 'recommended reading' section.

Some special research topics:

Note that the bulk of the research shows discouraging news for patients with diminished ovarian reserve (i.e., high FSH). One study cannot reverse this trend, however, the studies indicated below provide an indication that as RE’s experiment with different treatment options, a more favorable prognosis for some patients with high FSH may be possible.

High FSH and egg quality

Research indicating quality eggs may co-exist with high FSH

High FSH/Diminished Ovarian Reserve and general response to fertility treatment

Research indicating patients with high FSH should not be excluded from fertility treatment
Research indicating the low reliability of all factors in measuring ovarian reserve and predicting IVF success rates
Research indicating that ovarian volume and antral follicle count are among the best measures of ovarian reserve

Potential other causes of high FSH besides DOR

A study that speculates on potential other causes of high FSH besides poor ovarian reserve

High FSH and Age

Research indicating patients under 40 with high FSH have better pregnancy rates than those over 40:
Research indicating young patients with high FSH have worse pregnancy rates than their normal FSH counterparts but that pregnancy can be obtained with treatment for some patients

High FSH and Low Stimulation Protocols or Natural Cycle

Compilation of research studies presented at the first World Congress on Natural Cycle/Minimal Stimulation IVF in London in December, 2006
Research showing promising results for modified natural cycle using GnRH antagonist
Research showing promising results for minimal stimulation protocol using clomid and oral contraceptive pill
Research showing promising results for minimal stimulation protocol using clomid and gonadotropin
Research showing a comparison between micro-dose protocol and natural cycle
Research showing promising results for using low-dose GnRH and r-FSH with patients with DOR
Research showing promising results for using low-dose hMG and Clomid

High FSH and Micro-dose Protocols

Research showing promising results for patient swith DOR using micro-dose GnRH agonist and gonadotropin
Research showing promising results for patients with DOR using micro-dose GnRH and FSH plus growth hormone
Research showing promising results for patients with DOR (indicated by ovarian volume) using micro-dose GnRH agonist protocol
Research showing promising results for patients with DOR using micro-dose GnRH agonist flare protocol

High FSH and Acupuncture

Research showing promising results for the use of acupuncture for fertility (#1)
Research showing promising results for the use of acupuncture for fertility (#2)
Research showing promising results for the use of acupuncture for fertility (#3)
Research showing promising results for the use of acupuncture for fertility (#4)

Estrogen Priming

A document from the Sher Institute’s website discussing estrogen priming
Research showing promising results using estrogen priming for patients with ovarian failure
Research showing the utility of estrogen priming via birth control pills
Case study showing the successful use of estrogen priming patient with imminent ovarian failure
Case study showing the successful use of estrogen priming with extremely high FSH:

Sperm, Embryo and Egg Freezing

Freezing technology can impact any patient involved in Assisted Reproductive Technology. Patients with high FSH are particularly sensitive to this issue, however, because different freezing approaches result in some level of loss of the item being frozen. Patients with high FSH can have difficulty producing quality embryos and eggs and therefore want to minimize any damage or loss.

Overview on freezing technology by Dr. Sherman Silber (note that Silber’s clinic is not the only clinic doing vitrification)

What's On the Horizon for Treating High FSH?

There are a couple of emerging concepts in treating high FSH. The first is something called "in vitro maturation", which is on the relatively near-term horizon. The second is related to stem cell research and is further off in the future.

In Vitro Maturation (IVM). IVM is a process in which egg retrieval is done much earlier in the cycle - antral follicles rather than mature follicles are retrieved. Then they are matured outside of the body, fertilized, and then transferred back into the woman's body. This process appears to hold a lot of promise for so-called poor responders and may provide other options for women with DOR. Below are some links with more information:
- Compilation of research studies including several references to IVM presented at the first World Congress on Natural Cycle/Minimal Stimulation IVF in London in December, 2006 (also referenced above)
- Research article providing an overview
- News article
- Another news article
Stem Cell Research. There is talk of one day being able to use stem cells to actually allow the ovaries to generate eggs rather than continually release eggs which were present at birth. Eggs are the only (or nearly the only) cells in the human body that don't get generated or regenerated after birth - a woman is born with her lifetime supply of eggs and never makes any more. Here is an article that discusses the possibility of using stem cells to create sperm. And here is a very technical article that mentions the possibility of using stem cells to either create egg cells or - in a sense - fabricate eggs using donated egg material and the woman's DNA.

Interesting Links

Blog by Dr. Licciardi of NYU. Contains extensive information infertility and IVF and a search will turn up several articles on FSH.
Lemming Report. Website containing some additional, useful information about ovarian reserve.
Fertility Stories contains a collection of stories written by women dealing with infertility.
Pregnancy Stories by Age contains a collection of success stories grouped by age.
High FSH Success Stats contains an unverified, unscientific (but highly inspirational) list of success stories compiled by a woman with high fsh.