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Ovulation Testing After Tubal Reversal: A Fertility Surgeon’s Advice

If there is one thing patients commonly get wrong is how to properly perform ovulation testing after tubal reversal surgery.

Ovulation tests are a simple, over the counter test that help you know when you are ovulating (releasing an egg). If you know when you release an egg then you can increase the chance of getting pregnant.

After ovulation, the egg only lives for about 24 hours. So knowing when you ovulate can help you better time when to have sex and increase your chances of pregnancy.

We don’t routinely recommend ovulation testing after tubal reversal surgery for all of our patients….but for some women it can mean the difference between easily getting pregnant and having a hard time. Ovulation testing after tubal reversal surgery can be very beneficial for women who are older in age, who have irregular periods, or those who just want to get pregnant as quickly as possible.

We need to make sure we understand what the words mean before we can have a meaningful discussion about ovulation testing.

Understanding Basic Terms: What does ovulation mean?

To ‘ovulate’ means to release an egg from your ovary. If you want to get really technical, the unfertilized human egg is called an ovum. Ovums come from the ovary and to release an ovum from your ovary is to ovulate. The entire process of releasing an egg from the ovary is referred to as ovulation.

If you are a reproductive age woman you should be ovulating every month. Reproductive age is defined as being between the ages of 15 to 49.

Most women will release an egg 12 to 16 days after their menstruation/periods start. Every woman is different…some women ovulate sooner and others ovulate later. Some women may ovulate differently each month. Some women may not ovulate on any given month.

It is very common to skip ovulation. This condition is called ‘anovulation’…or not ovulating. This can be very common in teenagers and in women as they become older…and especially if they gain weight as they become older.

We can’t discuss ovulation unless we are all clear on what a ‘period’ is…..women commonly misunderstand and misinterpret what is and what is not a period.

To better understand your menstrual cycle read: Increase your chances of getting pregnant! Understand your menstrual cycle

Understanding Basic Terms: What is menstruation/period?

Reproductive age women should have regular vaginal bleeding every 28 to 35 days.

The medical term for regular vaginal bleeding is ‘menstruation’. The slang term for menstruation is most commonly ‘a period’…but there are many other slang terms for menstruation: on the rag, code red, Aunt Flo, my monthly, that time, etc.

For simplicity sake…lets refer to menstruation as a ‘period’.

Many women mistakenly believe any blood seen between their legs is a ‘period’. This is wrong.

A period is ‘regular, monthly vaginal bleeding’ that usually lasts for a predictable number of days (3 to 7 days). In between periods, women should have 21 to 25 days of no bleeding at all…none.

Some women will have a regular 5 day period…then 8 days later have 2 days of bleeding and say “My period came twice this month!”

No! Your period did not come twice in a month! You had a period and you also had an episode of intermenstrual (between menstruation) bleeding.

Intermenstrual bleeding can signify an entirely different set of problems. Many women with intermenstrual bleeding commonly say they have two periods a month…this is not possible. Intermenstrual bleeding is not a period!

Common causes of intermenstrual bleeding: not ovulating, vaginal/cervical infection, bleeding from hormonal birth control, cancer (cervical or uterine), pregnancy, or an abnormal growth (uterine polyp or fibroid).

Having intermenstrual bleeding does not mean you have irregular periods. You can have both regular periods and intermenstrual bleeding.

So…if you are having bleeding in between your periods you have intermenstrual bleeding….and that usually means a different set of problems than when you have irregular periods.

Let’s focus on irregular periods.

Common causes of irregular menstrual bleeding: pregnancy, being perimenopausal, or not ovulating.

So if you are skipping entire periods entirely…then you are:

  • pregnant (take a pregnancy test)
  • perimenopausal (between the ages of 45 to 55)
  • not ovulating

So all you need to do it take a urine pregnancy test (repeat in 1 week if negative) and figure out your age.

  • If you are not pregnant… then you are not ovulating.
  • If you are not pregnant and between the ages of 45 to 55 then you are not ovulating and you are perimenopausal.
  • If you are not pregnant and between the ages of 45 to 55 and have not had a period for 6 months then you are menopausal.

Simple…isn’t it? How can you tell if you are or are not ovulating?

How to tell if you are ovulating: The “Poor Woman’s Test”

You don’t have to do an expensive test to determine if you are releasing eggs. All you need to do is perform the “Poor Woman’s Test” for ovulation.

All you need for this test is a pencil and a calendar…or in today’s time….a cellphone with a calendar program or an ovulation tracking app!

The ‘Poor Woman’s Test’ relies on simple counting and observation.

Counting: The first day of your full period is day #1… most women will release an egg days 12 through days 16 after their periods starts.

Observation: Do you have a full period when expected? If so you ovulated and you are not pregnant.

Did you miss your period entirely? If so take a pregnancy test and repeat in 1 week if the first test was negative. If both tests are negative then 1) you are not pregnant and 2) you did not ovulate this month.

It is very common to not ovulate…if you don’t ovulate you won’t have a period. Problems with ovulation can start off in teenage years or problems with ovulation can also develop as you become older and, especially, if you gain weight.

Now you know understand the “Poor Woman’s Test’ to determining if you are ovulating. Here is the Poor Woman’s Test in its simplest form:

  • If you have a regular period you are ovulating.
  • If you don’t have regular periods you are not ovulating.

How to tell if you are ovulating: Use an ovulation app

Most people think the ovulation app on the cell phone is a great way to detect ovulation. Wrong!

You tell the ovulation app when your period starts. The app then starts counting and tells you when you are expected to ovulate…all the phone does is count. You can do the same thing with a pencil and a calendar.

Siri and your cell phone don’t know what is happening inside your body….maybe in 10 to 20 years Siri will know…but at this time Siri doesn’t know Jack about YOUR BODY’s monthly ovulation.

Apps for ovulation are helpful but they can’t tell you if you are actually releasing an egg…. they just tell you when you should be releasing an egg.

How to tell if you are ovulating: Basal Body Temperature Testing

Basal Body Temperature testing is one way to document ovulation testing. It is a crappy way…but it is a way!

Basal is resting…so your Basal Body Temperature is your resting, usually in the morning, body temperature.

checking-basal-body-temperature-for-ovulationYour body temperature often drops slightly before ovulation. Your body temperature then rises slightly after ovulation. After ovulation your ovaries make more progesterone hormone and the increase in progesterone hormone causes your body temperature to rise slightly.

Some women use the information obtained from their body temperatures to help detect…not predict… ovulation. They key word is detect…because when you detect ovulation with temperature testing…it has already happened. You may have lost your window to become pregnant.

The main problem with Basal Body Temperature testing is that it is a much harder test to do reliably. You must take your temperature the same time every day. Your body temperature can be changed by many different factors (drinking coffee, seasonal allergies, viral infection, taking a hot shower or bath, going outside in January, going outside in July, etc etc).

The are two main problems with Basal Body Temperature testing:

  • Body temperature can be influenced by many other factors
  • Basal Body Temperature does not predict ovulation… it detects ovulation…often after you have already released an egg. A rise in your basal body temperature usually means you have already released an egg 24 to 48 hours before the detected rise in your body temperature.

As a physician I have never recommend patients do Basal Body Temperature testing because I think the modern methods are more accurate, easier to perform, and give better information.

When I hear someone is doing Basal Body Temperature then I usually know a very, very old health care provider gave them that information. There are better tests out there ladies….dont waste your time with body temping unless you are bored and need something to keep you busy.

How to tell if you are ovulating? Blood tests for LH or Progesterone

You can also go to your doctor and asks for a blood test. I don’ recommend this but technically it can be done. Your doctor can test your LH hormone or test your progesterone hormone.

Blood LH testing. The problem with testing for LH hormone is you would have to get blood drawn every day. Also the results might not be made available to you for 12 to 72 hours after the blood was drawn. Not only would you get stuck with a needle for several days but you may only know about ovulation after it has occurred.

Blood Progesterone testing. The problem with testing for progesterone hormone is that progesterone hormone levels only rise after ovulation. So same as with daily blood LH testing, you would need to get stuck with a needle daily and a rise in your progesterone hormone can tell you that ovulated that month but it won’t let you know exactly when you ovulated.

Most infertility experts recommend testing your progesterone level on three (3) separate occasions during the last two weeks of your cycle to confirm ovulation and the quality of that ovulation…so a single progesterone blood test may not be sufficient.

Best way to tell if you are ovulating? Urine LH Surge Testing

lh-surge-testing-will-detect-ovulationThe best way to determine if you are ovulating is to test your urine for LH hormone. More specifically you are not testing your urine for the presence of LH hormone but you are trying to detect the surge (in increase) in LH hormone.

To test for LH surge you can use a readily available over the counter Ovulation Predictor Test Kit…some people refer to these tests as OPK’s.

Using an OPK test is easy to do and can help predict timing of ovulation.

How does ovulation happen?

We can’t have an intelligent conversation about ovulation if you don’t understand the actual hormonal process.

Ovulation happens about 12 to 16 days after your period starts….but how does it happen?

Your brain starts your cycle by secreting FSH (Follicle Stimulating Hormone). The FSH tells the ovary to start getting an egg ready for release. Ten to twelve days after your period starts your brain knows ‘it’s about time’ for the egg to be ready and the brain will release a surge of both FSH and Luteinizing hormone (LH)…this is referred to as the FSH/LH surge.

The ovary can detect the FSH/LH surge by sensing the presence of these hormones in the blood stream. It is simple:

  • You have a LH surge and you will release an egg that month
  • You don’ have a LH surge and…guess what…you don’t release an egg that month

Scientist have taken advantage of the brain’s hormonal signaling and developed a urine test for LH hormone. When LH hormone is detected in the urine above a certain amount then ovulation will happen within 24 to 48 hours. If LH hormone is not detected in the urine then you will not ovulate.

To understand why we DO NOT recommend FSH testing: Pregnancy and FSH Levels: Understanding a Crappy Fertility Test!

LH Surge and Ovulation: Ice Cream! Ice Cream!

To help people better understand FSH/LH surge and ovulation let’s use an analogy: the neighborhood ice cream truck.

When I was a kid the ice cream truck would usually (not always) come every day…and the truck would usually come between 2 and 5pm. If that truck did not come…we would be depressed little kids for the rest of the day.

Monthly ovulation and ovulation testing are very similar to kids waiting for the neighborhood ice cream truck.

best-ovulation-test-is-lh-surge-testingScenario #1: Aren’t serious about ice cream? Then you would go about your day as usual. If the truck came and you were outside…then you may or may not get some ice cream depending on your mood and how much money you had in your pocket.

This is very similar to how it is for most younger couples. They have sexual activity with no serious plans to get pregnant quickly. If they get pregnant then great and if they dont get pregnant they aren’t stressed about it and they just keep trying.

Scenario #2: Want ice cream and you were not that smart of a kid? The dumb (or super eager) kids would go outside and sit in their yard from 12noon (just in case the truck came early) and play outside in the hot sun until about 6pm (just in case the truck came later). If the truck came they got ice cream at the expensive of wasting 6 hours of their time in the hot sun. If the truck never came that day then they would be depressed …and they would have wasted 6 hours of their time in the hot sun.

This is very similar to people who use a calendar for ovulation counting or an ovulation predictor app on their cell phone. The have an approximate idea of when they are ovulating but they don’t know for sure when during that actual time frame they are releasing an egg.

Scenario #3: Want ice cream and you are a serious and smart kid? The smart kids would get another kid or an adult to be a look out. The smart kids would say, “Call me when you hear the music of the ice cream truck!” When they got a call they knew the truck would be there soon. They would also leave the windows open or listen out for the kids screaming…if they heard the music and heard kids screaming “Ice cream! Ice cream!” then they would know that truck is on the street and they had a certain amount of time to get outside and get their ice cream. Once the truck left you would be too late and have to wait until the next day.

Scenario #3 is similar to the people who perform urine LH ovulation testing. They know for sure if they ovulated that week and they know within a very narrow time frame when they are going to ovulate.

Now you understand LH surge testing to detect ovulation:

  1. Scenario #1: Not really stressed about getting pregnant…just do your normal thing and if ovulations happens then it happens and you may of may not get pregnant.
  2. Scenario #2: Do the Poor Woman’s ovulation test/ovulation app… have sex on the days you think you ovulate (96 hour time frame) and hope for the best.
  3. Scenario #3: Do the urine LH surge testing…. test your urine for LH hormone surge to determine ovulation within a 24 hour time frame and make the best use of your time.

Using the ice cream truck you can also better understand observation bias.

  • If you don’t really care about getting ice cream then you may not have noticed if the ice cream truck came that day or not. This is how my patients recall how easy it was for them to get pregnant when they were younger…maybe it was not that easy and you just didn’t focus on it that much?
  • If you really really wanted ice cream that day…and the truck did not come you would have noticed this and been focused on your disappointment for the rest of the day. You probably would have complained to your friends and your parents as well. This is how some of my patients comment about how much harder it seems to get pregnant after tubal reversal surgery….because they really want ice cream and when the truck does not come the notice it, dwell on it, and can’t get it out of their mind.

So if you really want to know if you are ovulating and really want to be able to better predict ovulation then do the urine LH surge tests…otherwise known as Ovulation Predictor Tests kits or OPKs.

Instructions for Urine LH Surge Testing

The biggest problems I see with patients is they don’t follow the instructions exactly as written.

You should always follow the instructions included with the LH test kit you are using.

The instructions for LH testing and urine pregnancy testing are not a cooking recipe. You can’t change it up…add a pinch of salt…or more spice…or let it cook longer to get a different result. These are medical tests and not recipes. The instructions need to be followed exactly for the results to be valid.

Think of testing instructions like recipes for franchise restaurants. McDonalds wants all of their food to taste the same and be reproducible across all of their stores. They have recipes that only their stores can use and you have to follow them exactly. You can’t change them. Medical test instructions are exactly the same.

The most common problem people have with LH testing and pregnancy testing is they don’t follow the instructions.

Please follow the instructions included in your testing kit exactly.

When do you start testing?

To know when to start testing for ovulation, you need to keep good track of your periods. Always refer to the instructions included with your kit to determine your cycle day length and the best time for you to start urine LH surge testing.

When you start testing depends on the length of your individual cycle. You want to start testing several days before your expected ovulation. The shorter or longer your cycle….then you may ovulate earlier or later than the average woman.

Most women have 7 days of bleeding with a 21 day interval on no bleeding. If this is you then you have a 28 day cycle.  Most women with a 28 day cycle will ovulate on day 14. This means LH surge usually happens day #12 or day #13.

The first day of vaginal bleeding is considered day #1. If you have a 28 day cycle then you should start testing your urine of cycle day #11.

  • If your cycle is shorter than 28 days then you should start testing earlier than day #11.
  • If your cycle is longer than 28 days then you should start testing later than day #11.
  • If your cycle is 40 days or longer or you skip entire months…then you are wasting your time testing your urine for something that is not happening. Your body is telling you that you are not ovulating and you should consult with your doctor and obtain treatment to help you ovulate regularly.

Urine LH Surge Testing: General Instructions

The following are general instructions for urine LH surgery testing. Please refer to the instructions included with your ovulating testing kit for specific details.

  1. First morning urine should not be used with this test. For best results, you should test around the same time each day.
  2. Urinate into a clean, dry cup or container.
  3. Remove the test strip from the pouch.
  4. Hold the test strip in a vertical position with the arrows pointing downward. Dip the test into the urine approximately 1/4 inch and hold it there for at least 5 seconds. Do not dip past the stop line.
  5. Remove the test strip and lay it down flat. Wait 5-10 minutes.

Again…the instructions for lab testing are not like recipe instructions. You cant change things to suit your fancy. Follow the instructions exactly.

Don’t use first morning urine for LH testing?

Pregnancy test are best when done with your mornings first urine. LH urine test should not use first urine of the morning.

Urine pregnancy test. If you are doing a urine pregnancy test you want to use your first urine of the morning because you are more likely to see a positive result and not miss a pregnancy.

Your kidneys filter your blood throughout the night and excrete the waste products into your urine. Your morning urine has been collected overnight and has concentrated amounts of waste products and hormonal chemicals being excreted by your body.

A urine pregnancy test detects HCG hormone. You only make HCG hormone when you are pregnant. The urine pregnancy test is designed to give you a “Yes” or “No” response.

If you have HCG then you are pregnant and most people want to know about it.

If you don’t have HCG then you are not pregnant. So it is better to use a morning urine to detect small amounts of HCG that could be collected overnight so you can get that real “Yes” or “No” answer.

LH surge ovulation testing. In comparison to the pregnancy hormone, LH is released almost every day of the month. You are not trying to detect LH when you test…you are trying to detect the SURGE…or the rapid increase of LH.

LH levels slowly rise the first half of your cycle, surge for 1 to 2 days, and then slowly decrease over the remainder of your cycle.

If you use your mornings urine you may see a false result because you are testing urine that may have more concentrated LH hormone because your kidneys have been working overnight and filtering out the small amounts of LH hormone. Your urine will be more concentrated with LH and give you a larger amount and falsely turn your urine LH surge test positive.

Test the same time every day

Testing the same time every day gives you more consistent test results. It also prevents you from testing multiple times a day.

If you test every hour you may gradually see the color of the line increase…you may even have 6 strips that all look the same and this makes it hard to determine when the surge is occurring.

So although it may seem like a good idea to test every hour on the hour for the entire day you are expecting to ovulate… DON’T DO IT!

The gradually increasing darkness of the lines will all look similar and your eyes won’t be able to see a difference. If you think you see a difference then you wont be able to detect the actual surge of LH.

Read test at recommended time: Earlier or later is not better

Most instructions say read the test result in 5 to 10 minutes. This means less than 5 minutes is too early….and more than 1o minutes is too late!

If the test is positive…most tests will turn positive quickly and you won’t have to guess. If it has not turned positive by 10 minutes then you have a negative test result. Throw it in the freakin trash…don’t take a picture of it with your ring or a negative image with you cell phone, post it on social media and ask all your friend what they think! They often only tell you what you want to hear.

Some tests will begin to have chemical reactions when exposed to air. The lines will turn faintly positive. Again if you come back 1 hour later and the line looks positive when it was clearly negative in the first 10 minutes…it is probably a testing artifact and not real. This is why the the test kit manufacturer gives you specific instructions to follow. Follow the directions exactly!

If you have a true positive it should be obvious….you should be able to see a positive result with your naked eye! You dont have to squint with your eyes, take a picture with the faint line inside your wedding ring, take a negative image with your smart phone camera, or hold it up to a black light to see a positive result!

Positives are easy to see and you won’t have to guess.

Stop Testing After You Detect The LH Surge

Some people get a positive LH test and they just keep testing for the rest of their cycle? Why…I have no earthly clue but many women do it. I guess they figure the more the better….”‘Just wanna’ make sure, right?”

Remember the ice cream truck analogy….would you continue to stay outside and wait for more ice cream after the once daily ice cream truck has left the neighborhood? Only the dumb kids would do that.

Your test will continue to remain positive for most of the rest of your cycle because your LH levels have peaked and are slowly dropping. Further testing of your urine will show positive test results until your LH levels drop below the detection limits of your test strip.

Some women continue to test because they think it tells them something about their ovulation or the sex of their baby or lets them know if they are having twins….none of these are true!

Once your test turns positive…your body has just had it’s LH surge. Just like a solar eclipse….once it happens then that is it…its over until the next solar event.  Once you get a positive LH surge test then stop testing for the remainder of the month.

What if your period does not start? Too irregular to count?

This is a common question. If your period does not start then you should take a pregnancy test. If the urine pregnancy test is negative then you are not pregnant. If your periods are that irregular then you are definitely having problems ovulating.

If your periods are all over the place and you have skipped several months…then your body is telling you that you are having a problem with ovulation. You do not even need to do the urine test. Just pick up the phone and call your doctor to be evaluated for irregular ovulation. They will need to conduct a careful medical history and check your hormone levels. Most likely you will need medications to help you ovulate.

Are there any medications that can interfere with urine LH testing?

Clomid, hormonal treatments, tetracycline antibiotics, hormonal birth control, and fertility treatments containing LH or hCG may affect the results of LH testing. Most medications will not cause a problem with the LH test.

What does a positive result mean?

If you followed the test instructions exactly and get a positive LH surge test then your body is going to release an egg within 12 to 36 hours. This is the best time to have sexual intercourse to increase your chance of getting pregnant.

The egg will be released roughly 24 hours after the LH surge. The egg can only live for 24 hours without being fertilized.

It may be a good idea to have sexual intercourse when you get a positive test result and then at least 2 additional times after that 12 hours apart.

Some people want to have sex every hour….dont do that. Your husband’s sperm production is like the back of a toilet…you can only pull the lever so many times to get a good flush. Give the guy a little break before you ask him to flush again.

The idea behind having sex when you get a positive result (essentially before the egg is released) is so that sperm can arrive at the end of the tube and be ready for fertilization to increase your chances of conception.

Okay I Am Ovulating…Now What?

If you have detected ovulation during a given month then congratulations. You did what most reproductive age women should be doing…which is…releasing an egg every month. Don’t stop with one positive ovulation test.

Have sex and hope for the best. Most people dont realize this but if you have sex on the day of ovulation and everything is perfect…meaning good sperm and good ovulation…then guess what? You only have about a 10% chance of getting pregnant that month…so keep trying. It may take a full year of trying before you see a positive pregnancy test.

You should also be documenting consistent, monthly ovulation. Ideally you should do ovulation predictor test for six (6) months continuously to prove you are ovulating every month and not skipping sporadic months.

Crap I Am Not Ovulating! What Should I do?

If you are not ovulating then you need to see your doctor for evaluation. Your doctor will need to take a careful medical history and perform an exam. They will also need to test your thyroid and prolactin hormones. They should also do a urine pregnancy test  (just to be certain).

Many doctors will want to check your FSH, LH, estrogen and progesterone hormones. Keep in mind these hormones change throughout your cycle….checking these hormones is usually a complete waste of time. Some doctors even want to do complicated calculus type calculations of LH to FSH ratios….another complete waste of time.

  • Do you report irregular and sporadic periods that are hard to keep track of? If so then you are not ovulating.
  • Are you overweight and do you have acne and male like hair growth…meaning hair on your upper lip and chin requiring you to shave or have hair removal? If so then you may have Poly Cystic Ovarian Syndrome (PCOS)…which is an extreme version of not ovulating.
  • Have you gained weight recently and your periods have become irregular? If so then you have weigh gain induced problems with ovulating.

Not ovulating: What can be done?

It depends on the cause of your irregular ovulation. If you are not ovulating then you need to have your thyroid and prolactin hormones tested.

If your thyroid tests are abnormal then you may have hypo (under) or hyper (over) active thyroid disease as the cause of your irregular ovulation. You should have your thyroid disease treated and see if your natural ovulatory rhythm resumes.

If your prolactin is elevated then you may have hyperprolactinemia (pituitary disease) as the cause of your irregular ovulation. You will need to have your prolactin hormone level lowered and see if your natural ovulatory rhythm resumes.

Do you have acne and male like hair growth? Then you have PCOS. There are a variety of medications that can be used to help treat PCOS.

Have you just gained weight? Then you have increased fat cells that make a weak form of estrogen called estrone…and this is throwing your hormonal balance out of whack. Weight loss and exercise will help decrease your fat tissue, decrease your estrogen levels, and bring your hormonal levels back into balance.

Treatments to help ovulation

Weight Loss

It is amazing how many of my patients want to do things ‘natural’. They don’t want to take ‘medications’ or ‘pills’….except when it comes to weight loss. Then everyone wants a pill or shot in the ass to make them instantly lose weight.

weight-loss-can-help-you-ovulateLosing weight is the best thing you can do to help spontaneously resume ovulation.

Most would prefer to take a pill or get a shot…but the best thing you can do is do it the old fashion way: exercise and lose weight. Why?

Fat cells interfere with ovulation by two main mechanisms: increased estrogen levels and increased insulin levels.

Increased estrogen levels. There are three types of estrogen: estrone, estradiol, and estriol. Fat cells make estrone. Estrone is considered the weakest form of estrogen.

The more fat you have on your body then the more estrone you make…the more estrone you have then the more total estrogen levels your body experiences. This is an over simplification… but the higher your total estrogen levels then the more your hormonal balance is out of wack and it can decrease the ability of the ovary to ovulate.

Increased insulin levels. The higher the amount of fat you have on your body… the higher your body insulin levels. Your body has to secret more insulin to help regulate the fat cells and your sugar levels. Doctors refer to higher levels of insulin as ‘insulin resistance’ and this is the earliest stage of Type II diabetes. Some health care providers refer to this as Pre-diabetes. Higher levels of insulin cause the ovary to not ovulate.

It is important to understand every woman’s body is different and has a different hormonal balance set point. There are many women who are over 300 pounds that ovulate every month like clockwork…never skip a beat….and there are some women who are 110 pounds who may gain 10 pounds and then develop irregular ovulation.

I advise patients if you had regular periods when you were younger and as you became older you noticed your periods became irregular…then figure out about what your body weight was when your periods became irregular. This might be your body’s natural ‘set point’. If you can lose enough weight to get back down to that lower weight level then you may restore balance to your body and restore regular ovulation.

If you decrease the amount of fat in your body then you lower your total estrogen levels, decrease the total level of circulating insulin, and restore your body’s hormonal balance and you may be able to resume natural ovulation without the need for for additional medical treatment.

Gastric Bypass

Gastric bypass is major surgery and no one would ever recommend gastric bypass surgery as a first line treatment for irregular ovulation; however, obesity is a growing epidemic in the United States and this surgery can be a consideration for patients with severe obesity who also have other medical problems as a direct result of their obesity.

Natural weight loss is ALWAYS the preferred and recommended way to lose weight. Natural weight loss means lower your calories, decrease your fat consumption, and exercise (burn more calories).

Gastric bypass should be considered for people with severe obesity (defined as BMI over 40) who are unable to lose weight through exercise and diet modification.

Gastric bypass surgery can also be considered for people who have obesity (defined as BMI over 35) and who also have medical problems that are a direct result of their obesity: high blood pressure, diabetes, sleep apnea, congestive heart failure, osteoarthritis, etc.

You can calculate your BMI using our BMI calculator: Calculator to determine Body Mass Index (BMI)

Studies have shown gastric bypass can immediately improve the health of people even before weight loss begins. Diabetes and high blood pressure can be improved soon after surgery and the reasons why are not clear.

Women who have gastric bypass will lose weight and many will resume natural ovulation if the weight gain is the main reasons for their irregular ovulation.

Gastric bypass surgery can have severe complications ( bowel complications requiring multiple surgeries and death) so this surgery should only be considered when the risk of the obesity and associated medical problems are higher than the risks of the gastric bypass.

Clomiphene Citrate or Clomid

clomid-helps-with-ovulation-and-PCOSClomiphene citrate is the pharmaceutical name and Clomid is the name brand. Clomid is an oral medication that helps your brain/pituitary start the LH surge.

Clomid must be prescribed by a medical professional. Clomid is only taken for 5 days of each monthly cycle.
You must take Clomid on cycle days #5 through #9. Women who take Clomid may have their LH surge and ovulation occur a little later than they normally would. It can be typical for women who take Clomid to ovulate on day #16 rather than day #14.

Clomid is often started at 50 mg per day. If ovulation does not occur on 50 mg then the Clomid dose should be increased to 100 mg per day and if that dose does not make ovulation occur the dose is increased to 150 mg per day. Typically most women will ovulate on 50 mg per day and the rest will ovulate on 100 mg per day.

There is no value to increasing the dosage of Clomid over 150 mg per day. If ovulation is not occurring on the 150 mg dose then you may be Clomid resistant and need additional treatments to help assist with ovulation.

Letrozole or Femera

Letrozole is the pharmaceutical name and Femera is the name brand. Letrozole is an aromatase inhibitor medication that works by decreasing estrogen levels.

femera-is-a-newer-medication-that-helps-with-ovulationLetrozole is the newest medication to help women ovulate…but it is not FDA approved for ovulation assistance.

Letrozole was initially used in the treatment of breast cancer. Letrozole decreased estrogen hormone levels.

Estrogen can cause some breast cancers to be more aggressive…so decreasing estrogen levels can decrease breast cancer aggressiveness and cancer reoccurrence. Letrozole is used in breast cancer patients to decrease estrogen levels and help them better treat their breast cancer. Physician using letrozole soon began to notice that breast cancer patients taking letrozole had higher rates of ovulation after chemotherapy treatment than women who were not using letrozole.

As a result of the observation that women taking letrozole ovulated better, some fertility experts began recommending using letrozole to help women who are anovulatory and were desiring to become pregnant.

It is important to understand the letrozole has not FDA approved to assist with ovulation but the latest medical evidence suggests that letrozole is better than clomiphene citrate at helping women resume ovulation. It is most effective in women who are clinically diagnosed with Polycystic Ovarian Syndrome (PCOS). PCOS is a clinical diagnosis made when a woman is obese, has irregular ovulation, has extensive acne, has facial hair growth in a male like pattern, and has ultrasound evidence of irregular ovulation.

So if you truly have PCOS then letrozole is a better medication to help with ovulation. If you don’t have PCOS then either medication should be okay.

Recent medical studies have demonstrated that letrozole was more effective than clomiphene citrate when used in women with Polycystic Ovarian Syndrome. Fertility experts have recommended letrozole be considered a first-line therapy for ovulation in women with PCOS because letrozole works better than clomiphene citrate.

Metformin or Glucophage

Metformin is the pharmaceutical name and Glucophage is the name brand.

metformin-decreases-insulin-levels-and-body-weightMetformin is a pill used to decrease blood sugar in patients with Type 2 diabetes. Metformin also helps patients lose weight and also decreases circulating insulin levels.

Taking metformin is medically equivalent to exercising. When you take metformin you lose weight and this decreases estrogen and insulin levels. Decreasing estrogen levels help restore your body’s hormonal balance. When you lose weight you are also decreasing your insulin levels. Decreasing insulin levels help the ovary to ovulate better.

Women taking metformin alone may see their ovulation resume without doing anything else.

If you are trying to become pregnant and you have problems with ovulation, most doctors recommend taking metformin along with clomiphene or letrozole for the best results.

Metformin is safe to use in pregnancy. Studies have shown if you become pregnant while on metformin…and stop metformin before 12 weeks of pregnancy then there is a higher chance of pregnancy miscarriage. So most medical professionals advise you not to stop the metformin during the first trimester of pregnancy.

About the author…

dr-monteith-tubal-reversal-specialist-raleigh-ncDr. Charles Monteith is a tubal reversal specialist located in Raleigh, NC. He specializes in providing highly successful, affordable outpatient tubal reversal surgery.

More information: Dr Charles Monteith Tubal Reversal Doctor

If you are interested in trying to become pregnant again after tubal ligation or are having problems from your tubal ligation and would like more information then visit our website:
Tubal Reversal A Personal Choice Raleigh NC

For more information about tubal reversal or vasectomy reversal surgery you are welcome to call his office at (919) 977-5050


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A Personal Choice Tubal Reversal Center is in Raleigh, North Carolina and specializes in tubal ligation, Essure, and vasectomy reversal surgery.

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