Does The Pill Lower Ovarian Reserve? (Episode 644)

Full Transcript: Episode 644

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 644.

Does the pill lower ovarian reserve? When a woman comes off the pill, is there a temporary period of subfertility? Well, that’s what we’re going to be talking about in today’s episode. And the answers may surprise you, they may not, but let’s get into what the research has to say about it.

In case you don’t know me, I’m Lisa Hendrickson-Jack, certified fertility awareness educator with over 20 years in the field, teaching women how to chart their menstrual cycles. And since then, I founded the Fertility Awareness Institute, and I train women’s health professionals to use the menstrual cycle as a vital sign and diagnostic tool in their practices. I’m also the author of The Fifth Vital Sign, co-author of Real Food for Fertility. And I have a whole lot to say about this topic. Let’s get into it.

Today, I’m looking at a recent paper that has come out. It is a brief communication clinical commentary on this exact topic. Specifically, it’s about the impact of hormonal contraceptives on ovarian reserve parameters, specifically AMH, anti-Mullerian hormone, and AFC, antral follicle count.

As a starting point, one of the main reasons that this communication was put out is because of the tendency of medical health professionals to diagnose women with conditions like premature ovarian failure based on low ovarian reserve parameters that just so happen to be tested in women who have just come off of birth control. And basically the researchers are saying, look, if a woman has just come off of birth control, we can’t actually conclude that these low results mean that she has a fertility issue. That’s essentially the conclusion.

But let’s talk about why this is important and why it’s even happening in the first place. The first point I want to address is the difference between women’s experience of actually taking birth control and how they’re counseled around it, the information they hear, the stuff we talk about, the stuff that your clients are hearing from their medical professionals versus what the research actually has to say.

Women are typically told that the birth control pill or other hormonal contraceptives, they’re totally safe, they’re reversible. There’s basically no downside. They’re not really taught about any potential risks around it. It’s so commonplace. The numbers are staggering of how many women have taken it throughout their lifetime. It’s a 30 plus billion dollar industry, so it’s kind of like water at this point. No one really thinks about any type of side effects of birth control.

When women are presented with birth control and specifically when they are looking to conceive — let’s say you have a woman who’s been on birth control for 10 years, 15 years, 20 years, whatever. She goes to her doctor and it’s like, okay, I’ve been thinking, my partner and I want to have a baby. I’ve been thinking about coming off the pill. What do you think?

I’ve spoken to countless women over the years who’ve had this experience. And what they’re told is, well, it’s not a big deal. Don’t come off too early. Wait until you’re ready to start trying to come off. Otherwise, you’ll just get pregnant when you’re not ready. And your fertility will come back pretty soon. Just come off, wait until you’re ready and start trying.

Now, this is a very common experience. This is what women are told. But what does the data and research actually have to say about it?

What the study highlights is that there’s a significant body of research that shows that when women are on hormonal contraceptives, that by definition is already suppressing their ovarian reserve parameters. It’s not me saying it, it’s the data and the research saying it. Women who are currently on contraceptives have a lower AMH, anti-Mullerian hormone level, lower AFC, antral follicle count, and even the ovarian volume, the size of the ovaries is actually smaller.

Now, this might seem like, how could this be? Or if this is new information to you — but ultimately, I think part of it is that we don’t really understand how the pill works. If you don’t really understand what’s going on with how the pill is suppressing your fertility in order that you don’t get pregnant, then maybe that’s the reason why people don’t think about this.

When women are on the pill — let’s just say combined oral contraceptives, the synthetic estrogen and synthetic progestins — what’s happening is that the hormones in the pill are suppressing the conversation, the normal conversation that’s happening between the hypothalamus, pituitary gland, and ovaries. And therefore, ovulation is largely suppressed in most hormonal contraceptive options.

If we kind of just focus on the oral contraceptive, the combined one, that is the primary mode of action to actually suppress ovulation. While women are told, oh, yeah, it just makes your body think you’re pregnant. That’s not what’s going on.

When you’re pregnant, you’re producing significant quantities of your natural ovarian hormones, your natural progesterone, your natural estrogen that your body produces are significantly higher to the point that pregnancy is kind of like another puberty because your whole body changes during the time of pregnancy because of the significant influx of hormones that is happening during that time.

However, when you’re on the pill, it’s not your natural hormones. These are synthetic hormones that do not act the same way in your body. What happens is your natural hormones actually are suppressed. If we were to look at the natural hormone production of women, their natural estrogen and their natural progesterone while they’re on the pill — well, and I just said the pill is suppressing ovarian function. They’re not actually ovulating.

What you would find is that the hormone levels in women, their natural hormones while they’re on contraceptives, are actually quite similar to the hormone levels of women who are in menopause. It’s not like, oh, it makes your body think you’re pregnant. It’s kind of like a temporary chemical menopause. And obviously that doesn’t work for marketing purposes, right? It just doesn’t have the ring to it that we’re looking for.

When we look at it from that perspective, then it actually makes sense that women who are on contraceptives would have lower ovarian reserve markers because their ovaries are quite literally suppressed. There’s nothing happening. And they’re essentially dormant.

And I mean, this is great news when you’re trying to avoid pregnancy, right? Because that’s the whole point. If you are not ovulating, you can’t get pregnant. But when we’re actually in that phase of transitioning from I’m not wanting to get pregnant to I actually want to start a family, then we need to start educating our clients and all women need to have this information so that they can then make informed choices.

Back to the point of the paper, the point that I’m bringing up here is that there’s a well-documented period of subfertility post-pill. It doesn’t mean that women can’t come off the pill and conceive, but it does mean that statistically, when we actually look at studies that measure this, there is a period of time where we could say there’s a period of subfertility, meaning that it could take a little bit longer for women to conceive.

And if we look at what is happening with regards to some of these numbers, like the ovarian reserve parameters, it actually takes a minimum period of about 6 to 12 months for the ovaries to fully rebound. And for those ovarian reserve parameters like AMH and AFC, anti-Mullerian hormone, antral follicle count, for those specific markers to rebound and go back into the normal zone, normal levels, that typically is taking anywhere from 6 to 12 months, depending on the study that you’re looking at.

What this means is that there’s a bit of a mismatch between what women are being told — oh, yeah, just wait until you’re ready to conceive — to what’s actually happening. Whether you are a women’s health practitioner and you’re working with clients who are having this experience and they’re starting to get frustrated or they’ve been trying to conceive for a while or they did wait until they were ready to conceive to come off the pill, they’re not incorporating this temporary period of subfertility into their plans.

When they’re coming off the pill, they’re not thinking, oh, I need to come off six months ahead so that my body can rebound and all that. They’re coming off and assuming that they’re going to get pregnant right away because this is what we’ve been told our whole lives. If you’re not on the pill, you’re going to get pregnant immediately. If you come off the pill, you’re going to be pregnant the next day. Oh my goodness, you could have been pregnant while you’re still on it.

And I’m not saying that it’s not — I know we all know someone who’s gotten pregnant on the pill — but I’m saying that what we need to be educating more about is fertility so that we are actually prepared to support our bodies so we actually can have a plan that is in line with what the research actually tells us that’s happening in our body while we’re on the pill and coming off the pill.

The second point we need to consider is how the ovarian reserve markers are used in practice. And again, how ovarian markers are used in practice is very different to what the research tells us.

The way it’s used in practice is that it’s used as a marker of fertility and often used to test women and tell them their chances of natural conception. If women are having ovarian reserve tests and they’re showing low AMH or low antral follicle count, then they’re often told that it will inhibit or impair their ability to conceive or they’ll be told something like, oh, the numbers are so low, you won’t be able to get pregnant.

And they may also be told, oh, your numbers are so low. And if you happen to be kind of younger, then they’ll tell you like, oh, you are possibly going into early menopause. Or they might even tell you that you are in the midst of premature ovarian failure.

Now, like I just mentioned, the research is in on ovarian reserve parameters for women who are using hormonal contraception. If you’re using hormonal contraception, if you’re actively on it and you’re doing these tests — well, A, like why? But if you’re on these tests and you’re doing these tests while you’re taking the contraceptives, then your numbers are going to be low. And they’re low because you’re on it because it’s suppressing ovarian function, right? But it has nothing to do with whether or not you’re going to go into early menopause or whether you can conceive naturally. Because again, the reason that they’re low for women who are taking contraceptives is because of the nature of the contraceptives and their suppressive effect of ovarian function.

That’s one thing, but then the other thing is that when you actually look at the research on these ovarian reserve parameter tests, the AMH level and AFC have actually been found to be better predictors of good candidates for IVF stimulation.

If you have good numbers that are in the normal range, then if you are going through the artificial reproductive technology situation and they are stimulating your ovaries to produce eggs so that they can then retrieve the eggs and fertilize in whatever way they choose to do that, then if your ovarian reserve parameters are good, then that would indicate that you’re a good candidate. If they’re too low, it would indicate that you’re likely not going to get a good yield. And if it’s too high, then you may actually be at risk of overstimulation.

And the research, it’s not divided, and it’s not like one study. There are multiple studies. There are multiple review studies, meta-analyses. It’s just very, very consistent, the literature and what it says about how ovarian reserve parameters are used and where they’re most effective.

The research also is quite clear that even if a woman has low ovarian reserve parameter numbers, it is actually not sufficient to predict her natural fertility because there are plenty of cases on record of women with low or even undetectable AMH levels who then do go on to conceive.

It doesn’t mean we ignore those numbers. If the numbers are low, there’s certainly things you would want to do overall to support egg quality and et cetera. However, it’s not this thing where if your numbers are low, you can’t get pregnant naturally.

If we go back to the study, this is another point that the researchers are making. They’re kind of saying, whoa, whoa, whoa, when you have a woman who’s just come off the pill, you can’t go and tell her that she’s in premature ovarian failure or that she’s not going to be able to have a baby. Because especially if she’s just come off, those numbers take at least six months or sometimes more to fully normalize.

This is kind of like — it’s really fun when newer research comes out to confirm things that we already know. It obviously supports the base of literature around this topic. But certainly, this is one of the things that the researchers are pointing out.

If I take one quote from the paper, the researchers say, quote, current clinical evidence indicate that AMH and AFC are poor predictors of natural or unassisted reproductive potential. And therefore, these measurements should not be performed in women with unproven fertility. They’re kind of cautioning.

I believe that’s one of the reasons that they even wrote this paper because they’re looking at these trends and they’re trying to say, hey, clinicians, chill out. Stop taking these women’s tests right either when they’re on birth control or immediately when they’ve come off and then giving them these sweeping statements about their fertility when it really has nothing to do with it. At least when they’re in that subfertile phase, when they’re in that transition phase.

You could also call it the post-pill transition phase. We need to allow the body to restore normal function after months or years or potentially decades of suppression with hormonal contraception.

Interestingly, in the paper, they actually highlight two different case studies to showcase their point. They’re trying to make their point, sharing the literature and kind of commenting on the body of work that shows this information has been very consistent in research studies. But they’re also then appealing to these specific cases, just to give an example so that people can be crystal clear.

In the first case, there was a woman who was on the pill for 15 years, and they tested her AMH levels and FSH levels two months out. Her AMH was 0.06, and her FSH was 51. AMH way too low, FSH way too high. If we were to just look at those numbers, she may be diagnosed with all kinds of stuff because of poor ovarian reserve markers. She may have been diagnosed with diminished ovarian reserve and told that she couldn’t get pregnant.

Well, when they tested her six months later — so just off the pill, now it’s been six months — AMH 1.64, FSH 5.2. Again, to the point that you can find this in the literature over and over again, that when women come off the pill, they know that these hormones suppress ovarian function. And if we allow that period of kind of restoration, that ovarian function can be restored and rebound and kind of get back into normal ranges.

They go on to say in this case, this woman conceived two children naturally. And even though she had previously frozen her eggs and all of these things that happened, she was actually able to conceive naturally.

And the second case involved a woman who had been using the vaginal ring for 12 years. And when she came off, again, low follicular count, so low AFC, and her cycles were actually irregular. And similarly, the initial assumption may have been something like diminished ovarian reserve.

In her case, it was the opposite. Once her levels normalized, her AMH was actually extremely high because she had PCOS. Actually, in her case, the contraceptives had kind of suppressed the full presentation of her polycystic ovary syndrome, now renamed polyendocrine metabolic ovary syndrome.

In these cases, in both of these cases, it just goes to show — A, the literature is clear on the effect of hormonal contraceptives on ovarian reserve. We know that there’s a temporary effect. It’s not a permanent effect. We also know that the concept of having a temporary period of subfertility post-pill is well established.

And it’s really interesting when you have all kinds of commentary out there in the ether about how it’s not a real thing and blah, blah, blah. When you just look at what the research has to say, I’m just reading what the studies have to say. I’m not making this stuff up, right? It’s showing us that these parameters are known to be suppressed while women are on the contraceptives and when they come off of it, it actually takes anywhere from six months to a year for these parameters to fully resume.

This doesn’t mean that we need to be afraid of this information. It means that we have to be educated about this information. If you are working with women, if you’re a women’s health practitioner and you’re working with women who are planning to conceive and have a history of contraceptive use, this is important information.

And of course, this is where advanced charting strategies come in. Women can actually start charting their menstrual cycles, start paying attention to what’s happening, identifying when ovulation is taking place and looking at these trends and even tracking how their cycles are rebounding during these transitional periods.

And this is a huge opportunity for women’s health practitioners to really deepen their knowledge of the menstrual cycle to be able to support their clients through this.

And for women who are going through this, just the first step of actually knowing — wait a minute, if I’ve been on the pill for a long time, it might make sense for me to come off even when I’m not ready to get pregnant and use an alternate non-hormonal contraceptive for a period of time so that I can allow my cycles to resume and kind of allow them to normalize following years, potentially, in some cases, decades of contraceptive suppression of your natural menstrual cycle.

That brings us to the end of today’s episode. If you enjoyed today’s episode, please do share it with a friend. You’ll find the show notes and all additional information over at fertilityfriday.com. And of course, as always, until next time, be well and happy charting.