Hormonal Contraceptives and Ovarian Reserve (Episode 511)

Full Transcript: Episode 511

Lisa Hendrickson-Jack: This is the Fertility Friday Podcast, episode number 511.

I’m excited to share part two of my three-part series, “The Impact of Hormonal Contraceptives on Fertility” today. And so in case you missed last week’s episode, last week’s episode really focused on the impact of contraceptives on the menstrual cycle. And when I talk about how contraceptives may affect fertility, there are always a few different ways to look at it, depending on what the research shows. And that’s essentially what this three-part series is looking at. One of the ways we can look and see is how does the pill affect menstrual cycle parameters. So when a woman comes off of the pill, how long does it take for her cycle parameters to normalize? So that’s what we covered in last week’s episode. And in this week’s episode, we’re looking at a different question. We’re looking at how does the pill impact the ovaries and ovarian function and ovarian reserve parameters. And so I think this is also an interesting angle to take, again, looking at what the research has to tell us, because a lot of what we’re told as women is, oh, it doesn’t matter and oh, it doesn’t affect you and everything goes back to normal, but we’re not necessarily being given an actual breakdown of what the research has to say and what impacts we are aware of.

So the question really that we’re looking at is what do we know? We must know something. The pill has been on the market since the 1960s. So we must know something about how the pill could affect fertility. So we’re looking at it in relation to these specific questions. And so this doesn’t mean that these are the only questions to ask, but I think these are three interesting ones. And so the first dimension is how does the pill impact the menstrual cycle? The second is how does the pill impact ovaries and ovarian function and ovarian reserve parameters, which we’ll deal with today. And then the third, which we’ll deal with in our next episode, is how does the pill impact time to pregnancy. And so again, these are all very interesting studies. And this is something that I mentioned in last week’s episode, but interestingly, all three of the studies that I chose to examine in the series, they are actually looking at — they’re breaking down the results month to month. So in last week’s study, they had women who had recently come off of contraceptives and they were actually looking at their cycle parameters month by month. So they were looking at, you know, cycle one off of contraceptives, cycle two off of contraceptives, and they were looking at, okay, how long is the cycle or how long is the luteal phase or what’s going on with the mucus or whatever. But they’re looking at that on a cycle-to-cycle basis. They’re not simply taking a data set and looking at everything at the 12-month mark, which is very common in this area of research. And similarly, in today’s study, the period of time the post-pill transition phase is actually broken down. So they are taking information and testing these women in month one post-pill and month two post-pill, etc., and making those distinctions and giving us that nuance. And like I said, I think it’s really fascinating when the researchers take this approach.

So let’s jump into it. A little bit about this study — it’s got a super long title so I won’t read it, but you can head over to the show notes page if you want to take a look at fertilityfriday.com/511. But in this study, what I find really interesting is that in order to get this data, I had to think about where’s the money in this research? It doesn’t benefit hormonal contraceptive manufacturers to share this type of information — that the pill has a suppressive effect on ovarian function. And so interestingly, this study was looking at fertility preservation in particular. So for those of you who may not be familiar, fertility preservation is the word for when women, for one reason or another, are wanting to preserve their eggs. So it’s like having half the IVF without that other part where they’re going in and extracting the eggs. And then from there you can decide how you want to store them. So some women will extract the eggs themselves and store them that way. Some women, if they are partnered, may then make embryos and then store the embryos. And so either way, this is an interesting study because these women, for one reason or another, are seeking this. So it could be that they’re single and they want to preserve their eggs in case — which is getting more common — and other women may have been using fertility preservation prior to undergoing a more severe medical treatment like a treatment for cancer or something like that.

And so essentially what happened in the study is that these women were then on contraceptives and they were coming off contraceptives and their ovarian reserve parameters were being measured. And they were looking at if being on the pill has a suppressive effect on their ovarian reserve parameters, and also if it could have a negative effect on the yield of eggs. And so just for a brief mention — in Real Food for Fertility, we go into the question of anti-Müllerian hormone and ovarian reserve parameters in significant detail in our egg quality chapters. So in chapter 10 of Real Food for Fertility, we really go into this in a ton of detail. So just to give you a little bit of background, some of the common ovarian reserve parameters that are tested would be things like AMH, anti-Müllerian hormone, and AFC, antral follicle count. And what’s interesting is that unfortunately this information is often used to discourage women who are trying to conceive naturally. So many women who I’ve worked with have been told if their AMH levels are low or low for their age group that it means they won’t be able to conceive naturally. But interestingly, what the research actually shows us is that there’s a link between the ovarian reserve parameter numbers like AMH and a woman’s ability to have a successful IVF procedure. So what that means is that if your AMH levels are low, then you’re less likely to stimulate well and get a good supply of eggs when they do the egg retrieval. And if your AMH levels are normal, then you’re much more likely to have a good result — meaning that if your AMH levels are normal and they go in to do an egg retrieval, you’re much more likely to get a good number of eggs. And on the flip side, one of the characteristics of PCOS, for example — polycystic ovarian syndrome — is characterized by having a large number of follicles that are not really developing. So you have these ovaries that are full of these little ovarian cysts, essentially at an earlier stage of development but they’re not ovulating. And so as a result, women with PCOS commonly have elevated antral follicle count, and they often as a result have an elevated AMH for their age category. And when they have this elevated AMH, they’re more likely to overstimulate. So interestingly, AMH has more predictive value for artificial reproductive technology and how well a woman will stimulate and how many eggs she might get in that procedure than it does for natural conception. So that was a bit of an aside for those of you who might not be familiar with all these terms.

But to bring it back to the study — again, you have a group of women who are looking to preserve their eggs. So they’re looking to come off birth control, do this procedure, get a good amount of eggs, to store them, to freeze them for future use. And what did they find? So one thing that is well-known and that you can find in a variety of studies on this topic is that when women are on hormonal contraceptives, hormonal contraceptives suppress ovaries. So if you listened to last week’s episode, this is what we talked about — the main modes of action. And so if you think about that, it’s suppressing ovaries, it’s suppressing ovarian function. So is it a stretch to think then that the pill could have a temporarily negative effect on a woman’s ovarian reserve parameters? Well, no, it’s not. So that’s one thing that’s very consistent — that we find that women who are currently on contraceptives do have lower ovarian reserve parameters. So I’ll just read from Real Food for Fertility here, in the pill chapter: in one study assessing ovarian parameters of 887 women aged 19 to 46, the ovarian volume of hormonal contraceptive users was 49.6% lower, AMH levels were 19% lower, and antral follicle count was 18% lower. So women on hormonal contraceptives — the ovarian volume means the ovary shrunk by 50% on average, that’s what it means to put it bluntly. AMH levels were just under 20% lower in these women, and then the antral follicle count was 18% lower. So while you’re suppressing the ovaries and they’re not doing anything — they’re basically in a dormant state similar to that of a woman in menopause — these ovarian reserve parameters are lower.

So when you look at the study that we’re looking at today, they were asking the question: if a woman comes off of contraceptives, knowing that it suppresses these ovarian reserve parameters, is it possible that that would have a negative impact on the oocyte yield? So if they come off the pill and do the procedure right away, are they going to have less eggs? And what the researchers found when they measured them month by month was that the best outcomes in this particular study happened for women who waited about six to seven months before they had their procedure. Because when they waited for the ovarian reserve parameters to normalize over that first six to seven month period, they ended up having much higher AMH levels — the AMH levels not necessarily totally back to normal, but definitely in more of a normal range — the antral follicle count, and all of those things. And so they found that the women who actually gave themselves a little buffer period, a little transition time, had better results and more specifically had more eggs retrieved as a result of the procedure.

So going back to the study, the researchers divided the participants into three groups. So one group were women who had never used contraceptives, one group were women who were coming off of contraceptives and then immediately went to do the egg retrieval procedure, and the other group was what they termed the break group. So they had the no-break group that just went straight to the procedure, and then they had the break group who took one or more months to allow their cycles to normalize a little bit. And interestingly, there’s a brief comment in here that the researchers basically say that they were tracking their patients and looking at the characteristics of their patients, and some of them obviously were going straight off of birth control and then doing the procedure, and others were waiting. And so they started to see the trend. It says here it was in January of 2012 that we chose that as the starting point, because that’s when we began to suspect that combined hormonal contraceptives could be leading to ovarian suppression. This observation led us to offer patients the option to take a break from the contraceptives prior to ovarian stimulation. So they were already starting to see that when women came off birth control and went straight to doing the procedure, overall they were having less success in terms of number of eggs that they were retrieving. And similar to other studies, the researchers found that women who had been on contraceptives, particularly those who had been taking it long-term, had lower ovarian reserve parameters overall — lower than expected antral follicle count, lower than expected AMH. But again, it’s across studies — it’s not new information, nor is it rare information to find. It’s quite well established that women who are taking contraceptives, especially long-term, do have this temporary suppressive effect on their ovarian reserve parameters.

So what the researchers found is interesting here. They’re talking about antral follicle count in particular — so how many little follicles there are toward the beginning stage of the menstrual cycle. And they say antral follicle count appeared more likely to rise in the 61 women in the break group who started with a less-than-expected antral follicle count. In these 61 women, AFC — antral follicle count — nearly doubled after the break from hormonal contraceptives. So they’re telling you that when they’re looking at the number of follicles that are developing in the ovary, the women who took a break from hormonal contraceptives before going on to having the procedure done had nearly a doubling of the number. And this is something that they found to the point that they started recommending that women looking at doing fertility preservation take a break. Interestingly, they have a heading that says it takes up to about six months to improve AFC — antral follicle count. It says overall the antral follicle count increased in approximately 80% of women, and approximately 60% of these women noted a normalization of their antral follicle count. So what they found was: by two months, 25% had some increase; by four months, half of them had reported an increase; and by six months, the majority of women had seen a bit of an increase. So they’re showing you, interestingly, with their results that as time passes — if a woman comes off contraceptives and they’re monitoring her ovarian reserve parameters — over time there’s this gradual increase. And again, this is supporting what we’re saying, that the pill is associated with a temporary reduction in overall fertility as evidenced by the impact it has specifically on the ovaries.
And so what I find interesting about this study is then from the perspective of these clinics that are offering fertility preservation: if you are wanting to support women to have these procedures and collect and store eggs, then it’s going to be in your best interest that these women actually get a good yield of eggs. And if any of you have ever looked into these procedures, you know they’re not cheap — they’re very pricey because it’s a big investment. And so from that perspective, given these results, it makes sense that they said in their study that they started to see this trend: women who were taking a break from contraceptives were getting more eggs, having more successful outcomes, and it was allowing their ovarian reserve parameters to normalize. And then they started offering women this option to take a break. So meaning that if you want to get your procedure done in June, maybe you need to consider going off the contraceptives in December or January or something like that to give yourself time.

Now what is the most infuriating about this piece of information is somehow this is not carried over to the average woman who’s trying to conceive naturally. I have not heard really this advice being given to women who are then trying to conceive by the conventional medical establishment. Because if you and your partner are thinking about starting to try in the fall — I always give that example — then why are you not told, maybe you should consider coming off of contraceptives early in the year, like January or February? Because what the research tells us is that it takes anywhere from — in this particular study they went up to about six to seven months. So arguably there’s a need for those other studies that look at what would be the impact if we looked at a 12-month period. If we had a group of women with a large sample size of women coming off the pill, and we were measuring those ovarian reserve parameters monthly from month one to month 12 post-hormonal contraceptives — would we continue to see an increase even more?

Because again, I speak to so many women on a regular basis, and I’ve spoken to many women who have had that test done right after they come off the pill. And even that’s not a good idea if you think about from what you’ve learned in this episode so far. If you’ve recently come off the pill — it’s not within a month or two — it’s not a great time to get your ovarian reserve parameters tested, given that we know that the pill suppresses those parameters. What could happen is that they’re likely going to be lower than what they’re going to be in a few months, and you could then be told all this information — that you won’t be able to conceive, or it won’t work, or you’re not a candidate for IVF, or whatever you’re told. And meanwhile, if they just waited like the six to 12 months, then they would get more of a normal-for-you idea of what’s going on, because that would allow time for these parameters to normalize post-hormonal contraceptives.

So again, going back to the action steps — what is the practical application of this information? And for the average woman, the practical application is just more evidence that we should be taking a period of time between our pill and when we’re trying to conceive, if possible. Especially if you’re planning ahead for pregnancy, this gives you the option to really start to consider your choice of birth control. And so from a practical standpoint, your body then obviously needs this time to just normalize the ovaries specifically. So today’s episode was focusing on the ovaries, and one of the ways to look at the impact on the ovaries would be looking at that follicle count, antral follicle count, looking at that AMH number, and even looking at the ovarian volume — which is known to be reduced so significantly. That’s one of the scary stats, that the pill shrinks your ovaries by half, right? It’s like it makes for a really scary tagline. And one thing I always want to stress is that none of these studies indicate that these results are permanent. When we’re looking at this type of study and this type of information, these factors, they do reverse. It’s not to say that we’re seeing evidence to show that they’re permanent. But we are seeing that it takes a period of time. And so based on what we’ve seen so far, the nine to 12 cycle period of time that it takes the menstrual cycle to normalize, and then, according to this particular study, it was six to seven months. But again, they didn’t necessarily go well beyond that. They just found that at about the six-month mark, a lot of women had a plateau — the antral follicle count wasn’t continuing to improve at that stage. But in this study it doesn’t appear that they were specifically measuring the AMH level — they were focusing quite heavily on the AFC, the antral follicle count.

So there’s room for another study that would actually look at all three of those factors in women post-pill, compare them to women who were not on the pill or who’ve taken a break from the pill, and see what’s going on there. Because I think there’s a lot more we can learn. But the takeaway I would say is that we definitely need some time for the ovaries to normalize. Now, does this mean that you wouldn’t be able to conceive? That’s not what it means. In order to conceive, you need to have a menstrual cycle with ovulation. So I always love to clarify when I’m talking about this topic that we’re not saying that pregnancy is going to be impossible, or that you have to have a perfect cycle to get pregnant, or that everything has to be in perfect alignment and all of your parameters have to be great. That’s not the case, because there are plenty of women who conceive when things are not all perfect. Things do not have to be perfect. You do not need a perfect cycle to conceive. But when we’re looking at how do I optimize fertility — if I have a bit of a time window here, what can I do to really just give myself the best chance — because when things are not optimal, it does relate to the overall picture. There are all of these pieces of the puzzle: your health, the health of your endometrial lining, your partner’s health — all play a role in not only the development of your baby, but even the placental development and all of these other factors that contribute to your likelihood of having a healthy pregnancy, a healthy baby, and the whole picture.
So when we’re looking at these questions, we’re not looking at this black and white — like, will you be able to get pregnant or not? Because sometimes even in circumstances that are not optimal or perfect, pregnancy can still happen, of course. And we’re thrilled when that can happen because pregnancy is only happening when your body is strong enough to make that happen. But with that said, we also want to look at this question. So after everything I’ve told you today, I think that there’s enough of a rationale for us to say, well, in an ideal circumstance, if we had the ability to plan ahead, it would make sense to actually give ourselves a little buffer period between coming off the pill and starting to conceive — even just to let the ovaries normalize, for those parameters to get more established, and for everything to rebound. Especially if you’ve used the pill long-term, because again, the pill has been suppressing that ovarian function. It makes sense: give your ovaries a moment to catch themselves and start making those hormones again, and get some of those ovarian reserve parameters normalized, to really optimize your chances of having a healthy egg, a healthy baby, and the best possible start for your little one.

So I’m going to wrap this up here. I hope that you enjoyed today’s episode, the second part in my three-part series. And so next week, we are going to tie this up with a little bow. We’re going to really go into the time-to-pregnancy study that I wanted to share with you — which is: how long does it actually take to conceive? Is there a difference between when you’ve come off the pill versus if you have not been on the pill? And spoiler alert — there is a period of subfertility that is known to be associated with pill use, particularly long-term pill use. And so again, this information can just help to inform us about what our choices are when we are in that phase of planning ahead for conception. To take a much deeper dive into this topic, make sure to head over to realfoodforfertility.com. You can find out more information about the book. We go into a ton of detail, not only into the pill, but also how to support your body to prepare for preconception — nutrition, egg and sperm quality — we go into a ton of detail about the topics that we’re talking about today. And also, of course, we dive into using fertility awareness techniques to optimize your chances of fertility. So lots of great information there. Again, realfoodforfertility.com, or you can head right over to Amazon and search “Real Food for Fertility.” So with that said, I hope you have a wonderful week — whenever you’re tuning into the show — and of course, as always, until next time, be well and happy charting.