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HCG ( also known as beta HCG or just beta) is a very special molecule. It's unique in that it's produced only by the placenta ( very very rarely, it's also produced by some ovarian and testicular tumours). This means that for all practical purposes, it's found only in pregnant women and is therefore a very good marker for pregnancy.

Since the HCG is produced by the placenta, the levels of HCG rise as the pregnancy develops, and there is very good correlation between the health of the pregnancy and the HCG level for the first few weeks of the pregnancy ( from about week 4 - week 7, as calculated from the LMP, last menstrual period).

However , it can be hard to make sense of your HCG blood levels. Let's look at some of the pitfalls in monitoring your beta levels.

Most patients naively assume that a beta of more than 1 mIU/ml means that it's positive and that they are pregnant. This is not true. The new kits are very sensitive , and even men can have levels of upto 10. This means that a level of less than 10 mIU/ml should be considered to be negative.

Secondly, remember that the HCG is produced by the placenta and not by the fetus. This means that the HCG levels may rise , even if the pregnancy is not viable ( such as an anembryonic pregnancy or a missed abortion).

Since HCG levels rises exponentially, there is a very very wide range of normal. This is why it's very hard to interpret just one level in isolation . It's important to check at least 2 levels at least 48 hours apart to determine the trend . In a healthy pregnancy, the levels should double every 48 - 72 hours. If they do not do so, this suggests your pregnancy may not be healthy.

It's not possible to determine whether the pregnancy is single or multiple based only on the HCG level. While it's true that HCG levels are higher in multiple pregnancies than in singletons, because there is so much overlap, you cannot jump to any conclusions based on the HCG level alone. This is why it's important to interpret the HCG level in conjunction with vaginal ultrasound scanning results.

Also, normal ranges can vary widely from lab to lab, because they use different kits. This is why it is important to check your HCG level from the same lab each time !

Finally, HCG levels are useful only in the first 7 weeks of pregnancy. After this, ultrasound scans are far more useful because they provide much more information about the location of the pregnancy; how many sacs there are; and whether the fetus is growing or not.

NORMAL SINGLE PREGNANCIES

Day after HCG or LH ( DPO)	Average mIU/ml	High mIU/ml	Low mIU/ml	#
14	48	119	17	12
15	59	147	17	18
16	95	223	33	23
17	132	429	17	21
18	292	758	70	19
19	303	514	111	23
20	522	1690	135	13
21	1061	4130	324	12
22	1287	3279	185	22
23	2034	4660	506	13
24	2637	10000	540	16

The information in the table above is part of a study carried out by Dr. Sherbahn

In normal healthy fertile females, ovulation with rupture of the mature ovarian follicle and release of the eggs occurs within 38 hours of the surge in luteinizing hormone (LH). However, in a small percentage of women, the dominant follicle will undergo the luteinization process but will not rupture following the midcycle LH surge. This is called LUF (luteinized unruptured follicle syndrome). As a result of the increased progesterone secretion, the endometrium undergoes the secretory changes, but, obviously, without the release of the oocyte , pregnancy cannot occur. This means that the cycles are regular; and hormonal studies ( Day 21 progesterone level) , the basal body temperature curve, and the findings in an endometrial biopsy will all be consistent with ovulation.

This is obviously a difficult diagnosis to make; and can only be made by serial vaginal ultrasound scans to track ovulation. These scans show that the follicle matures; but the dominant follicle fails to rupture. The lack of follicle rupture and the lack of free peritoneal fluid around the time of ovulation are used to establish the diagnosis of LUF. This condition is also called “trapped egg syndrome”.

LUF is more commonly seen in women with endometriosis; and PCOD. Often the diagnosis is made only when patients are being monitored for follicle tracking with serial ultrasound scans. LUF is a “silent” problem; and because it does not cause any symptoms or signs, it’s very easy to miss the diagnosis as well ! Since LH is responsible for inducing follicular rupture, LUF can be treated by giving an injection of Human Chorionic Gonadotropin (hCG) in a dose of 10,000 IU intramuscularly, when the lead follicle reaches 18-20 mm in diameter. Ultrasound can be used to document ovulation. It takes about 36 to 40 hours for the oocyte to be released after the injection. Intercourse or insemination should be timed accordingly. If it still does not take place, the dose of the hCG injection can be increased. If ovulation still cannot be achieved even with an increased dose of 20000 IU , then IVF is the best solution.

In our clinic, we really do not bother to make a diagnosis of LUF ! This is because this diagnosis does not really change your treatment options . After all, if you are infertile, this means the eggs and sperm are not meeting. The next step logically is to then do an IUI – and since an HCG injection is routinely given during IUI treatment to induce ovulation, the IUI automatically helps to treat patients who have LUF !

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Many infertile women have irregular cycles and they know that the reason for their infertility is related to their irregular cycles. However, many are quite confused as to the relationship. Some naively believe that if the cycles are regularised, their fertility will also automatically improve ! This is why they waste months taking birth control pills, without trying to address the underlying problem !

Today, we know that the commonest cause for irregular cycle is PCOD - polycystic ovarian disease. Unfortunately, many gynecologists blindly diagnose every patients with irregular cycles as having PCOD , without bothering to rule out other possibilities !

Let's look at some basics.

Women who ovulate regularly get regular periods. The reason a woman's periods are irregular is because she does not ovulate. This is called anovulation. While it is true that the commonest cause of anovulation is PCOD, it's equally true that this is not the only cause. A good doctor will do a careful workup to evaluate ovarian reserve, in order to determine what the reason for the anovulation is.

Thus, in some women the reason for the anovulation is poor ovarian reserve - a condition called the oopause. However, if this is mis-diagnosed as PCOD, precious time is wasted and the patient never gets a chance to get the right treatment !


If you have irregular cycles, please insist that your doctor do the following simple medical tests.

1. Blood tests for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs).

2. A vaginal ultrasound scan on Day 3, which should check for the following.

a. ovarian volume
b. antral follicle count

Patients with PCOD typically have a high LH:FSH ratio; a high AMH level; large ovaries; and increased ovarian stroma with many small antral follicles.

Patients with poor ovarian reserve, on the other hand, have a high FSH:LH ratio; low AMH levels; small ovaries and a reduced antral follicle count.

If you are not sure how to interpret your reports, please send me your medical details by filling in the free second opinion form , and I'll be happy to help !