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I Am in the Mood for a Chocolate Chip Cookie…Follicles and Ovarian Reserve.

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Who doesn’t like a good gooey, moist, chocolate-filled chocolate chip cookie? The more chips the better, says every part of your body but your tush! The same can be said for the follicles (and eggs) in your ovaries. The more, the better—at least most of the time!

A big part of the fertility assessment is ovarian reserve. You probably hear your fertility doctor throw this term around like it’s candy (or cookies! ): “Your ovarian reserve looks good!” “Your ovarian reserve is not so good.” You may be nodding and thinking, “What in the world are they talking about?”

Ovarian reserve is the medical way of saying how many eggs you have and what their quality is. While most of our assessment comes from hormones and blood work (cue FSH and AMH), a big “bite of the cookie” comes from our ultrasound. This ingredient is as basic as sugar and flour to making a finger-licking calorie worth its cookie.

An ultrasound performed in the early part of your menstrual cycle (a.k.a. the follicular phase) can tell us a lot about what your ovaries have left to give. Is your bag of chips half full, or are you running dangerously low on supply? By measuring the follicles (a.k.a. “chocolate chips”), we can get a good idea about the egg quantity (a.k.a. ovarian reserve). We call this measurement of follicles your antral follicle count (nicknamed AFC).

An AFC is ideally done on day 2–5 of the menstrual cycle. By doing it early, we can catch you at what we like to call baseline. “Home base” is when we can get the best idea about what is going on in those ovaries because no follicles have yet to start running the bases.

Eggs are invisible (to the naked human eye). It doesn’t matter how high we crank the ultrasound waves, we will never be able to see those eggs unless we bust out our microscopes and speed-dial our embryologist friends. Eggs live in follicles. (Picture a dozen eggs that you would buy in a grocery store—the shells cover the eggs. Unless you crack them, you won’t see them.) We need to count follicles to find out about egg number. Although it is an indirect measure of ovarian reserve, it is pretty on point.

We do a lot of ultrasounds. We can look at the screen and pretty quickly size up those ovaries. But a little baker’s secret for all of you laypeople—the little black circles in the ovaries are the follicles. (Anything fluid filled on an ultrasound will be black). The ovaries are usually grayish/white. So put that together, and what do you get? Bibbidi bobbidi CHEW! You probably get the visual at this point…the more follicles (number of chocolate chips) in the ovaries, the chewier they look. The chewier they are, the more eggs you have!

On the flip side (or the less tasty side), the fewer the follicles and the more white/gray ovary, the lower the antral follicle count. The lower the antral follicle counts, the fewer the eggs. It’s a simple as your most basic recipe!

Surprisingly there are some times when cookies can be just too sweet. You know when you take that first bite, and you think, hmm, I can’t go much further? Well, the same goes for ovaries. There are some with too many chips. Polycystic ovaries can have too many follicles or structures that look like follicles. There is a plethora (think many, many bags) of these small follicles/cysts that can impact the regularity with which you ovulate and your ability to make a baby on your own. It can also lead to elevated testosterone levels and cause all of those unfavorable side effects (think hair and pimples).

Back in the day, women with “PCO ovaries” were routinely taken to the operating room to remove a piece of their ovary to cut down on these small follicles/cysts and all the negative things that they bring.

Just like chocolate chip cookies, we all have brands we prefer. Some of us swear by Duncan Hines, while others of us go for the Nestle Tollhouse. And there are those that are out there and like to make them themselves (go, girl, go!). Whatever your sweet tooth desires, there is something to get it going. Ovaries are the same way. Some of us may have chocolate chips galore while others of us are more like a sugar cookie.

While antral follicle count tells us a lot about what your egg number may be, it does not mean that just because your bag needs to be refilled, you won’t have a baby. It just helps us pick the right ingredients (fertility meds) in the right amount to make your cookie!

The Most Unwelcome House Guest: Endometriomas

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When you can’t find your keys, what do you do? Most of us go to the “hot” spots and start searching. Hot spots are those places that you usually, on most days, drop your keys: on the kitchen counter, in the hallway, hanging on a hook in the garage. By hitting those high-traffic key spots, we are pretty likely to find a match.

When looking for evidence of endometriosis, we go to those hot spots, and the ovaries are the hottest of the hot spots. Endometriosis that implants on the ovaries and forms a cyst is called an endometrioma. News flash: endometriomas and the ovaries are not friends; in fact, they are not even frenemies. They are unwelcome guests that can make the ovaries incredibly unhappy. And here’s why.

Intruders are not fun in anyone’s house. This is particularly true in the ovaries that are already dealing with a limited supply of goods (a.k.a. eggs). Endometriosis on the ovaries can range from mild (a few spots) to major (a whopping 10cm, plus a cyst). Usually, the bigger the cyst, the bigger the problem. And although this may be hard or disturbing to picture, what’s inside the cyst bears a close resemblance to chocolate. While we hope that didn’t destroy your love of everything Hershey’s, Nestle, or Godiva, that is what the brown fluid that leaks out of the cyst looks like.

And while it may look like chocolate, it’s more of an inflammatory soup; factors and mediators lurking in this fluid are not pleasant. They’re irritants. They can damage the ovary and eat away at your egg supply—as well as your quality of life. It is for this reason and others that women with endometriosis often experience infertility.

The walls of endometriomas were not built in a day. They are usually quite tough and scarred. In many cases, the ovary-plus-cyst complex is stuck like glue to surrounding abdominal organs (intestines, uterus, etc.). This can make taking them out pretty challenging. Fortunately, surgeons that specialize in endometriosis surgery have a lot of weapons in their armamentarium.

You want to make sure the good guys are fighting for you, and for this reason, make sure you vet your endo surgeon well. Unlike those keys that you couldn’t find, you can’t just get a new ovary copied. If you lose it, it is forever lost. For this reason, you want to make sure whomever you are trusting to “hold them” knows what they are doing.

The good news about endometriomas is that the hot/cold/found-it game is pretty easy. An ultrasound is pretty spot on in identifying what is likely an endometrioma and what is not. On ultrasounds, the cyst/mass will look greyish/white and solid, and it usually has a lot of blood flow. If your doctor is still on the fence about what is plaguing your ovary or needs more information before surgery, an MRI is usually their go to. With these tools in our pocket, we can decide if surgery is needed, what the best approach for surgery is, and how major the surgery will be. It is important to take good before pictures (say cheese!) prior to surgery so that you have a good idea about what the after should look like.

Unfortunately, the recurrence rate of endometriomas is pretty high, especially when the surgeon does not remove the cyst wall in its entirety. Simply draining the cyst doesn’t do all that much for you or for your chances of being cured.

Word of advice…make sure to ASK your surgeon how he or she plans to remove the endo before signing that consent form. The reason for the high recurrence rate of all things endo is that estrogen is fueling its fire. If estrogen is around, endo will grow—sort of like, if you build it they will come. It is for this reason that, for women who do not have babies on the brain (because they are not ready or they are done), we recommend shutting the reproductive system down (pills, Lupron etc.) after undergoing surgery.

Cold, hot, hotter, hottest—you found it! Endometriomas are often a pretty good giveaway for underlying endometriosis. They have no game face, and when present, you can pretty easily guess what’s causing those unpleasant symptoms. While they may not need to be treated unless causing pain or contributing to infertility, they do shed some major light on what may be hiding in the dark in your pelvis. It may be the key to what you experience in the future—make sure you know where you put it!