Measuring and interpreting Blood hCG to Assess Pregnancy Viability Following ART Treatments

I know of no medical announcement associated with the degree of emotional anticipation and anguish as that associated with a pending diagnosis/confirmation of pregnancy following infertility treatment. In fact, hardly a day goes by where I am not confronted by a patient anxiously seeking interpretation of a pregnancy test result.

Testing urine or blood for the presence of human chorionic gonadotropin (hCG) is the most effective and reliable way to confirm conception. The former, is far less expensive than the latter and is the most common method used. It is also more convenient because it can be performed in the convenience of the home setting. However, urine hCG testing for pregnancy is not nearly as reliable or as sensitive e as is blood hCG testing. Blood testing can detect implantation several days earlier than can a urine test. Modern pregnancy urine test kits can detect hCG about 16-18 days following ovulation (or 2-3 days after having missed a menstrual period), while blood tests can detect hCG, 12-13 days post-ovulation (i.e. even prior to menstruation).

The ability to detect hCG in the blood as early as possible and thereupon to track its increase, is particularly valuable in women undergoing controlled ovarian stimulation (COS) with or without intrauterine insemination (IUI) or after IVF. The earlier hCG can be detected in the blood and its concentration measured, the sooner levels can be tracked serially over time and so provide valuable information about the effectiveness of implantation, and the potential viability of the developing conceptus.

There are a few important points that should be considered when it comes to measuring interpreting blood hCG levels. These include the following:

  • All modern day blood (and urine) hCG tests are highly specific in that they measure exclusively for hCG. There is in fact no cross-reactivity with other hormones such as estrogen, progesterone or LH.
  • Post conception hCG levels, measured 10 days post ovulation or egg retrieval can vary widely (ranging from 5mIU/ml to above 400mIU/ml. The level will double every 48–72 hours up to the 6th week of gestation whereupon the doubling rate starts to slow down to about 96 hours. An hCG level of 13,000-290, 0000 mIU/ml is reached by the end of the 1st trimester (12 weeks) whereupon it slowly declines to approximately 26,000– 300,000 mIU/ml by full term. Below are the average hCG levels during the first trimester:
    • 3 weeks LMP: 5 – 50 mIU/ml
    • 4 weeks LMP: 5 – 426 mIU/ml
    • 5 weeks LMP: 18 – 7,340 mIU/ml
    • 6 weeks LMP: 1,080 – 56,500 mIU/ml
    • 7 – 8 weeks LMP: 7, 650 – 229,000 mIU/ml
    • 9 – 12 weeks LMP: 25,700 – 288,000 mIU/ml
    • A single hCG blood level is not sufficient to assess the viability of an implanting embryo. Caution should be used in making too much of an initial hCG level. This is because a normal pregnancy can start with relatively low hCG blood levels. It is the rate of the rise of the blood hCG level that is relevant.
    • In some cases the initially hCG level is within the normal range, but then fails to double in the ensuing 48-72hours. In some cases it might even plateau or decline, only to start doubling appropriately thereafter. When this happens, it could be due to:
      • A recovering implantation, destined to develop into a clinical gestation
      • A failing implantation (a chemical pregnancy)
      • A multiple pregnancy which is spontaneously reducing (i.e., one or more of the concepti is being lost) or,
      • An ectopic pregnancy which will either absorb spontaneously (a chemical-tubal gestation), or evolve into a full blown tubal pregnancy continue and declare itself through characteristic symptoms and signs of an intraperitoneal bleed.
  •  The blood hCG test needs to be repeated at least once after 48h and in some cases it  will need to be repeated one or more times (at 48h intervals) thereafter, to confirm that implantation is progressing normally.
  • Ultimately the diagnosis of a viable pregnancy requires confirmation of the presence of an intrauterine gestational sac by ultrasound examination. The earliest that this can be achieved is when the beta hCG level exceeds 1,000mIU/ml (i.e., around 5-6 weeks).
  • Most physicians prefer to defer the performance of a routine US diagnosis of pregnancy until closer to the 7th week. This is because by that time, cardiac activity should be clearly detectable, allowing for more reliable assessment of pregnancy viability.
  • There are cases where the blood beta hCG level is extraordinarily high or the rate of rise is well above the normal doubling rate. The commonest explanation is that more than one pregnancy has implanted. However in some cases it can point to a molar pregnancy  
  • Finally, there on rare occasions, conditions unrelated to pregnancy can result in detectable hCG levels in blood and urine. They include ovarian tumors that produce hCG, such as certain types of cystic teratomas (dermoid cysts) and some ovarian cancers such as dysgerminomas.

1,351 Comments

mH

Hi Dr. Sher, my betas were tripling nicely but suddenly, they are taking much longer.
At 5w2d (23dpo)- 4100
5w5d (26 dpo) – 7450
Is this an impending problem, do you think? Thank you and bless you

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Mh

I forgot to add – I had an ultrasound on 5w5d and gestational sac and yolk sac were seen, but fetal pole was not.

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Dr. Geoffrey Sher

It is not unusual to see the betas slowing down with regard to increase, once the level reaches 5,oo! This alone is not very concerning to me.

Geoff Sher

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Mangostree

Hello Sir,
I was on just one round of clomid 100 mg last month and I got positive on 18th march.
My hcg level on:
19th march was 225,
24th march was 2972,
and 28th march is 12414.
.
I know hcg levels in itself aren’t definite indicative of twins, multiples, but still just curious to know your expert opinion whether it could be twins/multiples?
My US is not until next two weeks due to lockdown. Just anxious and seeking your opinion. Please oblige.

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mangostree

Also, 19th march was
15th dpo, when I got hcg level as 225.
Thereafter, 20th dpo and 24th dpo respectively.

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Vishu

In my 10 week but no pregnancy symptoms, im on progesterone pills and shot…i had a miscarriage in past so im paranoid that baby is not growing and because of progesterone im not even bleeding, what are the chances that progesterone can mask a miscarriage from happening…my clinic is closed for indefinite period coz of this virus thing so my scan is also cancelled

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Dr. Geoffrey Sher

Hi Vishu,

I previously responded to this post, stating that the the progesterone is unlikely to mask an inevitable miscarriage.

Geoff Sher

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Dr. Geoffrey Sher

So sorry!

Trisomy 9 is an extremely rare chromosomal developmental defect . I have never seen this before. I would wait another 3-4 weeks and do an amniocentesis before acting…but of course that would be up to you to decide.

Geoff Sher

Geoff Sher

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Victoria Tumolo

Hello doc! I had my hcg drawn at 12DPO (March 25, 2020). My level was 77. I’m concerned that is too low. Any opinion? Thank you!

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Dr. Geoffrey Sher

This is still acceptable. I suggest you repeat this in 2 days to see if it will double.

Geoff Sher

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Lauren Andrade

Complete molar pregnancy 8 months ago. Got okay to try again 6months after molar which was Janurary 2020
Positive pregnancy test march 14th
Hcg at 10dpo =10
Hcg at 13dpo =101
Hcg at 19dpo=1545
19dpo progesterone 9.69ng/lm

What do you think do you think based off those numbers my pregnancy is viable?

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Robyn

I am 9 weeks pregnant accordingly to the date of my last period – I had my HCG levels tested on Friday 20th March and again on Monday 23rd March and the level had only risen from 150,000 to the early 160,000 – I am having another blood test tomorrow Thursday 26th March so hopefully it has risen more – are these results normal or something to worry about as I am completely unsure.

I would appreciate a response.

thank you!

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Dr. Geoffrey Sher

That could well still be acceptable. The rise in hCG levels tend to slow down after 5-6 weeks and then tail off. US serial assessments are far more reliable.

Good luck!

Geoff Sher

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Marissa H

Hello Dr Sher! Hope you are well. I somehow got a positive beta doing a natural cycle. I ovulated on cd7, so super early, and didn’t have much hope. My Hcg has been tripling nicely every 48 hours. betas: 156 – 600 – 1500 – 4100. My only problem is my estrogen has been very low. It was 25 with no estrace. Now taking 4 mg of estrace a day, and it’s 125. Do you think this points to an unviable pregnancy given the estrogen? I am on oral and vaginal progesterone and it’s around 45.
Thank you for your time!

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Dr. Geoffrey Sher

I suggest you do a beta hCG test and then repeat in 2 days to see if the levels are increasing appropriately.

Geoff Sher

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Marissa

thank you! My beta hcg is doubling, but estrogen remains low. What is your opinion on the importance of estrogen in regards to viability? Thank you!

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Dr. Geoffrey Sher

In my opinion, as long as the hCG keeps rising appropriately, progesterone is >10ng/ml, you still are in the running for a favorable outcome.

Geoff Sher

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Mel

Hi there. My beta came back today it is 689 and I am 11dp5dt. Can you tell me if that is in the normal range?

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Dr. Geoffrey Sher

It is on the high side…Could be a multiple?

Good luck and G-d bless!

Geoff Sher

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Renee Smokovich

I had a beta test today at 6dpt5dt. Hcg was at 0.5 which went down from my first beta test at 4dpt5dt from 1.5. Is this drop due to The trIgger shot wearing off? Or is it not a good outcome?

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Dr. Geoffrey Sher

Hi Renee,
I regret to have to tell you that this is unfortunately a failed implantation!

So sorry!

Geoff Sher

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Chels

Hi Dr Sher,
I live in a small rural town and do not have my first obs/gyn appt until end of April,2020. I am 10 weeks 3 days today (23/3) have had some brown discharge with pelvic pain for the past 5 days, my HCG on 20/3 was 92,000 and dropped to 75,000 on 21/3. I had an ultrasound on 20/3 and bubs was right size with heartbeat of 160bpm. My GP has said that dropping HCG is a sign for impending miscarriage. Are they correct in this diagnosis?

Thank you so much for your time and expertise.

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Dr. Geoffrey Sher

At this stage of pregnancy, hCG levels can fluctuate. You cannot go by the hCG alone. Ultrasound will be more reliable at this stage….in my opinion.

Geoff Sher

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Chels

This has given me a glimmer of hope and fingers crossed all is still well, as it was at last scan 3 days ago. My GP is organising another ultrasound for this week and i’m pending a 3rd HCG BT results from today. We’ll take every day as it comes. Thanks Dr Sher, really appreciate your time.

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Mabel

Hi Dr. Sher,

I had a 5 day blastocyst transfer on 10 March, and the hcg test only showed a level of 10 on March 20. Will do another test in 48 hours. Can i ask if the hcg level is the only criteria? Shall i request for a progesterone test as well? When shall i make decision to give up? Can i start a new IVF cycle immediately?

Many thanks,
Mabel

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Dr. Geoffrey Sher

I do not personally believe that measuring progesterone will matter. I would however, not give up until repeated hCG tests and/or subsequent US done 2-3 weeks from now, discounts a pregnancy. Thereafter, my advice is to take a break for one full cycle before re-engaging.

Good luck and G-d bless!

Geoff Sher

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Sreeja Pradeep

Hi Doctor,
I am Sreeja, since 2 days i am waiting for your valuable answer. 2012 underwent open ovarian cystectomy, 2016 got married and after 2month ectopic salphinjectomy left done because there is adhesion of the open surgery. Tried 2 years ovulation induction and IUI, but failed, HSG done, and my doctor told that tube filled with dye but only some spillage is present to the peritoneum, there may be a distal block and he adviced 2 options, HLS to assess tube or IVF. Which is suitable for me. Will HLS help to remove distal block? I am eagerly waiting for your reply.

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Dr. Geoffrey Sher

You need IVF but if you have a hydrosalpinx, this should be addressed beforehand. Talk to your RE.

Geoff Sher

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Janelle

My hcg was 256 on March 5th. On March 17th at 3pm it was 2566 and on March 20th at 11 am it was 2839. Is there something wrong? Can I still have a healthy pregnancy. My last period was feb 5th

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Dr. Geoffrey Sher

This is a slow rise. Only time and ongoing testing can determine if this is a viable or non-viabl3e implantation.

Good luck!

Geoff Sher

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Destiny L.

Hi!. My IUI was 2/29/20.
3/16 was 212
3/18 was 590
Are those good numbers? What’s the likelyhood of twins with the numbers almost tripling in right at 48-49 hours.

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Jenny

Hello!

I had a single, 5 day transfer on 3/11/20. Beta HCG on 3/20 was 131, and repeat done on 3/24 was >1000. Im wondering your thoughts on this rise, is it a fast rise in your opinion?

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Dr. Geoffrey Sher

I suspect this is a healthy pregnancy on the make!

Good luck!~

Geoff Sher

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Priya

Hi Dr. Sher,
This is my first IVF cycle. 2 embryos were transferred at 5th day on Feb 26. I am now at 5 weeks and 5 days after LMP.
I had my first beta 7 days later. Progesterone was 29 on March 16. HCG levels were:
March 4 – 45
March 12 – 744
March 16 – 1300
March 18 – 1669

My RE initially said she was happy with the numbers and now says she is concerned that the number from March 18th isn’t higher and that I need to have an US to check. What are the chances this is still a viable pregnancy? What do you think is happening?

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Shara

Hi Dr,
My IUI was done on 02/29/2020. My hCG:
03/13 — 27
03/16 — 31
03/18 — 88
Do you think it is a viable pregnancy?

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Dr. Geoffrey Sher

It is too early. Repeat the hCG in 4 days , it should quadruple if OK. Then do an US in 2.5 weeks from now for a definitive answer.

Geoff Sher

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Shara

Thanks for your reply. I was curious to know even if this ends up as a viable pregnancy, does the low hCG mean that the fetus may have disabilities? Or there is no such connection?

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Dr. Geoffrey Sher

There is not necessarily a connection. However, a lot will depend on measurable, progressive developmental parameters. Discuss with your RE and Perinatologist..
Geoff Sher

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Christe Anastopoulos

Hi Dr. Sher,
I am officially freaking out! Any success stories with HCG not fully doubling? Or similar numbers?

10dpo (3 weeks 3 days)
Beta HCG: 37

13dpo (3 weeks 6 days)
Beta HCG: 140

17dpo (4 weeks 3 days)
Beta: 292

My last beta reflected HCG doubling every 3 days & 18 hours
(2 days increase 44%)

Going in for another beta tomorrow…
I have gone off the deep end reading studies….I have found 3 different opinions. Some studies say 60% increase in 48 hours, some say 50% and I saw another that said the threshold should be lowered to 35% increase in 48 hours. What are your thoughts on this being a viable pregnancy with the numbers above?

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Dr. Geoffrey Sher

I wish I could assure you that all is well Christe, but that is not possible. You will have to wait another 2 weeks and do an ultrasound. In the meanwhile ask your doctor to keep an eye out for a tubal (ectopic) pregnancy. I am not suggesting that this is what is happening but rather be safe than sorry. Report any pain, light headedness or bleeding to your doctor.

My thoughts and prayers are with you.

Geoff Sher

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Christe

Thanks! I’ll keep you posted. Just so anxious and sad regarding the last beta…. I had a MC in Sept and a second MC on Thanksgiving 2019. This is now my third pregnancy and no baby yet. I really hope the Beta’s make a turn for the positive.

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Christe

Got my results back. It went from 292 on 3/16 to 526 on 3/18
2 Day change = 80.1 % increase.
Doubling time =2.4 days or 56.53 hours

Hopeful?

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Zee

My betas have started slowing down. I’m 6w2d today and they’ve gone like this:
25dpo: 4689
27dpo: 7024
30dpo: 11732
The last two readings have a doubling time of 97hours. Does this look like it’s failing? A sac was seen in uterus at 5w5d
Thanks

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Dr. Geoffrey Sher

Not at all! At this stage of pregnancy the rise in beta hCG level slows down.

I think all is well!

Good luck and G-d bless!

Geoff Sher

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Lily

Hi,

I had two miscarriages before, now had a positive pregnancy test with 66 hcg 13dpo. I haven’t done a second test but just concerned that 66 is low. What do you think?

Thanks!

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Dr. Geoffrey Sher

Do a second test in 2 days to see if it doubles.

Good luck!

Geoff Sher

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Ali

Hello Dr Sher

Transferred two Embryos on 2/23/20

My Betas are

3/2/20 370 8DPT
3/6/20 2205 12DPT
3/9/20 6478 15DPT (Two weeks)

Is this a normal progression? Could it be multiples ?

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