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.

435 Comments

Crystal

Hello Dr!
I had two 5 day embryo transfer completed last week Tuesday (Oct. 16). I had my first beta HCG test done 8 days later on Wednesday, (Oct. 24th) and the result was 246. I had my second beta HCG test done today Friday, (Oct. 26th) and the result was 487. Not quite a “full” doubling so I will retest on Monday. Thoughts?

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Teresa

I was 4 weeks and 2 days on October 19 (based on the date of my IUI). My HCG level was at 29,448, then on Oct 22 it increased to 51,145. I did take Follistim, would that have any effect on why my HCG levels are so high for 4 weeks and 5 days? Those numbers look very high! If it’s not the Follistim, I am fearing the worst which is a molar pregnancy. Any advice or information would be great appreciated. Thank you!

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Dr. Geoffrey Sher

If you took the Pregnyl after you were already pregnant this could at least in part explain the high hCG level. But perhaps you are carrying twins. Have an US ASAP.

Good luck!

Geoff Sher

P.S. I don’t think it is molar.

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BP

Hi Dr. Sher,
What is your opinion on testing frozen embryos? I have nine left that I froze when I had just turned 36 and they have good ratings – most are one 1AA a few are slightly lower. I just had a chemical pregnancy after my first FET and I would rather avoid that again if possible, but I understand that it may be risky to the already frozen embryos. Thank you in advance!

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Dr. Geoffrey Sher

While pregnancies are reported through such secondary testing, it is my opinion that the thaw for biopsy…the refreeze to await a result and finally another thaw to transfer takes its toll and is ill-advised. I advise against it. Most importantly, testing will definitely not improve embryo quality. It is only a selection process.

Geoff Sher

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Naz

5 day frozen embryo transfer,
At 10 days hcg 553 and at 14 days (4 days later) 5833. Doubling rate 28 hours. Should I be concerned? We only transferred one?

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Dr. Geoffrey Sher

Likely one implanting but there is the possibility of it having split into 2 (uniovular twins).

Good luck and G-d bless!

Geoff Sher

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Danielle

We transferred two (2) fair quality Day 6 frozen blastocysts from a prior cycle on 8/13. My hcg level 7dpt6d was 25.9 (8/20). Retested on 8/27 (14dpt6d?) and the hcg level was 915. What are your thoughts on this rapid rise within 1 week?

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Jen

I’m concerned that at 12dp5dt hcg was 1302, then at 14dp5dt hcg was 2311. It was 46hrs in between blood draws. I’m almost 40, and we transferred 2 fresh untested “beautiful blasts.” We had 3 remaining blasts that we sent for PGS/frozen. Those results came back that only 1 of the 3 is normal. This makes me think that the odds for the current pregnancy aren’t so great if only 1 out of the remaining 3 is normal, coupled with the HCG that didn’t double. I’m 15dp5dt today, and scheduled for ultrasound at 19dp5dt.

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Dr. Geoffrey Sher

Hi Jen,

I understand your consternation. However, unfortunately the answer will have to wait for an ultrasound confirmation.

Good luck!

Geoff Sher

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Jen

Just an update- @19dp5dt- hcg was 15,660 E2- 2787 and P4- greater than 60. I was told to stop taking Estradiol at this point. 2 gestational sacs were found (one measuring 5w1d and the other 5w2d). Now we have to wait and see if both develop.

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Candice

I was wondering if you could give me your thoughts on my low hcg levels.
10 dpo- hcg 20, Prog 42
12 dpo- 34
14 dpo- 54
18 dpo- 149
20 dpo- 314
24 dpo- 1472
26 dpo- 1887
28 dpo- 3298
33 dpo- 6817
I have my first ultrasound in a week. Does this look promising? I’m concerned that the levels are low (even though they are considered normal on beta charts). Thank you for your time!

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Dr. Geoffrey Sher

It is an abnormal rise. Unfortunately you will have to wait for the ultrasound result!

But there is a chance….?

Geoff Sher

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BP

Hello Dr. Sher,
Thank you so much for your post about interpreting hCG results! This is a better explanation than I have gotten from my doctor and nurses! I am currently 10dP5dt with my first FET. I have had one loss last February after a Clomid cycle and positive tests and betas (although slow rising) up to 4 weeks, but nothing showing up on ultrasound followed by another loss after a spontaneous pregnancy in March, when we were able to see the sac on the ultrasound at 6 weeks, but nothing ever developed in the sac. We had the products of conception tested showing trisomy 16 for that loss. We had genetic blood testing, revealing nothing, and I also had recurrent loss testing revealing a “borderline” anticardiolipin AbIgm level of 16, for which I’m now on Lovenox (plus baby aspirin). We froze embryos two years ago and decided to use them now as we have six grade one AA embryos frozen! I got a positive HPT the night of 4DP5 DT and The lines have been getting darker every day, but my first Beta today at 10dp5dt was only 23.6. I know you need to know the rate of increase to be sure and I’m going in again in 2 days, but do you think there is still a chance? If so, is it only a small chance? My doctor’s office is not giving me much hope.

Thank you!

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BP

Forgot to mention – my progesterone was 11.9 today I am on twice daily Crinone and Pio shots every other day. They said that it is OK that my P4 was only 11.9 because the Crinone “does not show up in the blood“.

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Dr. Geoffrey Sher

The earliest and the most important indicator of IVF outcome is the blood beta hCG level. It is first measured about 10 days after egg retrieval with fresh (conventional) IVF, 10 days after ovulation in natural-cycle IVF and 10 days after initiating progesterone in embryo recipient cycles (frozen embryo transfer-FET; embryo donation; egg donation transfers; and embryo donation). The 1st measurement should be >10MIU/ml. This value should (roughly double every 48 hours until about 6 weeks into gestation and thereupon rises more slowly. Failure to follow this trend and sequence, usually is the result of failing implantation (a chemical pregnancy), an impending early miscarriage and in cases where the level continues to rise but erratically or slowly, could also indicate a tubal (ectopic pregnancy). If the level rises faster and more than doubles in the early stage of pregnancy, it could suggest a multiple gestation and if it sky-rockets upward to very high levels in the early stage of pregnancy it could suggest a molar pregnancy. In cases where the level starts high, then drops down for a day or two whereupon it resumes the doubling effect every 48 hours it may indicate that a multiple pregnancy has reduced spontaneously, to a singleton. In rare cases, the beta hCG might initially be undetectable or start off <5MIU/ml and thereupon start doubling appropriately, culminating in a viable pregnancy. This is why it is important to measure the hCG level at least twice before discounting a viable pregnancy being on the make.

Good luck!

Geoff Sher

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Elle

Hi Dr. Sher,
Asking for your help/opinion all the way from the Netherlands… We did a double FET (4BB and 2BB blastocyst) on 9/6/2018 and I received my first beta 8dp5dt, it was only 18. Didn’t expect anything very hopeful but got really surprised when my beta 11dp5dt turned out 140 and 13dp5dt 363. Should I be hopeful?

Kind regards, Elle

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Patel

Hello Dr

I have done fet this month. My first beta at 9dp5dt is 31. Second beta at 11dp5dt is 63. Progesterone level is around 20. I am so worried. Is this viable pregnancy?

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NIKO

Can clexane injection influence beta hcg test, depending on time blod was taken after this thetapy.. Meaning that after injection concentration can be a bit lower? Thank you

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Kiki

My beta 10 days past 5dt of 2 Perfect blasts was 998
5 days later it was 7,357.
Doubling rate of 41 hours.
Should I be worried about molar pregnancy? Is that even possible with IVF?

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Dr. Geoffrey Sher

Not really! However a multiple pregnancy is very possible!

Good luck!

Geoff Sher

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Kiki

Thank you Dr.! This is my first time being pregnant after 7 years of TTC and I think I am paranoid!

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Dora

sir LMP 1st July 2018, iui 13,14th July … but ruptured on 14th July with free fluid . July24th positive on clear blue preg test digital . 26th July beta HCG 82 repeat 28th July 252 … August 1st 696 … I’m worried about the last one . And August 1st early morning had very minimal brown discharge (very light brown) . Anything to worry . I’m on susten injection once a week and everyday susten tablet 300 mg … today 32days since LMP…

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Dr. Geoffrey Sher

I do not think…… so but I suggest you discuss with your RE.

Geoff Sher

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Kelli

I have just gone through my first ivf cycle (after 6 failed iui’s – 2chemical pregnancies over the past year) and received a beta of 45 at 7 dp5dt of a 3AA embryo. I know the doubling factor is what matters most, and I’ll be getting another beta tomorrow. What are your thoughts about a beta of 45 at this point? Thanks so much for your help!

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Kayte

Hello; 4th round of IVF; 5dt on 7/9/2018. First hcg was 14dp5dt 331 then exactly 48 hrs later 16dp5dt is 655. I go back in 2 days to do another beta test. Nurse doesn’t seem worried, BUT google has gotten the best of me, and I see ladies who are 5 weeks, like I am supposed to be today with numbers in 1000’s should I be worried?

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RS

Hi dr Sher.
I did a transfer of a day 6 blastocyst exactly one week ago and because of spotting had an early blood test this morning. The level came back as 6. Can you tell me if this is a chemical at this stage? I’ve been told to keep taking the medications and repeat the test on Friday (48 hours from now).

Your answer is so appreciated. Thank you in advance.

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Dr. Geoffrey Sher

You should repeat the hCG assay in 2 days. If it doubles (or better), you could still be in the running. However this is a very low level of hCG and it is quite likely that the pregnancy is not viable.

Geoff Sher

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April

Hi Dr. Sher,
I did a FET 5 day embryo transfer on 6/29/18. My first beta was (7/11/18) 141, 48 hrs later it was 323, 72 hours later 939.8 and then 72 hrs after that one it was 1572. Very concerned about this last one it did not double at 72 hours, i have another one on Monday 7/23/18. Have you seen where the beta slows down picks up again? Or could this mean i will miscarry. I am 5 weeks and 5 days

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Dr. Geoffrey Sher

I think this could still turn out fine. Have an ultrasound in 7-10 days.

Geoff Sher

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Melly

Good afternoon doctor, I just received a call today from my clinic 9days post FET. My beta came back at 5.8…they said it’s a very very low positive and to stop all meds immediately….do you think there is still hope? Should I ask them to check me again in 48 hours to see if my levels rise? Is this too low to ever end up in a viable pregnancy??? Ive been crying for the past 3 hours and am feeling hopeless…this would be my second failed IVf after going through failed IUIs and being on meds for a year now while ttc for about 2 and a half years….

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Dr. Geoffrey Sher

Respectfully, I would not stop meds. I would repeat the test in 2 days to see how it changes. If it >doubles you might still be OK!

G-d bless~!

Geoff sher

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Angela Oscarson

Good Morning Dr. Sher,

My husband and I had our 5 day 1 embryo transfer on 5 July, we did our first blood test on 13 July, 8dp5dt and our HCG level was 83. The nurse advised that this was a good sign that for the first test anything over 50 is a good level. We have our next HCG test on Monday the 16th, currently on progesterone suppository, No bleeding, nausea, occasional bloating and cramps and breast tenderness, but does this first HCG level seem okay or too low?

Thank you.

V/R,

Angela

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Maggie

I am 10dp5dt. One embryo. On days 7,8,9 HPT were all positives. Today, I took two (same brand as before and first urination of the day like before). Both came back negative. My blood test was this afternoon and my doctor called and said my HCG is low. He wants me to continue the meds for two days and redraw. I’m feeling very scared and anxious. I haven’t seen any positive literature on decreasing hcg. He didn’t give me the exact lab number but said it was pretty low. Thoughts? Thank you

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Dr. Geoffrey Sher

I share your concern but I would wait to see if the hCG doubles in the next two days!

Geoff Sher

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Lori

Hello doctor. I had 2 embryo 5dt. First HCG was 8dp5dt at 26. Went back 2 days later 10dp5t doubles to 67. Could this be a late implantation? I am a little worried. Tomorrow I will be testing again and that will be 14dp5dt. I have an US scheduled for end of next week. On day 9 past transfer I had a little bleeding and some spotting which didn’t last for more than an hour. Please give me your thoughts. Thank you so much!

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Dr. Geoffrey Sher

I am not overly concerned about your slight painless bleed. Time will be the determinant.

Good luck!

Geoff sher

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Alana

I had a very late starting hcg, but it has doubled more or less normally (I think!). It was 22 at 14dp5dt, then 136 at 18dp5dt, then 291 at 20dp5ft, 500 at 22dp5dt, and 1296 at 26dp5dt. I have been asked to come in for a scan in two weeks’ time, no more blood tests. I assume it will not end well, because of the low numbers (and why did it take so long to get started?). But others are saying it’s the doubling that counts and that this is fine. What do you think?

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Dr. Geoffrey Sher

It could still be OK. Have an US done in 1 week from now.

Geoff Sher

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Swetha

Hi Dr Sher,

My hcg level 10 days post IUI is 53. I’m waiting to get the next draw tomorrow at 12dpo. I just wanted to check if 53 is a good number for 10 days after IUI

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Swetha

Hi Dr Sher,
I got my results back from second blood draw at 13dpo and it is 140. Doubling time is 51.5 hours. I’m a little worried because the doubling time is usually less than 48 hours this early in pregnancy.
Thank you so much

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swetha

Hi Dr Sher,

Thank for your quick response. I really appreciate it.
I got my results from 15dpo and HCG is only 236. It increased from 140 to 236 in 48 hours. Now the doubling time is 63.5 hours. I’ve heard that 48-72 hours is ok but the doubling time is just increasing. I have another blood draw at 17dpo. I had a blighted ovum and a chemical pregnancy recently. Is there any hope at this point?

Dr. Geoffrey Sher

I would wait a week + andf do an ultrasound for an indication of viability!

Good luck!

Geoff Sher

swetha

Hi Dr Sher,
Thank you for your response. My doctor is not giving the ultrasound until atleast 2 weeks more. Following are my HCL levels. I’m listing them again for your reference
10 DPO 53
13DPO 140 (Doubling time 51 hours)
15DPO 236 (Doubling time 64 hours)
17DPO 592 (Doubling time 36 hours)
I will be going for another hcg tomorrow at 20DPO.
I would really appreciate if you can share your opinion based on my HCG levels.

Dr. Geoffrey Sher

Sorry Swetha,

Only time will tell!

Geoff Sher

Swetha

Hi Dr Sher,
I wanted to share an update. My hcg levels increased every 36 hours later on. We had an ultrasound today at 6 weeks 1 day. Doctor could see two sacs with fetal poles and heartbeats. Baby A had heart rate of 110 and baby B had heart rate of 105. Are these normal rates for 6 weeks 1 day ?

Dr. Geoffrey Sher

It is a little on the slow side but give it 1 more week and see. It could all turn out fine still!

Good luck!

Geoff Sher

Nicola

Sorry not sure what happened to my notes, here is the correct HCG/Blood work so far:
9 dpt: 12 HCG/ 9.0 Pro / 60 Pro / 118 Est.
15 dpt: will be taken in 2 days

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Nicola

9 dpt: 12 HCG / 9.0 Pro / less than 50 Est.

12 dpt: 23 HCG / 60+ Pro / 118 Est.

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Dr. Geoffrey Sher

That is a slow rise and in my opinion is of some concern . Follow up with hCG tests and in 2 weeks an ultrasound.

Geoff Sher

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Dr. Geoffrey Sher

That is different. I would need to see the new results when they are in.

Geoff Sher

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