I'm a female of reproductive age with a history of heavy menstrual flow during the first 3 days of my period, followed by spotting for 2-3 days, but now I'm experiencing a significant decrease in menstrual flow to just a few drops, and I've been trying to conceive, what could be causing this change and how can I improve my fertility?

Decreased Menstrual Flow While Trying to Conceive

Your significantly decreased menstrual flow from heavy bleeding to just a few drops warrants immediate evaluation to rule out pregnancy, hormonal dysfunction (particularly ovulatory disorders), intrauterine pathology, or thyroid/prolactin abnormalities before pursuing fertility treatment.

Initial Evaluation Required

You need specific testing to identify the cause of your changed bleeding pattern:

• First, confirm you are not currently pregnant with a sensitive urine or serum beta-hCG test, as light bleeding can occur in early pregnancy 1
• Assess ovulatory function through basal body temperature charting, mid-luteal progesterone levels (day 21 of a 28-day cycle), or ovulation predictor kits to determine if you are ovulating 2, 1
• Check thyroid function (TSH, free T4) and prolactin levels, as these commonly cause both menstrual changes and infertility 2, 1
• Evaluate estrogen status through assessment of cervical mucus quality, as adequate estrogen is necessary for normal menstrual flow and fertility 2
• Consider pelvic ultrasound if structural abnormalities like intrauterine adhesions (Asherman's syndrome), polyps, or fibroids are suspected, particularly if you've had any uterine procedures 3

Most Likely Causes in Your Situation

The dramatic change from heavy to minimal flow suggests:

• Ovulatory dysfunction is the most common cause of both menstrual changes and infertility, accounting for approximately 25% of infertility cases, with 70% of anovulatory women having polycystic ovary syndrome 1
• Hypothalamic amenorrhea or oligomenorrhea from stress, weight changes, or excessive exercise can present as progressively lighter periods 2
• Premature ovarian insufficiency should be considered if you're experiencing other symptoms like hot flashes, though this typically presents with irregular cycles first 1
• Intrauterine adhesions are possible if you've had prior uterine surgery, dilation and curettage, or severe endometritis 3

Fertility Treatment Approach

Once the cause is identified, treatment depends on your specific diagnosis:

• If you have anovulation with adequate estrogen levels, clomiphene citrate 50 mg daily for 5 days starting on cycle day 5 is the standard first-line ovulation induction therapy 2
• Clomiphene should only be used after confirming you are not pregnant, have no ovarian cysts, have normal liver function, and have no abnormal vaginal bleeding from neoplastic causes 2
• Treatment should not exceed 6 total cycles (including 3 ovulatory cycles), as prolonged use beyond this is not recommended 2
• Properly timed intercourse is critical—sexual activity during the fertile window (6 days ending on ovulation day) is necessary for conception, and cycles with intercourse show longer luteal phases and better cervical mucus quality 4

Important Considerations for Your Age

• If you are 38-40 years or older, immediate referral to a reproductive endocrinologist for consideration of in vitro fertilization as first-line therapy may be appropriate, as female fecundity declines significantly with age 1
• If you are under 38 years, 3-4 cycles of ovulation induction with timed intercourse is reasonable before considering more aggressive interventions 1

Critical Next Steps

• Do not attempt fertility treatment until the cause of your menstrual change is identified, as treating without diagnosis may delay appropriate therapy and waste valuable time 2, 1
• Seek evaluation now rather than waiting, as approximately 85% of infertile couples have an identifiable and often treatable cause 1
• Document your cycles carefully with basal body temperature and cervical mucus observations to help determine if and when ovulation occurs 2, 4