Monday 7 November 2011

Age and Infertility

What is the relation between my age and my chances of getting pregnant?

Most fertility patients are aware of the term "biological clock". Women are born with all their eggs and with each month passing, some of these eggs are used up. A woman’s reproductive potential declines, especially as she approaches her fourth decade of life. The total eggs that are left in a woman’s body is called her “ovarian reserve”.
Because women in our society are marrying later, and consequently attempting pregnancy later in life, evaluation of ovarian reserve is critical to understanding a patient’s reproductive potential. Unfortunately, there is no perfect test and it is difficult to answer with certainty the question that is often asked by anxious patients. How much time do my ovaries have left? And; How long can I wait to have a baby?

Can I get pregnant even if I am in my forties?

A little assistance is needed if you are in your fourth decade of life but definitely, a pregnancy can happen. The assistance might be in the form of IUI or IVF/ ICSI.

How to get pregnant if I have gone through menopause?

If you are postmenopausal, it means that you have finished with your supply of eggs. However with egg (ova) donation, you can borrow an egg from a young donor, get it fertilized with the sperm of your husband and then the embryo transfer is done to your uterus. You then carry the pregnancy to term in your own uterus. This is what is called egg donation or Donor Egg IVF

What infertility tests will tell me how good are my chances of getting pregnant at my age?

The infertility tests to determine your fertility potential are called tests of Ovarian reserve.

Follicle Stimulating Hormone (FSH). This is a blood test that measures the negative feedback from the ovary to the pituitary gland, which makes follicle stimulating hormone. It is done preferably on the third day of your periods (the first day being the day the periods began). FSH is the hormone that causes follicular recruitment and development in the ovary.
As ovarian function declines, and premenopause approaches, the negative feedback to the pituitary is decreased and the FSH level rises as the pituitary tries to drive the ovary harder. Commonly accepted values for a reassuring day 3 FSH value are less than 10 iu/ml. A slightly higher level may be compatible with development of an ongoing pregnancy with the use of appropriate therapy.
Unfortunately, this test is not a perfect predictor of reproductive potential because it is only one measurement in one cycle, and because ovarian function varies from cycle to cycle. Some cycles provide more fertility potential than others, especially in premenopausal patients. Sometimes it is possible to successfully treat a patient who has had a previously high FSH in a cycle that is more optimal by using hormonal medications to reduce the basal FSH level and then administering fertility medications.
These patients may become pregnant, especially if other markers of ovarian reserve are normal. In summary, one elevated FSH level on day 3 is not necessarily a steadfast indicator of an impossible case but should be interpreted in the light of further testing. Treatment should be started immediately if ovarian reserve is diminished as the ovarian function declines with age.

Inhibin B- Inhibin B is a specific hormone secreted by the ovarian follicle and is the most specific marker assessing ovarian reserve. The test appears to be more reliable than just a day 3 FSH blood test and is more consistent from cycle to cycle offering a more reliable evaluation of the true state of ovarian reserve. It is a marker of how the ovaries will respond to fertility drugs. The mean value at 95% confidence limits for day 3 inhibin evaluations is 33-45 pg/ml in normally fertile women. Since inhibin is a messenger hormone secreted by a healthy ovary to influence the pituitary gland, a low inhibin less than 30 pg/ml is a bad prognosticator of future reproductive potential. But a normal inhibin, even in the face of a slightly elevated day 3 FSH, can be encouraging and compatible with the initiation of a successful ongoing pregnancy.

Anti Mullerian hormone (AMH) is another new accurate marker of ovarian reserve. The advantage with AMH is that it can be done anytime during the women’s cycle.

The Clomiphene Challenge test provides an additional measurement of ovarian reserve. The principle of the test is to measure the basal FSH and estradiol levels on day three of the patient’s cycle. In order to evaluate the ovarian response to fertility drugs, 100 mg of Clomid is administered between days 5-9 of the cycle. The ovarian response on day 10 is further evaluated by checking the response to Clomid and measuring the FSH and estradiol. The test is abnormal if the day 3 or day 10 FSH is elevated above 10 iu/ml.
Stimulating the ovary with gonadotropins to see how they respond. An ovulation study is done and the number of eggs produced in response to the gonadotropins is evaluated. This is the ultimate test of ovarian reserve.

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