from
the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani,
MD.
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Ovulation -- Normal and Abnormal (Page 2)
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Older Woman (Page 2)
Table of Contents
How
does age affect fertility in the woman ?
What
are the tests for measuring ovarian reserve ?
What
is the relationship between infertility and the midlife
crisis ?
How does age affect
fertility in the woman ?
Most infertility specialists define
an older woman as one who is more than 35 years, but
this is an arbitrary number. A woman's fertility does
not fall off at a particular age, but starts declining
gradually after the age of 30. After 35, the drop is
fairly dramatic; and after 38, it's even more so. However,
there is no magic number at which fertility disappears
and this decline is a progressive irreversible process.
In the past, it was assumed that as
the woman got older, her entire reproductive system
started failing. However, today we know that the uterus
and the fallopian tubes remain relatively unaffected
by age; and that the reason for the decline in fertility
is the diminished number of eggs left in the ovary.
Every girl is born with a finite number of eggs, and
their number progressively declines with age. A measure
of the remaining number of eggs in the ovary is called
the "ovarian reserve"; and as the woman ages, her ovarian
reserve gets depleted. The infertility specialist is
really not interested in the woman's calendar ( or chronological
age) , but rather her biological age - or how many eggs
are left in her ovaries.
What are the
tests for measuring ovarian reserve ?
Various tests have been described ,
to measure the ovarian reserve, so that we can determine
which patients are good candidates for treatment. These
tests are based on measuring the level of the FSH level
in the blood; and include a basal ( day 3) FSH level.
A high level suggests poor ovarian reserve; and a very
high level is diagnostic of ovarian failure. A test
that can provide earlier evidence of declining ovarian
function is the clomiphene citrate challenge test (
CCCT). This is similar to a " stress test " of the ovary;
and involves measuring a basal Day 3 FSH level; and
a Day 10 FSH level , after administering 100 mg of clomiphene
citrate from Day 5 to Day 9. If the sum of the FSH levels
is more than 25, then this suggests poor ovarian function,
and predicts that the woman is likely to have a poor
ovarian response ( she will most probably grow few eggs,
of poor quality) when superovulated. Another test which
has been recently developed is the measurement of the
level of the hormone, inhibin B , in the blood. Low
levels of inhibin B ( which are produced by " good "
follicles) suggests a poor ovarian reserve. However,
just because a test result is normal does not mean that
the quality or number of the eggs will be good - the
final proof of the pudding is always in the eating !
The menopause is easy to define, because
it is the point at which the menses cease, and at this
time the eggs in the ovaries are
finally depleted. However, the quality
of eggs starts declining well before the menopause starts.
Dr Jansen calls this the "oopause" - the time
period before the menopause, during which fertility
progressively declines because of deterioration in the
quality of the eggs. This can manifest itself in many
ways, some of which are extremely subtle, which is why
the oopause can be so hard to identify. Initially, these
women may present as having recurrent miscarriages,
and then as having "unexplained infertility". While
the number of eggs they grow seems fine initially, they
do poorly in the IVF lab. Initially they may
have unexplained implantation failure of apparently
satisfactory embryos; and later, poor quality
embryos; and then failure of fertilization.
What
is the relationship between infertility and the midlife
crisis ?
Many women in their late 30s early 40s have postponed
marriage or childbearing to obtain their education,
establish themselves in careers, and become financially
secure. These aspirations frequently have worked against
the decision to have children. The passage of time,
however, alters the way many women feel about motherhood
by changing their perceptions about themselves as well
as about the world around them. Additionally these changes
may also have to do with having a new sense of maturity
as well as a feeling of accomplishment. Thus, as women—and
men—feel more secure about themselves, their feelings
and ideas about children and parenthood may also change.
As a couple moves into midlife, they
must also begin recognizing and coming to terms with
their own mortality. For many, parenthood is a part
of successfully completing an important stage in life.
As couples begin to see and understand the passage of
their own lives, the need to pass along life experiences
to new generations enhances the meaning of life.
Men and women in midlife, who have made
the decision to have children , may find to their dismay
that they are frequently thwarted by the inability to
conceive or by recurrent miscarriages. For women, the
realities of the biologic clock cannot be overlooked.
At this point, many couples are faced with dual crises
which can compound their problems —infertility , as
well as a midlife crisis - the developmental life changes
that normally occur in the middle years. This is why
we suggest that women who are more than 30 and who wish
to postpone childbearing should get their FSH levels
checked on Day 3 of their cycle. This is a simple blood
test which allows the doctor to check your ovarian reserve
( the quantity and quality of the eggs in your ovaries).
A high level suggests poor ovarian reserve and should
be a wake-up alarm that your biological clock is ticking
away rapidly. It's important that this test should
be done in a reliable laboratory.
As women reach menopause, they begin
to realize that the option of conceiving and bearing
a child is closed to them. Just as the array of other
life choices begins to narrow, the loss of this ability
to choose to have a child can result in sadness and
deep disappointment. The realization of this "missed
opportunity" can also lead to self-recrimination and
depression.
continued
. . .
Next page: The
Older Woman (Page 2)
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Ovulation -- Normal and Abnormal (Page 2)
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