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From the book
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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.
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.
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.