Aging and Fertility – tic toc, tic toc

Wish me a happy birthday today – I guess that means it’s time to talk about aging.  And the clock is ticking for everyone who still wants to start or extend their family.  For baby boomers the alarms have already gone off, but even for couples in their late thirties, there are concerns as the number of eggs start to decline.  It is probably just denial that allows couples to put off childbearing to a time when it is the most difficult. We feel healthy when we turn 40 and there’s the career to think about.  “I’m sure my eggs will be OK” – don’t be too sure.

I don’t want to spread doom and gloom, especially on my birthday, but here are some things to be aware of:

1) Natural fertility declines in women starting around age 35. The number of women unable to conceive goes up with age

Percent of women remaining childless on no contraception, by age

2) IVF success rates drop steadily with age

Success rates decline with age with in vitro fertilization

3) The chance of having a miscarriage goes up with age

The percent of women who have miscarriage after getting pregnant with IVF goes up with age

4) The male partner may decline as well after age 50, but unlike the female there no absolute age when men cannot father a child (its so unfair!)

The physiology of this process in women is well understood. A woman starts with 1,000,000 eggs at birth, has 400,000 by the time of puberty and uses them up in a continuous fashion, until the peri-menopause when the depletion rate picks up – then there are none left. Nothing can slow it down and nothing speeds up the process.

The evaluation of the female includes an ultrasound to look at “antral follicle count” (see glossary), anti-müllerian hormone (AMH) that goes down with egg number, and day 3 FSH (follicle stimulating hormone) that goes up with loss of eggs. A clomiphene citrate challenge test is often done after age 35: obtain an FSH on day 3 along with an estradiol level, then take clomiphene citrate 100 mg on days 5 to 9 and then get another FSH on day 10. If either FSH is above 13, it is not good news and a level above 15 usually means that there a very low chance for successful pregnancy without donor eggs.

Counseling for older (over 37) women trying to conceive should include assessment of the ovarian reserve and perhaps more aggressive therapies. Time should be optimized for each couple to avoid getting bogged down doing the same thing over and over. (I saw a women recently who have been on clomiphene citrate for 12  months and was approaching 40).

Treatments including ovulation induction with oral medications, oral meds plus gonadotropin injections (sequential therapy) and superovulation with intrauterine insemination. In vitro fertilization (IVF) can be considered if the FSH is not too high. During IVF there are tricks that can be played on the ovaries to get them to respond better, including DHEA-S treatment, a micro-dose flare protocol using lupron®, using estrogen or OCPs before IVF, avoiding lupron® altogether (substituting an GnRH antagonist) and increasing the amount of medication used. Finally, for women who have very high FSH levels, donor eggs can completely resolve the problem and the success rates (in the setting of IVF) are usually very good.

So my advice is not to put off ’til tomorrow what you can do today, especially if it means trying to have a baby.

I hope that wasn’t too depressing. I think I’ll go have a piece of cake.

(Source material: ASRM Practice Guidelines on Aging and Fertility)