Trying to Conceive Over 40: Does Age Play a Part?

I am 41 and have not used birth control for the two years I have been married. I have erratic periods. What testing is indicated?

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Infertility and Age

Women are born with two to three million oocyte/follicle complexes, which naturally degenerate leaving only 200,000 to 400,000 remaining at the time of puberty. While spontaneous pregnancy rates in fertile couples are 20 to 25 percent per cycle for women less than 25 years old, the rates may decline to approximately 15 percent per cycle at 35, and 5 percent per cycle at 40 years of age, respectively. It appears that the decline infertility with age is related to decreased oocyte quality. Testing is now available which may indicate if oocyte quality is decreased.

Ovarian Reserve Testing

Ovarian reserve refers to a measure of the biological competency of a woman’s oocyte/follicular complexes (egg and surrounding cells which assist in maturation of the egg). Diminished ovarian reserve refers to the diminished biological competency of a woman’s oocyte/follicular complexes and often correlates with age. Because women are born with all the oocyte/follicular complexes they will ever have, the natural aging process is associated with a progressive diminution of ovarian reserve. Diminished ovarian reserve is clinically manifested by relative infertility initially, and eventually progresses to a complete nonfunction of the oocyte/follicular complexes with a lack of estrogen production and anovulation (lack of ovulation). This final state of diminished ovarian reserve is commonly known as menopause.

Measurement of the ovarian reserve is accomplished through the measurement of a day 3 FSH. Elevated levels of FSH on day 3 indicate that the pituitary gland must send more FSH hormone to the ovary to get an appropriate response. This indicates that the oocyte/follicular complexes remaining in the ovary are either less responsive or that there are fewer complexes able to respond. Most assisted reproductive technology (ART) programs have determined at what day 3 FSH level treatments will not improve pregnancy rates over those achieved without treatment. In these cases, the woman is most effectively treated using oocyte donation. Your reproductive endocrinologist will perform this or another type of test (clomiphene challenge) which provides similar information. The cutoff level varies between laboratories therefore your physician will advise you regarding your test’s interpretation.

Recommendation

Women over 35 years of age, and women with prolonged unexplained infertility which has been fully evaluated by a reproductive endocrinologist and no obvious cause has come to light, should have a day 3 FSH (or other similar evaluation) evaluation to determine their ovarian reserve. Erratic cycles may signal early stages of diminished ovarian reserve or impending menopause. If the day 3 FSH is elevated over the cut off value established by your ART program donor egg IVF, which is highly successful, may be the best option available to you.

 

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