Thursday, November 6, 2008
The Infertility Diaries
I am now the on-call fertility expert for Redbook blog, The Infertility Diaries. View posts and answers to key infertility questions every Wednesday, at Wisdom from Wisot Wednesdays.
Tuesday, November 4, 2008
Fertility After Forty
More than 15 percent of couples in the reproductive age group in the U.S. have difficulty conceiving a child. The tendency to delay childbearing in order to pursue an education and career has meant that more women in their late 30s and early 40s are attempting conception for the first time. Studies have demonstrated that almost 50% of women over the age of 40 will experience infertility. Because fertility in women decreases with advancing age, prompt evaluation and aggressive treatment are critical in infertile women close to or over the age of 40.
Numerous demographic studies suggest a consistent decline in fecundity (the chance to conceive in any given month) with increasing age. The average 25 year old woman who is trying to conceive may have a 25% per month chance of conceiving if all fertility factors are optimal. Compare this with the 5% per month chance for conception of the average 40 year old woman. This age associated decline in live births is due largely to abnormalities in the egg. The meiotic spindle, which helps the chromosomes segregate for cell division, exhibits abnormalities in chromosome alignment. This high rate of abnormal chromosome distribution is the major factor that can explain a lower rate of successful pregnancies in older women. In addition to decreasing fecundity, older women experience an increasing incidence of miscarriage. Women over age 40 have approximately a one in three chance of having a miscarriage in any given pregnancy. In addition, at age 40 one in sixty live births is genetically abnormal.
With this in mind, it seems reasonable to promptly evaluate women over 40 who are concerned about fertility. Before starting an evaluation, however, it is important to discuss some of the special considerations for the woman over 40 trying to conceive. These include general health issues, since women over 40 are more likely to have medical problems including diabetes, hypertension, heart disease, all of which can complicate a pregnancy. Therefore, we recommend that an over 40-year-old woman contemplating a pregnancy have a thorough medical evaluation, including a mammogram. The increased incidence of genetic abnormalities in infants born to women over age 40 and the recommendation for prenatal genetic diagnosis should also be discussed.
Patient Evaluation
The usual trial period of one year of attempting conception prior to an infertility evaluation is not appropriate for women who are close to forty years old.
A basic infertility evaluation is indicated for any couple who have been attempting conception for six months if the woman is approaching 40. First, an infertility history should include how long the couple has been trying to conceive, method of timing and the frequency of intercourse, as well as questions regarding menstrual regularity, premenstrual symptoms, and any prior pregnancies. Factors suggesting problems with the patient’s fallopian tubes, such as a history of sexually transmitted diseases, IUD use, or pelvic infection, should be noted, as well as any previous cervical procedures such as cryotherapy or conization. In addition, the patient should be asked about early menopausal symptoms.
Laboratory and other tests should include:
• A semen analysis for the patient's partner.
• Evaluation of ovulation: basal body temperature charts, a midluteal serum progesterone level, a urine luteinizing hormone ( L H ) t e s t using an ovulation predictor kit, or ultrasound monitoring of follicular development.
• An evaluation of the patient’s fallopian tubes and uterine cavity with a hysterosalpingogram.
• Evaluation of ovarian reserve (see below) Ovarian Reserve
Studies suggest that a woman's chronologic age and her ovarian reserve are independent predictors of fertility. Ovarian reserve describes a woman’s reproductive potential with respect to egg quantity and quality.
Perhaps the best method we have readily available to measure ovarian reserve is a cycle day 2 or 3 blood FSH (Follicle Stimulating Hormone) level and an estradiol (estrogen) level. This measurement may be very important in evaluating how aggressively to treat women approaching the age of 40 and also to give that woman a realistic idea of her chance for a successful pregnancy. The levels of FSH that are considered in the normal range are dependent on the lab where the test is performed. With modern techniques for measuring FSH, generally, a level of less than 10 is good, 10-14 borderline, and 15+ suggests a very low chance for successful pregnancy with fertility treatment with a woman’s own eggs. A single elevated FSH level predicts a poor prognosis even when subsequent FSH levels are normal. In women with a normal FSH, a Clomiphene
Challenge Test may provide more information about a patient’s ovarian reserve than a day 3 FSH level. Blood testing is done on day 3 for FSH & estradiol, clomiphene 100 mg day is taken on days 5-9, and a blood test for FSH level is taken on day 10. Elevation of either FSH level (day 3 or day 10) is a poor prognostic sign. Also a cycle day 3 estradiol level above 70 may suggest a lower chance for success. In a general infertility population an abnormal clomiphene challenge test predicts that a successful pregnancy will be achieved only about five percent of the time. Risk factors for early loss of ovarian reserve include smoking, family history of early menopause, shortening menstrual cycle interval and previous ovarian surgery.
The basic evaluation can be performed over a period of one month in women approaching 40 years of age, rather than spreading it over a number of cycles. Any abnormalities that are uncovered in the basic evaluation should be corrected promptly. If the evaluation is normal, or if abnormalities have been corrected and the patient still does not conceive in a short period of time, aggressive therapy is indicated. It may be difficult to convince a couple that has been trying to conceive for only six months that a very aggressive approach such as IVF may be necessary. Similarly, use of controlled ovarian hyperstimulation (COH) with gonadotropins (injectable fertility drugs) combined with intrauterine insemination (IUI) may be unacceptable to some couples. Knowledge of the patient’s blood FSH level may help to convince the couple that an aggressive approach is needed.
Treatment
Treatment options for age-related infertility include controlled ovarian hyperstimulation with intrauterine insemination (COH-IUI), IVF, and ultimately in nothing else works, egg donation. COH-IUI and IVF help by increasing the chance to conceive in any given cycle. They cannot improve egg/embryo quality. COH-IUI involves taking gonadotropins to increase the number of mature eggs released in a given cycle and the placement of washed sperm into the uterine cavity at the time of ovulation. This treatment has fair success in women forty and older, with pregnancy rates of 10 percent per cycle in a 2004 study. For couples with tubal disease, endometriosis, or sperm abnormalities, as well as couples with unexplained infertility who want to accelerate their chance for pregnancy, IVF is an appropriate option. Per-cycle pregnancy rates with IVF are higher than from COH-IUI, but do decline significantly with increasing age.
Egg Donation
Egg donation has become an accepted and successful technique to achieve pregnancy in older women. Studies show that average delivery rate of over 50 % per cycle can be expected in recipients who are aged 40 and older. This treatment is the only treatment available to improve egg/embryo quality in older women. Egg donation involves preparing the recipient’s uterus with estrogen and progesterone to create an optimal bed for implantation. The egg donor undergoes hormonal stimulation to produce multiple eggs. The eggs are retrieved with a minor procedure and fertilized with sperm from the recipient’s partner. Fertilized embryos are then placed into the recipient’s uterus.
Egg donation offers couples a number of advantages over adoption. First, the sperm is obtained from the patient’s husband, and therefore the child is genetically related to him.
Second, since the pregnancy develops inside the patient herself, she has control over such factors as nutrition, smoking, drinking or taking recreational drugs during the pregnancy, control she would not have in the case of adoption.
Finally, the woman experiences the positive feelings of pregnancy and delivery and is able to breast-feed. These are all important experiences in establishing positive feelings toward the infant. For the present, egg donation is the best medical option for women over the age of 40 who have repeatedly failed other fertility therapies, as well as for women with elevated FSH levels. Adoption is a wonderful alternative for women who do not wish to use a biological ortion.
Recommendations
One approach to therapy for the infertile woman aged 40 and over who has a normal evaluation is to first consider one or two cycles of COH-IUI. This will give the patient a chance of conceiving and also allows the physician to evaluate ovarian response for a future IVF cycle. In addition, it helps the patient get used to the idea of a more aggressive, "higher-tech" approach. For the patient who desires the highest chance for pregnancy with her own eggs, IVF is a more successful treatment per cycle.
If the patient does not conceive with COH-IUI, IVF is a next possible step. If her ovarian response is suboptimal, her embryo quality is very poor, or she does not conceive with IVF cycles using her own eggs, egg donation or adoption may be considered. For a patient with an FSH level of 10 to 12, it may be best to direct her promptly to an IVF cycle with her understanding that the chance for a successful pregnancy is reduced. Patients with a day 3 FSH greater than 14 might best be offered egg donation as the first-line option.
Summary
Some women seeking to conceive after the age of 40 have little difficulty in achieving a pregnancy. For those who do not, however, prompt evaluation and aggressive treatment are critical. The serum FSH level, along with the patient’s comfort level with aggressive treatment can help to guide the treatment. Egg donation offers hope to women who can not achieve a pregnancy using other treatments with their own eggs.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Numerous demographic studies suggest a consistent decline in fecundity (the chance to conceive in any given month) with increasing age. The average 25 year old woman who is trying to conceive may have a 25% per month chance of conceiving if all fertility factors are optimal. Compare this with the 5% per month chance for conception of the average 40 year old woman. This age associated decline in live births is due largely to abnormalities in the egg. The meiotic spindle, which helps the chromosomes segregate for cell division, exhibits abnormalities in chromosome alignment. This high rate of abnormal chromosome distribution is the major factor that can explain a lower rate of successful pregnancies in older women. In addition to decreasing fecundity, older women experience an increasing incidence of miscarriage. Women over age 40 have approximately a one in three chance of having a miscarriage in any given pregnancy. In addition, at age 40 one in sixty live births is genetically abnormal.
With this in mind, it seems reasonable to promptly evaluate women over 40 who are concerned about fertility. Before starting an evaluation, however, it is important to discuss some of the special considerations for the woman over 40 trying to conceive. These include general health issues, since women over 40 are more likely to have medical problems including diabetes, hypertension, heart disease, all of which can complicate a pregnancy. Therefore, we recommend that an over 40-year-old woman contemplating a pregnancy have a thorough medical evaluation, including a mammogram. The increased incidence of genetic abnormalities in infants born to women over age 40 and the recommendation for prenatal genetic diagnosis should also be discussed.
Patient Evaluation
The usual trial period of one year of attempting conception prior to an infertility evaluation is not appropriate for women who are close to forty years old.
A basic infertility evaluation is indicated for any couple who have been attempting conception for six months if the woman is approaching 40. First, an infertility history should include how long the couple has been trying to conceive, method of timing and the frequency of intercourse, as well as questions regarding menstrual regularity, premenstrual symptoms, and any prior pregnancies. Factors suggesting problems with the patient’s fallopian tubes, such as a history of sexually transmitted diseases, IUD use, or pelvic infection, should be noted, as well as any previous cervical procedures such as cryotherapy or conization. In addition, the patient should be asked about early menopausal symptoms.
Laboratory and other tests should include:
• A semen analysis for the patient's partner.
• Evaluation of ovulation: basal body temperature charts, a midluteal serum progesterone level, a urine luteinizing hormone ( L H ) t e s t using an ovulation predictor kit, or ultrasound monitoring of follicular development.
• An evaluation of the patient’s fallopian tubes and uterine cavity with a hysterosalpingogram.
• Evaluation of ovarian reserve (see below) Ovarian Reserve
Studies suggest that a woman's chronologic age and her ovarian reserve are independent predictors of fertility. Ovarian reserve describes a woman’s reproductive potential with respect to egg quantity and quality.
Perhaps the best method we have readily available to measure ovarian reserve is a cycle day 2 or 3 blood FSH (Follicle Stimulating Hormone) level and an estradiol (estrogen) level. This measurement may be very important in evaluating how aggressively to treat women approaching the age of 40 and also to give that woman a realistic idea of her chance for a successful pregnancy. The levels of FSH that are considered in the normal range are dependent on the lab where the test is performed. With modern techniques for measuring FSH, generally, a level of less than 10 is good, 10-14 borderline, and 15+ suggests a very low chance for successful pregnancy with fertility treatment with a woman’s own eggs. A single elevated FSH level predicts a poor prognosis even when subsequent FSH levels are normal. In women with a normal FSH, a Clomiphene
Challenge Test may provide more information about a patient’s ovarian reserve than a day 3 FSH level. Blood testing is done on day 3 for FSH & estradiol, clomiphene 100 mg day is taken on days 5-9, and a blood test for FSH level is taken on day 10. Elevation of either FSH level (day 3 or day 10) is a poor prognostic sign. Also a cycle day 3 estradiol level above 70 may suggest a lower chance for success. In a general infertility population an abnormal clomiphene challenge test predicts that a successful pregnancy will be achieved only about five percent of the time. Risk factors for early loss of ovarian reserve include smoking, family history of early menopause, shortening menstrual cycle interval and previous ovarian surgery.
The basic evaluation can be performed over a period of one month in women approaching 40 years of age, rather than spreading it over a number of cycles. Any abnormalities that are uncovered in the basic evaluation should be corrected promptly. If the evaluation is normal, or if abnormalities have been corrected and the patient still does not conceive in a short period of time, aggressive therapy is indicated. It may be difficult to convince a couple that has been trying to conceive for only six months that a very aggressive approach such as IVF may be necessary. Similarly, use of controlled ovarian hyperstimulation (COH) with gonadotropins (injectable fertility drugs) combined with intrauterine insemination (IUI) may be unacceptable to some couples. Knowledge of the patient’s blood FSH level may help to convince the couple that an aggressive approach is needed.
Treatment
Treatment options for age-related infertility include controlled ovarian hyperstimulation with intrauterine insemination (COH-IUI), IVF, and ultimately in nothing else works, egg donation. COH-IUI and IVF help by increasing the chance to conceive in any given cycle. They cannot improve egg/embryo quality. COH-IUI involves taking gonadotropins to increase the number of mature eggs released in a given cycle and the placement of washed sperm into the uterine cavity at the time of ovulation. This treatment has fair success in women forty and older, with pregnancy rates of 10 percent per cycle in a 2004 study. For couples with tubal disease, endometriosis, or sperm abnormalities, as well as couples with unexplained infertility who want to accelerate their chance for pregnancy, IVF is an appropriate option. Per-cycle pregnancy rates with IVF are higher than from COH-IUI, but do decline significantly with increasing age.
Egg Donation
Egg donation has become an accepted and successful technique to achieve pregnancy in older women. Studies show that average delivery rate of over 50 % per cycle can be expected in recipients who are aged 40 and older. This treatment is the only treatment available to improve egg/embryo quality in older women. Egg donation involves preparing the recipient’s uterus with estrogen and progesterone to create an optimal bed for implantation. The egg donor undergoes hormonal stimulation to produce multiple eggs. The eggs are retrieved with a minor procedure and fertilized with sperm from the recipient’s partner. Fertilized embryos are then placed into the recipient’s uterus.
Egg donation offers couples a number of advantages over adoption. First, the sperm is obtained from the patient’s husband, and therefore the child is genetically related to him.
Second, since the pregnancy develops inside the patient herself, she has control over such factors as nutrition, smoking, drinking or taking recreational drugs during the pregnancy, control she would not have in the case of adoption.
Finally, the woman experiences the positive feelings of pregnancy and delivery and is able to breast-feed. These are all important experiences in establishing positive feelings toward the infant. For the present, egg donation is the best medical option for women over the age of 40 who have repeatedly failed other fertility therapies, as well as for women with elevated FSH levels. Adoption is a wonderful alternative for women who do not wish to use a biological ortion.
Recommendations
One approach to therapy for the infertile woman aged 40 and over who has a normal evaluation is to first consider one or two cycles of COH-IUI. This will give the patient a chance of conceiving and also allows the physician to evaluate ovarian response for a future IVF cycle. In addition, it helps the patient get used to the idea of a more aggressive, "higher-tech" approach. For the patient who desires the highest chance for pregnancy with her own eggs, IVF is a more successful treatment per cycle.
If the patient does not conceive with COH-IUI, IVF is a next possible step. If her ovarian response is suboptimal, her embryo quality is very poor, or she does not conceive with IVF cycles using her own eggs, egg donation or adoption may be considered. For a patient with an FSH level of 10 to 12, it may be best to direct her promptly to an IVF cycle with her understanding that the chance for a successful pregnancy is reduced. Patients with a day 3 FSH greater than 14 might best be offered egg donation as the first-line option.
Summary
Some women seeking to conceive after the age of 40 have little difficulty in achieving a pregnancy. For those who do not, however, prompt evaluation and aggressive treatment are critical. The serum FSH level, along with the patient’s comfort level with aggressive treatment can help to guide the treatment. Egg donation offers hope to women who can not achieve a pregnancy using other treatments with their own eggs.
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Clomid—Moodiness and Multiples
Clomid is an anti-estrogen drug used to stimulate the ovaries to produce mature eggs, and it's often the first choice for women who don't ovulate regularly. "Lots of people feel lousy on Clomid. We get a lot of complaints about feeling moody and out of sorts," says Dr. Arthur Wisot, MD, F.A.C.O.G., executive director of Reproductive Partners Medical Group, which has offices throughout Southern California, and author of Conceptions & Misconceptions: The Informed Consumer's Guide Through the Maze of In Vitro Fertilization and Other Assisted Reproduction Techniques. Most women only take Clomid for a few weeks and weather the emotional storms. But one of Clomid's most notable side effects is permanent! "The biggest side effect is multiple births," says Wisot.
Read more ….
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Read more ….
Arthur L. Wisot, M. D.
Reproductive Partners Medical Group, Inc.
A Southern California Fertility Center
Credits –
This information is provided by Arthur L. Wisot, M.D., F.A.C.O.G., one of the team of outstanding fertility doctors at the Southern California fertility center, Reproductive Partners Medical Group. For more information on IVF and the many available infertility treatments please visit www.reproductivepartners.com.
Subscribe to:
Posts (Atom)
Posts
