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Peak infertility in women occurs before age 30 with a monthly fecundity (pregnancy) rate of 20-25 percent. Beginning around age 32, this monthly rate declines and experiences a rapid acceleration during the later 30's and into the 40's. By age 40, approximately 1 in 3 women experience infertility.
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Mark P. Trolice, M.D., FACOG, FACS
Board Certified, Reproductive Endocrinology and Infertility
Director, Fertility C.A.R.E.
(October 2004)
As more women are delaying childbirth and more
"baby boomers" are reaching midlife, the problem of diminished ovarian reserve (DOR) is increasing. Ovarian aging has several major medical consequences including decreased bone mass with risk of fracture, abnormal uterine bleeding from anovulation, infertility, and vasomotor symptoms.
This article will address ovarian reserve testing and its impact on treating infertility in order to educate women on the important relationship of age and fertility.
A woman is born with her entire life complement of oocytes, approximately 1-2 million. Through the biologic phenomenon of apoptosis, this amount at birth has already experienced a rapid decline from 6- 7 million at mid gestation in-utero.
At the time of menarche, the oocyte cohort has diminished to 300,00-400,00. Each cycle, hundreds of oocytes undergo stimulation with one achieving monthly ovulation while the rest become atretic. Of the entire oocyte endowment, approximately 1 percent eventually undergoes ovulation. This in contrast to men where puberty initiates spermatogenesis and new sperm are continuously produced throughout the remainder of life.
Peak fertility in women occurs before age 30 with a monthly fecundity (pregnancy) rate of 20-25 percent. Beginning around age 32, this monthly rate declines and experiences a rapid acceleration during the later 30's and into the 40's. By age 40, approximately 1 in 3 women experience infertility.
The main impact on their pregnancy rate is oocyte quality and quantity. As a result, fertilization is impaired, implantation is reduced, and miscarriage is increased along with the increased potential for chromosomal abnormalities of the fetus.
Ovarian Age Testing
Several tests are available to measure ovarian age. These include menstrual cycle day three (CD3) serum FSH and Estradiol, ovarian volume and antral follicle count (OVFC), and the Clomiphene citrate challenge test (CCCT). In general, these tests are more specific than sensitive; i.e., "normal" results do not necessarily exclude DOR.
CD3 testing is the simplest screening assessment. Elevated values for FSH and/ or estradiol are poor prognostic indicators for pregnancy, and are laboratory specific due to different assays (between labs). FSH levels will gradually increase in the early follicular phase as a result of ovarian follicle decline. Additionally, a shortened follicular phase occurs in DOR and estradiol levels may become elevated early. Obtaining both FSH and estradiol levels will allow for more information since an isolated FSH level mat be "falsely" low from negative feedback of high estradiol level.
Transvaginal ultrasound and OVFC on CD3 has also been used as screening tests. An ovarian volume of less then 2 cm and / or a combined antral follicle count of less then 11 reflects DOR. Lastly, CCCT utilized the common fertility drug to measure FSH and estradiol levels.
Please contact us at Fertility C.A.R.E for more information on these tests or the protocol.
Fertility C.A.R.E. can perform all these ovarian age tests. Initiation of testing should begin as a woman nears 35 or has other risk factor such as cigarette smoking, ovarian surgery, or signs of premature ovarian failure. A well-informed patient can contribute to her care and this testing may expedite fertility treatment in her goal of a healthy child.
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