Infertility and Older Women
Evaluation of Ovarian Reserve
Most fertility patients are aware of the term "biological clock". A man can father children at any age but unfortunately a woman’s reproductive potential declines, especially as she approaches her fourth decade of life.
Because women in our society are marrying
later, and consequently attempting pregnancy later
in life, evaluation
of ovarian reserve is critical to understanding
a patient’s reproductive potential. Unfortunately,
there is no perfect test and it is difficult to answer
with certainty the question that is often asked by
anxious patients. How much time do my ovaries have
left? And; How long can I wait to have a baby?
Commonly used fertility tests
including the following:
A) FSH, and estradiol. This is a
test that measures the negative feedback from the
ovary to the pituitary gland, which makes follicle
stimulating hormone. FSH is the hormone that causes
follicular recruitment and development.
As ovarian function declines, and premenopause approaches, the negative feedback to the pituitary is decreased and the FSH level rises as the pituitary tries to drive the ovary harder. Commonly accepted values for a reassuring day 3 FSH value are less than 10 iu/ml. A slightly higher level may be compatible with development of an ongoing pregnancy with the use of appropriate therapy.
Unfortunately, this test is not a perfect
predictor of reproductive potential because it is
only one measurement in one cycle, and because ovarian
function varies from cycle to cycle. Some cycles
provide more fertility potential than others, especially
in premenopausal patients. Sometimes it is possible
to successfully treat a patient who has had a previously
high FSH in a cycle that is more optimal by using
to reduce the basal FSH level and then administering
has treated many patients over the years who were
rejected by other fertility clinics because of a slight
elevation in FSH level. These patients may become
pregnant, especially if other markers of ovarian reserve
are normal. In summary, one elevated FSH level on
day 3 is not necessarily a steadfast indicator of
an impossible case but should be interpreted in the
light of further testing. Treatment should be started
immediately if ovarian reserve is diminished as the
ovarian function declines with age.
B) Inhibin- Inhibin B is a specific hormone secreted by the ovarian follicle and is the most specific marker assessing ovarian reserve. The test appears to be more reliable than just a day 3 FSH blood test and is more consistent from cycle to cycle offering a more reliable evaluation of the true state of ovarian reserve. It is a marker of how the ovaries will respond to fertility drugs. The mean value at 95% confidence limits for day 3 inhibin evaluations is 33-45 pg/ml in normally fertile women. Since inhibin is a messenger hormone secreted by a healthy ovary to influence the pituitary gland, a low inhibin less than 30 pg/ml is a bad prognosticator of future reproductive potential. But a normal inhibin, even in the face of a slightly elevated day 3 FSH, can be encouraging and compatible with the initiation of a successful ongoing pregnancy.
C) Antimullerian hormone is another new marker that is showing promise as an accurate marker of ovarian reserve in research studies.
Clomid challenge test provides an additional measurement
of ovarian reserve. The principle of the test
is to measure the basal FSH and estradiol levels on
day three of the patient’s cycle. In order
to evaluate the ovarian response to fertility drugs,
100 mg of Clomid is administered
between days 5-9 of the cycle. The ovarian response
on day 10 is further evaluated by checking the response
to Clomid and measuring the FSH and estradiol.
The test is abnormal if the day 3 or day 10 FSH is
elevated above 10 iu/ml. Many fertility clinics will
reject a prospective IVF patient because of a poor
Clomid Challenge test. Dr. Kustin has helped numerous
couples over the years who have abnormal Clomid challenge
tests, but other more positive markers. The secret
is to individualize the treatment protocol based upon
the results of this and other tests as well as explaining
to the couple what the test results actually mean.
the ovary with gonadotropins to see how they respond.
This is the ultimate test of ovarian reserve. Many
couples feel that they must try to achieve a pregnancy
with the female partner's own eggs before taking the
psychological step of using a donor's eggs. Sometimes these patients respond well to induction and may be candidates for IUI with gonadotropins. However; most of these patients will require IVF. Dr.
Kustin is committed to giving every patient a chance
to pursue the dream of parenthood provided that the
patient’s expectations are realistic after preliminary
is available to help those women who cannot use their
own eggs to achieve a much wanted pregnancy. See the
donor egg section of
the Web site.