When You're Hoping to Conceive Again

My OB/GYN patted me on the shoulder. "Your uterus and ovaries are normal, and your health is excellent," he said, smiling. "I'd say you've got at least a couple more years of baby-making in you." It was exactly the vote of confidence I needed. I was turning 40 and my fiancé and I planned to have a child together as soon as we got married. Since my two boys (then 6 and 8) had both been conceived on literally the first attempt, I had no reason to doubt my doctor's prognosis. There was just one problem. He was wrong. More than a year and countless tears later, an infertility specialist told me why. "Your eggs are no longer viable," he said. "Your FSH levels are too high." Fertility experts evaluate a number of hormones to determine a woman’s ovarian reserve; FSH (follicle stimulating hormone), when measured on day three of a menstrual cycle (along with estrodial), can assist a physician in assessing a woman’s egg quality. Fertility experts agree that the reading isn’t an absolute, as FSH levels can vary from cycle to cycle, but typically, the higher the FSH, the lower the egg quality. The lower the egg quality, the closer a woman is to menopause and the greater the likelihood is for infertility. In my case: secondary infertility. The fact that I’d been as fertile as a rabbit less than a decade ago wasn’t relevant. But the fact that this was the first I was hearing about FSH, was. According to the National Center for Health Statistics, secondary infertility – the inability to conceive after having at least one child – affects more than 3 million women in the U.S. today. This figure is a dramatic increase over prior years, and the incidence continues to climb. While many factors can cause infertility – decreased thyroid, excessive prolactin, obesity, and endometriosis, to name a few – a woman’s age and egg quality are two prime factors today. And it’s a result, experts say, of an increasing number of women and couples delaying childbearing until their 30s and beyond, combined with exploding divorce and remarriage rates. This surge isn’t startling; it’s expected. It’s also expected that most women today are well-aware of their biological clocks. However, according to a recent survey by the American Infertility Association (AIA), a national reproductive health information and assistance organization headquartered in New York City, many women know far less about their reproductive lives than they think they do. Of more than 12,000 women surveyed by AIA about rudimentary fertility facts, the average respondent answered less than half of the 15 questions correctly, and just one respondent got all 15 answers right. While infertility affects both males and females, the vast majority of secondary infertility problems lie with women, says Rebecca Brightman, M.D., an OB/GYN at Weill-Cornell New York Presbyterian Hospital. “Typically we find, especially as women get older, it’s an issue with respect to egg quality.” “A lot of women don’t realize that they’re born with a limited number of eggs,” says Melvin Thornton, M.D., a specialist in obstetrics, reproductive endocrinology and infertility at the Center for Women's Reproductive Care at Columbia University/New York Presbyterian Hospital. A female child is born with about 2 million eggs in her ovaries. By the time she reaches puberty, that number has already decreased to around 400,000, of which just 400 to 500 will ripen into mature eggs during her reproductive lifetime. At age 27, she’ll have about half of what she started with when she began menstruating; at age 37, approximately 25,000 remain. As the quantity declines, so does the quality, Dr. Thornton explains. While most women know they have a biological clock, many are unaware of the age at which it actually stops ticking. Many women think they only use one egg a month, but every cycle six to eight follicles are released, each attempting to be the one that ovulates, explains Claudia Ravins, M.D., director of OB/GYN at North Shore Hospital at Forest Hills. “As we get older and our estrogen levels go down, the mechanism of ovulation changes, and the eggs themselves change. They just don’t function properly in an effort to create new life.” Measuring FSH (along with estrodial) on day three of the menstrual cycle can, in combination with a woman’s age, provide a physician with a gauge for prognosis. “An FSH of 10 or less is the ideal number for conception,” Dr. Thornton says. As it rises, however, the odds for success drop. With an FSH of 15, the success rate for conception is about 5 percent, even with aggressive in vitro fertilization (IVF). And that’s regardless of age, notes Dr. Thornton. “A 28-year-old woman with FSH of over 15 has basically the same percentage chance of having a baby with IVF as a 43-year-old woman with a normal FSH. Even though the 43-year-old isn’t menopausal, her eggs aren’t as viable as they were 10 years ago,” Dr. Thornton says. “And the 28-year-old probably started with fewer eggs, and those she has remaining aren’t as good as the average 28-year-old.” While FSH is a screening test for prognosis, experts agree it should be used with caution. “It’s really only useful in the short-term,” Dr. Thornton says. “We might see a woman with normal FSH today, but you wait six months, and now the FSH is over 15. It can’t be used as a long-term gauge.” Dr. Brightman concurs. “It’s not absolute. I certainly have seen patients over the years who have abnormal FSH, yet they’ve subsequently gone on and gotten spontaneously pregnant.” More often than not, however, women with high FSH require donor eggs from younger women in order to achieve a pregnancy. Dr. Ravins recently saw a 35-year-old patient who ceased menstruating when she was 27. “Doctors told her it was from stress,” Dr. Ravins says. “But it turned out she had premature menopause “and it took three physicians about a year to figure it out; nobody bothered to do any levels.” If this young woman had been tested earlier, she could have avoided considerable emotional turmoil and started IVF with donor eggs sooner. “She didn’t know what was going on, and the concept that she could have been going through premature menopause had not dawned on her or anybody else.” “You never know when that biological time clock is going to stop,” Dr. Thornton says. Testing for FSH can give you a prognosis, but that’s all it is: a prognosis. “There is no test that can be done to say how much time you have left before those eggs run out.” Couples who plan to delay having another child should take a proactive approach while waiting, Dr. Ravins says. Number one: “If you’re a smoker, quit, because you’re just pushing your menopausal age down; you’ll menopause sooner.” Number two: If you’re obese, lose weight. “Controlling obesity will lead to improved ovulation.” Number three: Watch the menstrual cycle. “Keep a period calendar and be aware if there have been changes or shifts in the cycle.” If you detect shifts, see your gynecologist for an evaluation and possible tests. For couples in new relationships, where the man has had no children, he should be evaluated to rule out issues with semen quality or motility. If you’re not getting the information you need or want from your doctor, seek out another physician. And speak openly about your plans and concerns, Dr. Brightman advises. “Some of my patients don’t want to talk about it, and I say, ‘Look, it’s my responsibility to discuss this.’ People often put things off until they’re financially stable or they’re secure in their jobs, but sometimes there’s a price to pay.”

Infertility Resources:

• American Infertility Association: www.americaninfertility.com • Resolve: The National Infertility Association: www.resolve.org • American College of Obstetricians and Gynecologists: www.acog.org/ • Infertility in America: www.ivfinamerica.com • Inconceivable: A Woman’s Triumph over Despair and Statistics, by Julia Indichova (Broadway Books)


Our Finite Egg Supply

The maximum number of eggs a woman will ever have in her lifetime is about 5 million, fertility experts say. But that’s when she’s a 5-month old fetus. The majority of those eggs are absorbed during gestation, and at birth the average female child has about 2 million eggs remaining in her ovaries. When a girl begins menstruating, her supply has decreased to 400,000. She has just begun her reproductive life, yet, based on current societal trends, she most likely won’t have a child for at least a decade. Maybe two. By the time most women and couples today are ready to actually “plan” a family, a woman’s egg supply has already dwindled to one-tenth of what it was at birth. We may be able to “turn back the clock” and temporarily halt the effects of time on our faces, our figures, and even our outlook on life. But our biological clock has no reset button.

Approximate Number of Eggs in a Woman’s Ovaries at:

5 months gestation 5,000,000

Birth 2,000,000

Puberty 400,000

Age 27 200,000

Age 37 25,000

Menopause (average age: 51) 1,000