Mark Bush, MD

Age is one of the most important factors affecting fertility. As women age, the quality and quantity of their eggs declines. This is called decreased ovarian reserve. Even if a woman regularly ovulates, has regular periods, and feels fine from adequate estrogen and progesterone secretion from the ovary, the eggs that the ovaries produce as a woman ages have a decreased ability to establish a pregnancy. Because this decline in egg potential can vary from woman to woman, it is important to seek a consultation with a specialist for baseline FSH and estradiol levels and provocative testing after the age of 30.

Premature ovarian failure
Premature ovarian failure (POF) is the absolute cessation of ovarian function in women under age 40. This is typically heralded by the cessation of menses with accompanying hot flashes because the ovaries are no longer secreting adequate amounts of estrogen.

If the woman is under age 30 when her menses cease, it is imperative that she undergoes a chromosomal analysis to determine whether her ovaries are at risk for tumor formation. If she is at risk, the ovaries need to be removed.

Furthermore, premature ovarian failure is often linked with autoimmune disorders of other organ systems, most commonly the thyroid and pancreas, which puts the woman at risk for the development of hypothyroidism and diabetes. These and other autoimmune disorders require screening. Lastly, the lack of estrogen also puts women at risk for osteoporosis. Urogenital symptoms, including vaginal dryness and pain with intercourse can result if left untreated.

POF is a cause of infertility and affects approximately 250,000 US women, according to the National Institutes of Health. While only one woman in 10,000 will suffer from POF by age 20, the rate increases with age, affecting approximately one woman in every 1,000 by age 30 and one woman in 250 women by age 35.

Donor eggs
The mainstay of therapy for women with POF or decreased ovarian reserve who desire children is donor egg. With this therapy, the eggs of the donor are retrieved and in-vitro fertilization is performed. The embryos are then placed in the uterus of the women afflicted with POF after she has taken hormones to build up the uterine lining to support a pregnancy.

The implantation and pregnancy rates with this therapy are excellent and mimic the health of the young donor's eggs. These donors are typically in their early 20s and motivated by a desire to help infertile couples. Donor egg is an effective and prevalent therapy in the United States, accounting for more than 10 percent of all in-vitro fertilization cycles performed.

Tests
A baseline FSH and estradiol level are simple blood tests that give us a means of gauging ovarian health. In women older than 30 or with other forms of infertility, it is recommended to repeat these two lab tests after taking two tablets of clomiphene citrate each day for five days. This additional lab draw often unmasks those women with decreased ovarian reserve that demonstrated normal baseline levels.

FSH and estradiol levels are efficient ways to measure ovarian health and diagnose POF in its earliest stages. These simple tests make sense for any woman who thinks she wants to have children -- even if she and her partner are not thinking of starting a family in the immediate future. Because diminished ovarian reserve occurs in women who are otherwise healthy, the test also can tell women whether or not they can afford to wait to have children and aid in diagnosing infertility in women experiencing difficulty conceiving.

Genetics plays a strong role ovarian health
That's why it's important for women to realize that age is not the sole factor when it comes to healthy ovarian reserve and the ability of the eggs to establish a healthy pregnancy. Young age can provide many women with a false sense of security. I've had patients as young as 28 take the FSH and estradiol blood tests and find that their ovarian function is declining.

However, the most common situation is where a woman has delayed childbearing and then at 35 discovers that she has decreased ovarian reserve. The natural reaction is: "How come no one told me about these simple tests?" Because these women are otherwise healthy, there are few indicators that would alert them to the fact that something was wrong. Ovarian function can decline without a woman even realizing it.

For POF, there is currently no cure and no effective treatment to restore normal functioning of the ovaries or to improve fertility. The National Institutes of Health (NIH) is conducting research that hopefully one day will lead to advances in treatment options for women suffering from POF. Until then, women can be proactive and get their FSH and estradiol levels tested if they are having difficulty conceiving or they are over age 30, even if they are not planning a family at this stage in their lives.

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About the author: Mark R. Bush, MD, of Littleton, CO-based Conceptions Women's Health and Fertility Specialists, has extensive experience in all aspects of reproductive endocrinology, infertility and assisted reproductive technologies. Dr Bush received his medical degree from Georgetown University and completed a fellowship in infertility issues at Duke University Medical Center. Among his many awards is the American College of Obstetricians and Gynecologists CREOG National Faculty Award in 2001. For more information about Conceptions Women's Health and Fertility Specialists, visit www.conceptionsrepro.com.