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Is My Biological Clock Running Out?

By Dr. David Kreiner

Tears started to course down the cheeks of my patient, her immediate response to the words I just uttered to her. Minutes before, with great angst I proceeded to explain how her AMH (Anti Mullerian Hormone level) was low and her FSH was slightly elevated and on ultrasound examination her antral follicle count (the number of follicles visible on ultrasound) was a disappointing 3-6 follicles. I was careful to say that though this is a screen that correlates with a woman’s fertility, sometimes a woman may be more fertile than suspected based on the hormone tests and ovarian ultrasound. I also said that even when the tests accurately show diminishing ovarian reserve (follicle number), we are often successful in achieving a pregnancy and obtaining a baby through in vitro fertilization especially when age is not a significant factor.

These encounters I have with patients are more frequent than they should be. Unfortunately, many women delay seeking help in their efforts to conceive until their age has become significant both because they have fewer healthy genetically normal eggs and because their ability to respond to fertility drugs with numerous mature eggs is depressed. Women often do not realize that fertility drops as they age starting in their 20s but at an increasing rate in their 30s and to a point that may often be challenging to treat in their 40s.

Recent studies have reported a trend in society to have children at an older age. Over the years, some women may be exposed to increased sexual partners and therefore have a higher risk of developing pelvic inflammatory disease with resulting fallopian tube adhesions. When patients have endometriosis, delaying pregnancy allows the endometriosis to develop further and cause damage to a woman’s ovaries and fallopian tubes. Women are more likely to develop diminished ovarian reserve at a younger age due to the destruction of normal ovarian tissue by the endometriosis. Even more important is that as women age the number of follicles and eggs decreases and the percentage of those eggs that are nonviable increases.

Annual screening with blood tests for AMH and FSH on day 3 (should be combined with estradiol as a high estradiol can lower the FSH and give a confusing result) and ultrasound antral follicle counts allow a physician to assess whether a woman is at high risk of developing diminished ovarian reserve. Alerting a woman to her individual fertility status would allow women to adjust their family planning to fit their individual needs.

I recommend aggressive treatment when it appears that a patient is running out of time. Ovulation induction using hormone injections with intrauterine insemination and IVF speed up the process and allow a patient with diminished ovarian reserve to take advantage of her residual fertility.

With fertility screening of day 3 estradiol and FSH, AMH and early follicular ultrasound antral follicle counts, the biological clock may still be ticking but at least one may keep an eye on it and know what time it is on the fertility clock and act accordingly.