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Archive for the ‘Anti Mullerian hormone’ tag

Is Your Biological Clock Running Out?

By David Kreiner, MD

January 10th, 2014 at 10:35 pm


image courtesy of photo stock/freedigital

Tears start to course down the cheeks of my patient, her immediate response to the message I just conveyed to her. Minutes before, with great angst anticipating the depressing effect my words will have on her, I proceeded to explain how her FSH was slightly elevated and her antral follicle count 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 barely treatable in their 40s.

A common reason women delay seeking help is the trend in society to have children at an older age. In the 1960’s it was much less common that women would go to college and seek a career as is typical of women today. The delayed childbearing increases the exposure of women to more sexual partners and a consequent increased 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. They 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 aging results in natural depletion of the number of follicles and eggs with an increase in the percentage of these residual eggs that are unhealthy and/or genetically abnormal.

Diminished ovarian reserve is associated with decreased inhibin levels which decreases the negative feedback on the pituitary gland. FSH produced by the pituitary is elevated in response to the diminished ovarian reserve and inhibin levels unless a woman has a cyst producing high estradiol levels which also lowers FSH. This is why we assess estradiol levels at the same time as FSH. Anti-Mullerian Hormone (AMH) can be tested throughout a woman’s menstrual cycle and levels correlate with ovarian reserve. Early follicular ultrasound can be performed to evaluate a woman’s antral follicle count. The antral follicle count also correlates with ovarian reserve.

By screening women annually with hormone tests and ultrasounds a physician may assess whether a woman is at high risk of developing diminished ovarian reserve in the subsequent year. Alerting a woman to her individual fertility status would allow women to adjust their family planning to fit their individual needs.

Aggressive fertility therapy may be the best option when it appears that one is running out of time. Ovulation induction with intrauterine insemination, MicroIVF and IVF are all considerations that speed up the process and allow a patient 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 and act accordingly.

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Did you realize that aging is not the only factor in the biological clock race? Did you know that certain conditions, like endometriosis, can play a part, too?


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IVF When Single

By David Kreiner MD

February 17th, 2012 at 3:33 pm

No knight in shining armor? No Mr. Right? Biological clock pounding in your ear?

Long Island IVF’s Dr. Kreiner helps the single ladies out there TTC who’ve found themselves at a “reproductive crossroads”:

Last week a patient presented to my office with a question that made me feel like I was responding to a Dear Abby letter requesting help to make some crucial life decisions that were related to her reproductive health.  As I pondered her query that I had heard so many times before I wondered how terribly nerve racking it must feel like for this woman.

Dear Fertility Doc,

“I am 39 years old, single and I enjoy my career.  However, I always dreamed I would have children.  Unfortunately, I have not yet met a man that I would feel comfortable with to marry and with whom to have a baby.  What should I do?”


At Reproductive Crossroads

The issues that this woman brings up are universal in my practice.  She basically has to weigh her desire to have children now rather than delay, using her own eggs or potentially with an egg donor or to adopt.   She needs to consider the ramifications of taking time off from her career as well as creating a child with donor sperm.  She expressed concern to me that if she were to meet Mister Right how will he respond to this child?  Are there any tests that I can perform that can help this woman make a decision?

First of all, it is imperative in cases like this to do a full fertility screen so that we understand from a fertility perspective how much time she has left and how urgent this patient needs to make a decision. 

To assess her fertility I do a Day 3 serum Estradiol and FSH, an AntiMullerian Hormone and a sonographic antral follicle count.  The FSH is regulated by negative feedback from serum Estradiol and inhibin both of which are produced by the granulosa cells of the ovarian follicles.  With diminishing ovarian activity there are fewer follicles, less estradiol and inhibin so with less feedback, the FSH level is high.  Occasionally, in patients with low ovarian activity, often called reserve, a patient may have an ovarian cyst that produces estradiol.  This will lower the FSH level to otherwise normal activity levels even when there is minimal ovarian activity and inhibin.  One would misinterpret the low normal FSH in the presence of higher estradiol which is why this must be measured concurrent with FSH.

AntiMullerian Hormone is also produced by the granulosa cells and low levels therefore indicate depleted ovaries.  Likewise, few antral follicles seen on ultrasound typically performed during the early follicular phase of the cycle will indicate low ovarian reserve.

Once we know a patient’s relative fertility through this screen we need to decide whether she is prepared to delay her career for pregnancy and motherhood or should she do IVF and freeze her embryos thereby freezing her fertility potential at the current state.

Since she is single without a participating partner we would be using the sperm from an anonymous donor.  The specimens are obtained from sperm banks that are certified byNew YorkStateby virtue of their screening and testing for infectious and hereditary diseases.  Patients may review what is available from the sperm banks.  They can review on the internet the donor’s demographic information, physical attributes, educational and occupational histories, etc for the offered specimens.

If a woman does not have any infertility issues I would attempt donor insemination.  However, due to her advanced age, I would progress to more aggressive therapies if we were not successful after a few cycles.

A common concern for women in this circumstance is that they may meet their soul mate in the future and he may not be comfortable with a child produced with someone else’s sperm.  This is an issue that is very individual and I can only offer to support the patients as they decide what is best for them.

As she prolongs the decision her fertility is diminishing, and thereby risks not being able to have a child using her own eggs.  If conceiving with one’s own eggs is crucial then she must weigh the downside of conceiving a child from an anonymous donor and if she does so, the potential problems associated with finding a man in the future who she may want to have a family with.

It is enormously stressful making these decisions at these reproductive crossroads.

I discuss these issues with my patients and help them arrive at the decision that is right for them.

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Do you go forward with single motherhood, figuring the true Mr. Right would accept this child from your egg and donor sperm? Or do you wait, remain childless, and hope to find Mr. Right only to give up your ability to use your own eggs, having to use donor eggs and his sperm? What would you do?


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