Fertility At 40 After Having Had Children Earlier In Life: Is It Still Good?

Question:

Hello. I just turned 40 years old. I am healthy. I had 1 miscarriage in my early 30s. I waited a few years to conceive after that and conceived two children back to back in the first month of trying so I am hoping my fertility is still good. Obviously Im reproductively old and there is an issue of egg quality. Is it always better to try to conceive naturally. We are worried about chromosomal disorders. I had testing done at a fertility clinic. My AFC was 14, my FSH was 6 point something and my AMH was 5 point something. Can you help me interpret this? Again, is it always better to try to conceive naturally? Thanks!!! S. from the U.S.

Answer:

Hello S. from the U.S.,

Having had children previously does extend your fertility in my opinion so although you are "reproductively old", you may still be quite fertile.

The tests mentioned, AFC, FSH and AMH are all INDIRECT measures of ovarian function and NOT fertility or egg quality.  They give us an idea of how well the ovaries will respond to stimulation, which statistically can increase or decrease your chances of success.  In older women, the more eggs you get in an IVF cycle, the higher the chances of finding a good egg because there are fewer good eggs with increasing age.  That is all that those tests reveal.

In terms of what may be the best way to get pregnant, certainly trying natural has significant advantages: it is more fun and pleasurable, it costs less.  The disadvantages are: there is an increased risk of genetic disorders (based on your age), it may not work, and there is a higher risk of miscarriage.  So, in terms of whether to try naturally or go with a technological means, it depends completely on your personal preference and goals.  Unless you want to do something like genetic testing of embryos for normality or sex selection or want to increase your chance of pregnancy in the shortest possible period, then I would recommend that you try naturally for at least 6 months.   If not successful by that point, then I would recommend that you consider proceeding directly to IVF, which is the recommendation if you say yes to either of the previous criteria.  The downsides of IVF are: cost, not fun, unnatural and it's a medical procedure.  The upside is it is more efficient (higher chance of pregnancy per attempt, you can genetically test the embryos to minimize the risk of miscarriage or genetically abnormal child and you can achieve pregnancy faster.  Because your ovarian testing is so good (more like a 20 year old), you are a very good candidate for IVF and I would probably give you a high chance of success per attempt (50-60%) in a good IVF center.

 

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

 

Stage 2 Endometriosis Patient: Life & Fertility After Lupron?

Question:

Hi. My name is B. I am 26 and I live in Mississippi. I was diagnosed with Stage 2 Endo in June of 2009. Within 4 months of the lap (performed in June) I was already experiencing high levels of pain during urination, bowel movements and intercourse. My doctor had previously recommended Lupron, but I had declined so I went on continuous birth control. I still had high amounts of pain on a regular basis. I decided to do the treatment after the pain returned so quickly.

While on the shots, I didn't experience nearly as many hot flashes as I had expected and I only gained about 12 -15 lbs. I had my last shot about 27 days ago (3.75mg) and I want to know what I can expect.

When should I start having a cycle again? Also, I have had some mild-moderate pain during the last 3 months of my treatment and occasionally what felt like menstrual cramps. My doctor said he thought it was probably scar tissue.

Any thoughts on the pain I experienced during the second half of my treatment? Any thoughts on my statistical time frame for the possibility of having a family vs. infertility. My boyfriend is very cynical and doesn't believe my best chance at a family is within the next two years. How adamant should I be about going for it considering my circumstances? Thank you!

Answer:

Hello B. from Mississippi, let me answer your questions in sequence:

1. In general, the normal cycle will resume within 3 months of the last month of Lupron injections. That means, give yourself three months after the one month from the injection.

2. I can't explain the pain that you had in the last 3 months of treatment. Scar tissue is a possibility but the symptom is so nonspecific that I can't give a more definite answer.

3. In general, I advise patients to begin trying for pregnancy immediately after completing a Lupron treatment because there is a 6 month window before the endometriosis will return and inhibit fertility. If you are not in the position to try for pregnancy right away, then you should follow the Lupron with some type of prophylactic treatment to prevent the immediate return of the endometriosis. I recommend Depo provera but if you don't want to take this, then a low estrogen dose, high progesterone birth control pill is second best. Do not use a high dose estrogen pill (30mcg or greater) because the estrogen feeds the endometriosis. Again, Depo provera is my preference.

4. Lastly, I hope you don't mind this piece of advice: You should never insist on having a child with a partner. It needs to be a mutually acceptable proposition. Having a child is a life-changing event. You want your situation to be stable before then.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Twitter with me at @montereybayivf and follow me on Facebook at http://bit.ly/9Iw9oV

Very Weak, One-Day Menstrual Flow - Is There Something Wrong & Will It Affect Fertility?

Question:

I am a 26 year old female and for the past few months I have been having very weak periods that often last no longer than a single day. They are so weak that I don't need to use tampons and pantyliner will suffice. They are however extremely regular and fall every 30 days. I came off the pill last year and for after a few months my periods returned to normal. It is in the past 6 months or so that they have become so weak that they are causing me concern. A few years ago, I had a big cyst on my right ovary and late treatment meant it twisted and resulted in me having to have one ovary removed along with the cyst. I have researched possible reasons for weak periods and polycystic ovaries seem to be one of the main explanations. However I do not have any of the other symptoms usually associated with this condition and I am not over- weight.

I am extremely concerned of the implication my weak periods may have on future fertility but when I have taken my concerns to my GP he has dismissed them. I was hoping you could maybe give me some possible reasons as to why this may be happening.

Many thanks for your time. K. from the U.K.

Answer:

Hello K. from the U.K.,

The amount of bleeding a woman has with her periods is dependent on the amount of tissue there is to slough. That is, the thickness of the endometrial lining. Even if the amount is small, at this point it would not be of concern. The amount of bleeding will vary from person to person and cycle to cycle. As long as your cycles are regular, that is the important part. Certainly if the endometrium is not developing adequately, that could impair implantation of the embryo and your fertility. But, I doubt that would be the case. I would not worry about this at this point in time. Just wait and see what happens when you begin trying for pregnancy. If you have difficulty, then testing and evaluation will be done to see if the endometrium is not developing adequately. If that is the case, then supplemental hormone can be given.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Alchohol Effects on Sperm

Question:
Hello and thanks in advance for your services. I'm a 24yr otherwise healthy male, and my fiance is a 22yr old healthy female. My question is can alcohol affect fertility? I recently was a heavy drinker and party goer, drinking around 8 beers a day and on the weekends more, I know the health affects it has on my body otherwise that is why I dont do this anymore. Me and my fiance was looking to have a baby and about a week ago, when I was still partying hard, she doesn't drink but MAYBE once a week, and during this particular night she endulged in quite a few, we came home and had unprotected sex in hopes that maybe we could conceive, it was around the 13th-16th day of her cycle. My question is what are the chances we could concieve given my strong previous alcohol use before and that night, and her VERY mild alcohol use before but strong that night?????

Answer:
Hello Michael from the U.S.,
　
Yes, alcohol can affect one's fertility, both male and female. Male sperm is produced on a 90-day cycle. That means that the sperm you are producing today won't come out for 90 days. So, whatever you did 90-days ago (alcohol or drugs) that may have affected the sperm production and quality, will be manifest in the sperm you give out today.

If you are trying to conceive, then both you and your fiance have to lead a healthy lifestyle in order to enhance your fertility and so that you have a healthy baby. That means no smoking, no alcohol, no drugs, healthy diet and exercise.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf

CHOOSING A FERTILITY SPECIALIST

I've often been asked by patients, when and how to choose a fertility specialist. The question they have is whether to stay with their current OB/GYN physician or seek out an infertility specialist. First, if you are undergoing some evaluation and possibly treatment by a Family Practice physician or General practitioner, you're in the wrong hands. Your doctor may feel he or she can do infertility, and may have had some exposure to infertility in their training, but it was hardly enough for them to be evaluating and/or treating infertility patients. I have even had patients that were under the care of physician assistants and nurse practitioners! These are the wrong providers for your problem. Speciality care should be done by a specialist, an OB/GYN physician, Infertility specialist or Reproductive Endocrinologist, not a general practitioner. See "Infertility Evaluation" for more information.

The easy answer to the question is seek out the physician that you feel you need to see. If you want a basic level of evaluation and treatment, or want minimal intervention, then most OB/GYN physicians have adequate training and knowledge of infertility to help you. However, this varies among OB/GYN docs so make sure your doc has this knowledge. One good way of screening is to simply ask what levels of treatment they provide: Clomid ovulation induction, Gonadotropin ovulation induction or Insemination (artificial insemination)? I would choose a doc that can do at least insemination. If they don't do that, then their training and knowledge is probably not adequate for your needs. The problem with docs that only do a little, is they tend to get stuck in the little that they can do and are slow to refer you to a higher level of care. For example, a doc that can only do Clomid ovulation induction, but not insemination, tends to treat their patients for months with just Clomid, often without even doing a complete infertility evaluation to see if this is the best treatment. Clomid ovulation induction should probably not be done for more than 6 months. If your doc gives you a prescription for Clomid, that is a year's supply, and says call me if you miss your period, then you need to find another doctor. Or, if you go to your doctor with your infertility problem and the doctor sends you away with a Clomid prescription before even suggesting an infertility evaluation, then that is another sign that you need to seek out a different doctor. As a consequence, you end up losing valuable time, and money. A good OB/GYN and Infertility specialist will lay out a clear and concise plan for evaluation and treatment, and give a defined timeline for each.

However, that being said, you may also want to avoid the clinic that provides only IVF, because they will not offer other choices of evaluation or treatment. If you are just starting your infertility care and evaluation, that may be the wrong choice for you. Many large IVF clinics are like that. They only provide IVF. You want an infertility specialist that offers IVF, in addition to, a broader level of evaluation and care. Find someone who can provide all levels of infertility evaluation and treatment.

So, when should you seek a specialist? The answer is when you feel you need a specialist. For some that will be right from the start, when you realize you are not getting pregnant. For others, that will not be until they have exhausted their options with their Ob/Gyn doctors. My advice is this: if you are under 35 years old, then either a well-trained Ob/Gyn doc or an infertility specialist will do, depending on your problem. If you decide to go to an Ob/Gyn doc, then do not spend more than 6 months on a treatment plan. If it doesn't work by that time, then it's time to move on. If you are over 35, then you should go directly to see an infertility specialist, because time is working against you. Also, if you have tubal blockage, stage 3 or 4 endometriosis, a very bad semen analysis or failed four IUI's, then you should see an infertility sub-specialist directly.