Ovarian Failure

Delaying child bearing is more common today as more women focus on establishing their careers and decide to marry later. Although the life expectancy has increased, the reproductive window has not, with the average age of menopause remaining around 50 years. The decrease in fertility begins about age 35, and accelerates after age 37. Fertility is almost 0 by the age of 45. Along with the decrease in fertility, there is an increase in the risk of miscarriage, with a rate of 35% in women over 40 years of age. Women with premature menopause can experience this age related decline in fertility much younger.

The decrease in fertility with age is due mainly to ovarian aging and a decrease in ovarian reserve. Women are born with all the eggs that they will have throughout life. Every month, besides ovulation, several hundred eggs die in a process called atresia. Most women lose their best quality eggs earlier in their reproductive lives and the eggs that remain in the ovaries of women in their forties are mostly abnormal. These eggs offer fewer chances of fertilizing, implanting, and maintaining a normal pregnancy. Age is also associated with higher risks of chromosomal abnormalities, such as Down syndrome, which increases from 1 / 500 at 20 years of age to 1 / 20 at 45 years.

In addition to ovarian aging, uterine abnormalities, such as fibroids, polyps, adenomyosis, and other problems, such as endometriosis and scar tissue ( adhesions ), become more common as women age. Sperm count also is adversely affected by male age.

Treatment options in older women usually involve superovulation ( administration of ovulation inducing drugs ) to increase the number of eggs released per month. However, older women often respond poorly to the stimulation, thus IVF success rates are much lower than in younger women. The live birth rates per IVF attempt are approximately 15% for females at age 40 compared to less than 5% for females over 42.

Other strategies in older women undergoing IVF include assisted hatching of the embryos, or preimplantation genetic diagnosis, which allows the transfer of genetically normal embryos. Unequivocally, the highest success rates are seen with egg donation with pregnancy rates over 50% per IVF attempt.

Embryo donation, surrogacy, and adoption offer other options for fertility.

Decrease ovarian reserve and ovarian failure.

Although the average age of menopause is 51 years, some women experience ovarian failure and stop ovulating prior to age 40. Often, this is associated with an autoimmune disease, such as thyroid dysfunction or surgery on the ovary. Therefore, the Jones Institute performs hormonal testing to assess ovarian reserve in all women regardless of age, as well as ultrasound for ovarian volume and antral follicle count.

The reduction in number of follicles and eggs leads to a decrease in levels of estrogen and progesterone, resulting in elevated levels of FSH and LH. Most commonly, we measure the cycle serum levels of FSH, LH, estradiol, and sometimes inhibin B on day three. In cases of premature ovarian failure, karyotype ( chromosomal analysis ) and thyroid antibody testing is performed. Although 5 - 10% of patients with premature ovarian failure become pregnant, there is no proven method to increase the chance of conception in women with high FSH levels.

Low ovarian reserve is a good predictor of poor stimulation in ART and in combination with age predicts a low chance of pregnancy. Egg donation is recommended to these women.