Never a Better Time to Try

You’ve waited until the time was just right in your life to try and have a baby. Or you’ve tried to get pregnant for months now and are worried that the chance may be passing you by. The last thing you want to hear is that the older a woman is, the harder it is for her to get pregnant and have a baby.

“It’s an unfair reality,” sympathizes Dr. Gilbert Mottla of Shady Grove Fertility’s Annapolis office, “but it is far from being a hopeless situation.”

The good news, he says, is that there’s almost no one who cannot benefit from today’s latest fertility treatments.

Our Current Understanding of Age and Fertility

Dr. Mottla and other experts refer to a disconnect between our society and biology. Not so long ago, women typically welcomed pregnancy when they were younger. Culturally, our activities have stretched out over a greater timespan, in part maybe because we’re living so much longer. It’s only been in the past handful of decades that people in their 20’s are very often still not ready to “settle down and have kids.”

Though our bodies are living longer, our fertility remains concentrated in our very young adulthood. No matter what you think about the “best time” to have a baby, cellular issues stand in the way of successful pregnancy.

There are marked biological differences in fertile potential for men and women. Men generally continue to make brand new sperm cells until well into elderly ages. Women, unfortunately, are born with all the egg cells they’ll ever have.

When a healthy girl baby is born, she usually starts her life with roughly 300,000 egg cells. Roughly 50 years of reproductive lifespan equates to about 300 ovulations. The rest of those eggs grow and wither each month. Younger egg cells have a greater chance of dividing normally upon fertilization. Older egg cells more often wind up creating embryos with too many or too few chromosomes (aneuploidy) such as Trisomy 21 which results in Down Syndrome. A host of other chromosome abnormalities result in more frequent miscarriage for older women.

“There’s no way to ‘save’ eggs in advance,” he explains. “It’s not possible to use birth control pills, pregnancy, or drugs like Lupron to sort of suspend good egg cells in your ovary and keep them on reserve.”

Menopause happens. Dr. Mottla says that “the wall” of fertility for most women is around age 44 -- which is actually about a decade prior to the time known as menopause.

“Women who experience menopause at age 40 or older are considered medically normal. Menopause at younger than 40 is called premature. Women begin losing fertility roughly 10 years before menopause.”

There’s an important point that Dr. Mottla aims at our fitness-obsessed society: age-related loss of fertility is not related to overall health.

“This type of infertility is not a health or longevity issue; it’s not an anatomy problem. It’s not the uterus that ages, it’s not the fallopian tubes. It’s the egg cell itself,” Mottla says. He says that women beyond menopause, so long as there are no other serious health conditions, have been able to successfully maintain pregnancies with the use of egg cells from younger donors.

“There’s no real way to positively influence the health of your eggs, although certainly there are behaviors that can detract from your egg cells’ viability -- smoking, chemotherapy, and some drugs.”

“Women in particular need to balance recognizing their biology and making informed decisions,” says Dr Mottla, and women today are in a much better position to do both.

Assessment and Evaluation of Fertility Potential

Testing to determine a woman’s ability to conceive will vary depending on their age. Test results are used to help counsel patients on what their prognosis is and what kind of treatment may help maximize that potential.

Levels of follicle stimulating hormone (FSH) and estrogen are measured by taking blood samples on the third day (Day 3) of a woman’s menstrual cycle. These numbers will help predict if a woman’s ovaries are still ovulating “good” eggs.

A low FSH is good. A high number will indicate that the pituitary gland is pushing an ovary that’s becoming stubborn and not making eggs easily.

A stimulated test, called the Clomid Challenge Test (CCT), resembles (in terms of cardiovascular health diagnosis) a “stress test” as compared to a Day 3 FSH which might be analogized as an EKG administered to someone sitting still. The woman takes the drug called Clomid, which stresses the ovary, and results can be compared to the static FSH result.

More recently a very predictive sonogram test -- the antral follicle count (AFC) -- can render images of the ovary so that resting follicles can be counted. Resting follicles are waiting in reserve for ovulation. The size of a woman’s ovaries and the number of resting follicles can help physicians determine which treatments would most likely render the best results.

Customized Treatment Options, Tailored to Your Window of Opportunity

Results from diagnostic fertility testing are discussed with patients from the perspective that the least amount of optimal treatment is the best place to start.

"The goal of reproductive medicine is to raise a couple's sub-fertile conditions up to normal levels of fertility," Dr. Mottla says. "For some, that could mean nothing more than ovulation induction and intrauterine insemination, IUI."

He offers an example of how experts piece together the fertility puzzle for a patient:

“If a 35 year old woman has an elevated FSH, an abnormal CCT, a low antral follicle count, her window of fertility is limited. We don’t propose to put a number in terms of timeframe on a person’s fertility, but it’s clearly limited compared to a woman with better numbers. That couple might want to maximize their treatment efforts, say with IVF.”

IVF cuts fertility corners in numerous ways. “We can do things we can’t do with insemination. We can maximize the number of available eggs. We can fertilize the eggs through either insemination or sperm injection. We can choose the healthiest embryos and transfer them back to the uterus.” These are all points along the pregnancy path where things can go awry, and where IVF can optimize success along the way.

In addition, Dr. Mottla points out that if additional embryos are created from the IVF process and frozen, when the couple returns to use them, “The embryos were literally frozen in time, regardless of how much older the mother has become by then.”

With pre-screening for health issues, Shady Grove Fertility has seen women in their late 40’s and as old as 50 come back to use their frozen embryos for successful pregnancy and healthy babies.

Finally, for people who’ve either tried and failed several treatments or who start trying to get pregnant very late and have no fertility remaining, egg donation with IVF can actually provide a way for the woman to be a birthmother to her child. “She has that nine month bonding experience, she can breastfeed… it’s the closest thing to a biological child that we can help couples with,” says Mottla.

Not Necessarily the End of the Line

Fertility is not an “on or off” concept. We may have the idea that menopause is an event that occurs more rapidly than it does in reality. Dr. Mottla hopes to convey that “the age of 35 or 39 is not a gong going off, sounding the end of fertility.”

“Things in biology happen in windows of time, across the board. When it comes to our health, whether it’s heart disease or fertility, people don’t typically go from healthy and normal to impaired in a day. The concept that fertility diminishes several years before menopause is something young women need to know about.”

“As a doctor, it’s exciting to always have something to offer your patients, and we do.”