Beating Your Biological Clock
by Sherman J. Silber
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Summary Of How You Can Preserve Your Fertility
1) Transvaginal ultrasound examinations are routinely performed by gynecologists, obstetricians, and IVF doctors, as well as in radiology imaging centers, but no one has bothered before to pay close attention to the small one- to two-millimeter follicles present in the ovary because no thought was given to their great significance. Thus, you will probably have to understand the scientific detail that has preceded this summary in order to explain to your physician what you would like to have done. I am sure that in the next five years we will see a revolution in the counseling of young women so that in addition to their yearly Pap smear, they will have this simple ultrasound exam to guide them in their reproductive planning. But it is not just a routine exam that I am suggesting — it is a specific counting of the number of one- to two-millimeter follicles, the so-called antral follicles [see video]. This number is constant throughout your menstrual cycle and gives a true measure of your reproductive outlook.
2) The antral follicles (the small one-millimeter to two-millimeter follicles located on the surface of the ovary) should be abundant in number, certainly greater than twenty. Your antral follicle count is the same at any time during your menstrual cycle and is unrelated to any hormone-dependent aspect of your monthly cycle. This makes sense because the follicles are not visible to ultrasound until they reach the size at which they first become hormone dependent. Thus, there is a continuous daily process of antral follicle formation that began nearly three months earlier (seventy days) with the emergence from the resting follicle state.
3) There are problems with all the other methods of trying to determine ovarian reserve. The day three FSH, the day three estradiol, and even the Clomid challenge test have been shown to be very faulty and to reveal a problem only if you are near the extreme edge of the reproductive lifetime. Ovarian volume and overall physical fitness have no relationship to the number of eggs you were endowed with at birth. Normal twentyeight day cycles and ovulation detection kits are also of no use whatsoever. Even women who are in their forties, with very few follicles left, can have normal twenty-eight-day cycles and ovulate.
4) The antral follicle count can then be used to determine when you will be likely to have your last naturally conceived child, and even when you are likely to go through menopause. Of course, a high antral follicle count does not guarantee that you are fertile. However, the age-related decline in fertility that people are most worried about in making their life decisions can be determined by the antral follicle count. Of course, even with many eggs, older women are less fertile than younger women with the same number of eggs. But if at a young age, you have a low antral follicle count, that surely means you are in trouble and have to take some action.
5) Once you know where you are on your biological clock, you can now do something about it. You can have your eggs frozen, or ovarian tissue biopsied and frozen, and thus preserve your fertility for the future, and thereby expand your reproductive lifetime.
Age-Related Decline in a Woman’s Fertility
Most Infertile Women Were Once Fertile
Most infertile women were fertile when they were younger. In their early twenties, less than 2 percent of women are infertile. But by their late twenties, 16 percent are infertile, and by their mid thirties (when, in the modern era, most women will first begin to think about having a child), almost 30 percent are infertile. Nonetheless, some women remain fertile into their forties, while others lose their fertility early in their twenties. At some point in time, as the biological clock ages, no matter how much you spend on sophisticated treatment (other than donor eggs), you will no longer be able to get pregnant and have a baby. You need to figure out at what age this will occur for you, and how you should plan your life. Whether you are a young woman in her early twenties who has just finished college and wants to pursue a career, or whether you just want to learn more about relationships and grow further emotionally before you finally settle down, this inexorable biological clock, which you have heard so much about, will become perhaps your major conflict in life.
Where Are You on Your Biological Clock?
Although we know that the biological clock is inexorable, the dilemma that most women face is not knowing just where they personally happen to be on that time scale. Women in their late twenties can be infertile, and women in their early forties can be fertile. Although all women undergo an eventual decline in fertility, the big question for every individual woman is just when that will be. If the 44 year-old woman could have known twenty years earlier that she would retain her fertility into her mid forties she might have avoided two decades of worry and fear. If the twenty-six-year-old woman had known she would run out of eggs so early in life, she and her partner might have planned their lives differently as well.
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