sperm.
For the first month after their initial visit to the fertility clinic, after having her cycle monitored, Avery and Walter had timed intercourse. It was more accurate than self-testing by peeing on a stick because the technician visually tracks the growth of the egg and follicle, and checks hormone levels via bloodwork. The nurse called, directing them to have sex as Avery would be ovulating within the next day or so.
Avery’s test results
Timed intercourse is the most basic intervention a fertility clinic offers. They administer no drugs, just monitor eggs and hormone levels so intercourse can coincide with ovulation. Unfortunately, Avery did not become pregnant this way. So a month after their first visit, Avery and Walter returned to meet with the doctor. The good news was that Walter’s sperm count was good: he had 100 million sperm per millilitre, well within the normal range of 20 to 300 million. Avery, however, was devastated to learn that, as a woman over age thirty-five, she had poor ovarian reserve (POR) and they would likely need greater intervention to achieve pregnancy.
Although the doctor said they could try a round of IUI, he warned them not to waste time and recommended they move straight to IVF before Avery “ran out of eggs.” Or perhaps, he suggested, they should use donor eggs from a younger woman, fertilized with Walter’s sperm. He offered these options while handing them a brochure for their donor egg program, which Avery interpreted as, “You are over the hill in terms of trying to get pregnant.”
Avery was in shock. She’d gone to the fertility clinic seeking hope and encouragement, and instead felt old, broken, and depressed. How could her eggs be too old when she had regular periods, was healthy, active, and looked younger than her age?
They decided to try an IUI cycle with a hormone medication called Letrozole to increase their odds of getting pregnant by releasing multiple eggs at ovulation. She produced two eggs, which the doctor said would double her chances of conceiving.
For two weeks after the insemination, Avery convinced herself she was going to have the baby of her dreams. After she went into the fertility clinic for an early-morning blood test, she waited anxiously by the phone for the results of the pregnancy test. Every passing minute felt like an eternity.
When she received the phone call that afternoon, the nurse apologized and told her the blood test had come back negative: she was not pregnant. She would need to return to the fertility clinic on the third day of her menstrual cycle to start cycle monitoring again. Instead, Avery came to my clinic.
What is poor ovarian reserve?
There are three main markers of poor ovarian reserve (POR):
•High follicle stimulating hormone (FSH). FSH is a hormone released by the pituitary gland (which is in the brain) to stimulate the growth and maturation of follicles and the eggs within them. Measuring a woman’s blood levels of FSH on day two or three of her menstrual cycle tests her ovarian function. If her FSH levels are above ten, it suggests she is approaching menopause because her ovaries are working harder to produce eggs. High FSH means the woman would respond poorly to IVF because FSH is the drug used to stimulate egg production.2
•If FSH is already high, adding more FSH will not help. Think of cooking with gas. You release gas to turn on the flame and start cooking. To a point, you can turn the gas higher to speed up the cooking. But after a certain point, more gas and a higher flame won’t help the cooking process; it will just burn the food. Similarly, in a woman’s body, adding more FSH will help stimulate egg production to a point, but after that point, it will actually make things worse.
•High FSH was once considered a key marker of POR, but we now know that FSH can go up and down over time, which makes it less reliable as a marker of infertility. That said, it is a reliable way to determine how women are likely to respond to FSH drugs. If FSH is normal, they’re likely to respond well; but a high FSH indicates a poor response to stimulation drugs for IVF since these drugs use FSH.
•Low anti-mullerian hormone (AMH). Until recently, women were thought to be born with their lifetime supply of ova (immature eggs), which secrete AMH. (Research has now shown egg precursor, or stem, cells in the walls of the ovaries of mice3 and women,4 dispelling this belief.) The amount of AMH in a woman’s blood, which remains constant throughout her menstrual cycle, is considered a good indicator of the quality and quantity of remaining eggs in her ovaries, and therefore a better measure of ovarian reserve than FSH.
•That said, AMH levels are considered controversial, because it’s unclear how accurate or cost-effective it can be at predicting live births or improving reproductive health care, and there’s a lack of international standards for interpreting test results accurately.5 And personally, I have witnessed some women’s AMH improve with treatment.
•Low antral follicle count (AFC). AFC is the number of follicles visible on day three of a trans-vaginal ultrasound. Each antral follicle contains one immature egg, which potentially develops and is released by the ovaries during ovulation. AFC indicates a woman’s ovarian reserve, expected response to ovarian stimulating drugs, and chance for successful pregnancy through IVF.
•For IVF, the more antral follicles visible to stimulate with hormones from the third day of menstruation, the greater the chances of having them all mature so they can be retrieved surgically through the vagina and become fertilized in a petri dish. More follicles mean potentially more embryos and a greater likelihood of conception.
What TCM thinks of your “old” eggs
When Avery started trying to have a family at thirty-six, like many women her age, she believed she had lots of time to have a child. She began worrying about her age when, at thirty-eight, she still hadn’t conceived. Unfortunately, her fertility doctor did not provide comfort or reassurance. When she came to see me, she was not only upset that she hadn’t conceived after her first IUI but was still troubled by the things her doctor said at their first appointment. She didn’t know how to get past the statistics the doctor had presented and she admitted to having negative thoughts and feelings that were interfering with her ability to stay positive.
Instead of talking about biological age as markers for fertility, in TCM we speak about fertility in terms of our vitality and energy. In the ancient practice of TCM, we believe we are born with a certain amount of energy, which we inherit from our parents. This finite amount of energy is referred to as Jing Qi (primordial, congenital, source energy, or Essence). In addition, we are able to tap into and produce energy through food and drink, which TCM refers to as Gu Qi (acquired nutritive energy). We also acquire energy from the air (oxygen) we breathe and metabolize it into usable energy for our bodies. This includes energy for procreation. While we can replenish the nutritive Gu Qi, our Jing Qi declines with age and living.
Women’s energetic life stages
Chinese medicine goes on to say that women and men have energetic stages in their lives. For women, these stages are in cycles of seven years (for men it’s eight):
•At seven, a girl’s Jing essence (her inherited energy) becomes bountiful and manifests in permanent teeth and healthy hair.
•At fourteen, she enters puberty as her essence fills her reproductive organs and menstruation begins.
•At twenty-eight, her sexual energy peaks.
•At thirty-five, her sexual essence begins to decline. Jing Qi energy is divided into different functions, which includes sexual energy/essence.
•At forty-nine,
