to conceive with no success. They may learn they have primary ovarian insufficiency (POI, which is sometimes also called premature ovarian failure, or POF, in cases where the ovary has stopped working completely) when a physician takes—and often retakes—a Day 3 FSH (follicle stimulating hormone) level, AMH (anti-mullerian hormone) levels or levels of other hormones such as estrogen. Together, these tests can provide an indication of a problem with egg quantity and/or quality.
As if it is not confusing enough, there are some women whose FSH and other levels appear to be normal but who, nonetheless, are probably infertile due to poor egg quality. These women are usually considered to have unexplained infertility until they undergo more extensive testing. To everyone’s surprise, they are then found to be “poor responders.” This unfortunate label refers to those women who, even when prescribed large amounts of potent ovulation-stimulating drugs, fail to produce more than a few follicles at best. However they come upon it, the diagnosis of poor ovarian reserve in a young woman is bewildering and often devastating. Women wonder how this could be, what they might have done to harm their eggs, why they had no warning of a problem. Indeed, they, like their fellow travelers, will learn, again and again, that reproduction is a mystery, but, at the time of diagnosis, it is only natural to look for answers, for causes, for blame and responsibility. Some will explore environmental factors, such as exposure to toxic chemicals, which can damage both eggs and sperm. Others will wonder about genetics. For example, I (Ellen) have a client, a young physician, who was found to have POI at age 33. When she discussed this with her mother, who had had her three children in her 20s, her mother remembered that she had begun to experience symptoms of menopause in her early 30s.
When a young woman under 40 learns that she has “old eggs,” she faces several questions. The first is: is the condition permanent? While a 44-year-old woman with high FSH should be pretty certain that her egg supply is not going to be replenished, a young woman may wonder if the condition might reverse itself. Most reproductive endocrinologists have had a patient, here and there, who had elevated FSH, or otherwise documented poor ovarian quality, and who spontaneously became pregnant. Despite discouraging FSH or AMH levels, a good egg happens along and is fertilized. Sadly, this is not the norm.
In addition to hoping for a spontaneous reversal and pregnancy, questions inevitably arise about what a woman might do to improve her egg quality. Since it is a mystery why she has diminished ovarian reserve, she must also wonder whether there is something she can do to give her a better chance of conceiving. Some women have turned to acupuncture, diet or herbal remedies in an effort to reinvigorate or regenerate their eggs. In the book Inconceivable: A Woman’s Triumph over Despair and Statistics (2001), author Julia Indichova claims to have lowered her FSH through more holistic approaches. However, scientific evidence of women improving their egg quality through alternative therapies or diet is not well established.
The young women who come to the departure lounge for egg donation because they have “old eggs” may not be so quick to request egg donation. For one thing, they may need to take some time before they are really convinced that they can’t use their own eggs. Some are hoping for a medical advance that will resolve their problem. Or they may simply want to wait a bit in the hope that they may be one of the lucky ones who find themselves unexpectedly pregnant.
There are other reasons for waiting. Cost is one. Egg donation is costly, and young couples are the least likely to have the savings at hand to pursue this option. For them, infertility is all the more devastating because it comes at a time when they are still launching their careers and perhaps saving for a house.
FXPOI
FXPOI (Fragile X-associated primary ovarian insufficiency) is a condition in which the ovaries are not functioning at full capacity in a woman who is an FMR1 premutation carrier, which is the gene that causes Fragile X syndrome—a genetic condition that causes intellectual disability, behavioral and learning challenges, and various physical characteristics. Common symptoms of FXPOI include absent or irregular periods, symptoms of menopause such as hot flashes and vaginal dryness, and infertility. For women who are diagnosed with POI, it is important to know if you also have an FMR1 premutation. If you have already been tested and are confirmed to be a FMR1 premutation carrier, there is about a 20–25 percent chance you will also experience POI. While many women with the FMR1 premutation can become pregnant, all carriers are at risk for having children with Fragile X syndrome so it is important to talk with a genetic counselor about your risk.
Declining ovarian reserve
There was a time, not all that long ago, when a woman giving birth after age 30 was labeled a “geriatric mother.” In fact, there was a documentary in the 1970s called Joyce at 34 (Chopra and Weill 1973). It was about a couple who decided—at the “old age of 34”—to have a baby. The film shows the couple announcing their “geriatric” pregnancy to Joyce’s family, all of whom react with surprise and wonder.
The August 3, 2012, issue of the New York Times Magazine features an interview with then Cosmopolitan magazine’s editor-in-chief, Kate White, in which she says:
We ran an article that pained me to run, but I felt it was important. It basically said the key time to try to get pregnant is between 25 and 35. There has been so much said about still waiting until you’re older, and I didn’t have my first kid until I was 37, but we’re taking a chance—you need to know it. (Zimmerman 2012)
The author (Edith Zimmerman) writes, “I asked her why it pained her.” White offered the following response: “I want every girl to feel that she can have her first child at 50 if she wants.”
Perspectives have changed and the popular media has played a big role in promoting these changed perspectives. White openly acknowledges the wish to let women think that they can have children at 50, but she also acknowledges that biology has not changed. The fact is that although many women want to become pregnant in their late 30s and early 40s, and shifting social norms support this, women’s eggs still age at the same pace. Although some women are able to conceive successful pregnancies with their own eggs into their early 40s, the fact remains that women experience declining fertility after age 35 and rapid drop-off after age 40.
Many women in the departure lounge of egg donation are in their late 30s and early 40s. They have come here from various places. Some have delayed childbearing while others have been struggling with infertility for a number of years. Along the way their eggs have aged and diminished ovarian reserve compounds their problems. Some were worried about fertility all along and had considered having a baby on their own or explored egg freezing. I (Ellen) recently had a client who was one of the first to electively freeze eggs five years ago. Sadly, when it came time to thaw them and attempt pregnancy, few survived the thaw and none of the resulting embryos led to an ongoing pregnancy.
Another group are women with secondary infertility. Some may have had a child or children years earlier and now find themselves wanting another. However they got here, women who arrive at the departure lounge of egg donation in their late 30s and early 40s feel they are racing against a biological clock that is ticking rapidly. Each month that passes weighs heavily upon them. They fear that the last good eggs are slipping away, and they worry that even if they do conceive, they will be prone to miscarriage. FSH numbers loom large, taking on a life and power of their own.
Women with diminished ovarian reserve are not in menopause. These are women whose egg quality is declining, but it is unlikely that all their “good” eggs are gone. While fertility starts to decrease significantly after the age of 35, it is impossible to predict exactly when this will happen for individual women or how long a woman’s eggs will actually last. Hence they face a dilemma in considering egg donation: if they move forward and conceive with donated eggs, they may miss out on that one last opportunity to have a baby with their own eggs. Such “miracle” conceptions could occur with IVF or spontaneously. Some of these women face this dilemma and conclude that it is more important to have a baby now than to hold out for the off chance
