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. Nevertheless, viable and healthy pregnancy can be achieved by IVF in women 40-44 years of age.
Other strategies in older women undergoing IVF include assisted hatching of the embryos, or preimplantation genetic screening, which allows the transfer of genetically normal embryos.
Embryo donation, surrogacy, and adoption offer other options for fertility.
Decreased 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.
Tubal Factors
Tubal ligation (severing the fallopian tubes) is the most common form of permanent female sterilization and can usually be reversed surgically. Tubal reanastamosis (reconnection of the tubes) is a procedure performed through a mini laparotomy by a reproductive surgeon. The surgeon removes the blocked portion of the fallopian tubes and then microscopically sutures the tubes back together.
We offer tubal reanastamosis (reconnecting the fallopian tubes), which in otherwise fertile patients is the most successful type of tubal surgery. Success rates vary according to where the tubes were cut, if scar tissue has formed, and other confounding factors. We offer both IVF and tubal reanastamosis. The best method depends on the patient's age, semen parameters, and method of sterilization.
Before tubal reversal, a fertility evaluation is performed to ensure that ovulation occurs regularly and that there are no secondary causes of infertility. If other disorders are identified, they usually can be treated effectively.
Tubal reversal microsurgery should be performed by a reproductive surgeon with advanced training in microsurgery. The surgeons at the Jones Institute have undergone extensive advanced training and have vast clinical experience in laparoscopy and microsurgery.
Tubal Factor: Tubal Occlusion and Pelvic Adhesions
Tubal and peritoneal pathology is among the most common causes of infertility and the primary diagnosis in approximately 30% of infertile couples. A history of pelvic inflammatory disease (PID), septic abortion, ruptured appendix, tubal surgery, or ectopic pregnancy suggests the possibility of tubal damage.
Other causes of tubal factor infertility include inflammation related to endometriosis, inflammatory bowel disease, or surgical trauma. HSG and laparoscopy are the two classic methods for evaluation of tubal patency in infertile women and are complementary rather than mutually exclusive; each provides useful information that the other does not and each has advantages and disadvantages. HSG images the uterine cavity and reveals the internal architecture of the tubal lumen, neither of which can be evaluated by laparoscopy. Laparoscopy provides detailed information about the pelvic anatomy that HSG cannot, including adhesions, endometriosis, and ovarian pathology.
Distal tubal occlusive disease exhibits a wide spectrum of severity. HSG will generally reveal complete distal tubal obstructions but cannot reliably detect or define lesser degrees of disease when the tubes are patent. Laparoscopy is the definitive method for diagnosis of distal tubal occlusive disease and also provides the means for treatment. As might be expected, surgical outcomes are inversely related to the severity of disease. Results achieved with surgery for more severe disease have varied widely but success rates are overall low and usually result in increased risk for ectopic pregnancy. Postoperative tubal patency rates far exceed pregnancy rates; patency is more easily restored than function. The majority of pregnancies occur within the first two postoperative years. IVF is the treatment of choice for moderate-sever tubal inferility. If hydrosalpinges are present (blocked and dilated tubes), IVF results should be optimized by performing salpingectomy or proximal tubal disconnection (laparoscopically) prior to IVF.