I wanted to post something on a topic that I think is extremely important - evaluating your ovarian reserve.  For those of you who have already started down the road of infertility evaluation and/or treatment, some of this might sound familiar. 

Currently, there are several ways to evaluate ovarian reserve.  There are tests of hormonal levels (FSH, estradiol, AMH, and  inhibin B), ultrasound tests (antral follicle count, ovarian volume and ovarian blood flow), and dynamic tests (clomiphene citrate challenge test.)  The most important and predictive parameter of all however, is something very simple and inexpensive, and isn't actually a test at all - it is simply the woman's AGE.  It turns out that age is the most important factor influencing reproductive outcome. 

Observations of natural and IVF birth rates grouped by age illustrate this concept nicely.  In studies of natural populations of woman who are not using any consistent method of contraception, it has been shown that fertility starts to decline after age 30, and this decline accelerates in the mid 30's, leading to sterility at a mean age of 41. We see this same phenomenon of fertility decreasing with age in the IVF success rates -  the CDC's published 2009 national live birth rates percentiles are in the 40's for women under 35, in the 30's for women age 35-37, in the 20's for women age 38-40,  in the teens for women age 41-42, and less than 5% for women age 43-44.  If you look at donor egg recipient cycles however (in whom the women are often in their late 40's) the live birth rates are a striking 55%. The donor's age is usually less than 32.  These observations I think, illustrate nicely the concept that fertility (both natural and IVF achieved) declines with age, and this decline is due to ovarian aging.  That is to say that if an  older woman were to use a younger woman's eggs, as is done in egg donation cycles, that this older woman can reinstate her fertility rates that she had when she was younger.  

So as we can see, AGE is a very important predictor of a woman's chance at having a live birth (except in the case of egg donation.)  However,  fertility potential DOES vary among women in each age group.  In a group of women who are all 30 years old, for example, some may have a better chance of getting pregnant than others, due to differences in ovarian reserve.  Likewise, in a group of women aged 42, some may also have a better chance of getting pregnant than the others.  (As a general rule however, the group of women aged 30 have a significantly higher chance of conceiving than the group of women aged 42 - that is true even in women aged 30 who have lower ovarian reserve.)  This is where the "ovarian reserve testing" comes in - the tests that you may have, the ones that are mentioned above, may help us to distinguish where in your age group you fall, in terms of fertility potential.  

In my next several blogs, I will begin to weed through the various ovarian reserve tests that we do, giving you some information on each one, with the hopes of clarifying what all of this information may mean for you.  Stay tuned......

Rachel Bennett M.D. 
www.WestchesterReproductiveMedicine.com 

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It's been several weeks since my first post.  I have spent these weeks thinking about what the most useful posts would be for women and couples who will be reading my blog and have decided that initially at least, I would like to answer common questions that women who are trying to get pregnant, and may be going through infertility treatments, may have.  FYI, I have many years of medical experience treating patients in this field.  I finished residency in OB/GYN at The New York Hospital/Cornell Medical Center in 1993 and immediately did a fellowship in reproductive endocrinology and infertility at Harvard's Brigham and Women's Hospital from 1993-1995.  Since finishing fellowship in 1995, I have accumulated (now) 16 years of practical experience treating patients.  In 2006 I started Westchester Reproductive Medicine, as I wanted to create a more personal, intimate and nurturing place where women could get the help they needed.  Since I do  every procedure on every patient and therefore have excellent followthrough on the treatments, my years so far in my new practice have been invaluable in giving me even more insight into the best ways to treat various situations.  My blogs will therefore be aimed at imparting the knowledge and wisdom that I have acquired from taking care of my patients all these years, onto you.

This blog will be a primer on the menstrual cycle, and I will include information on when the best times to "try" during the cycle are. 

Most women have a 26-29 day cycle, from the first day of a period, to the first day of the next period.  The cycle can be divided, from the ovaries' point of view, into 2 phases - the FOLLICUAR phase (the first phase) and the LUTEAL phase (the second phase.)  The follicular phase is when the follicle (the fluid filled sacs in the ovary which contain eggs) which is destined to release an egg in that cycle grows larger and the egg inside it matures.  After the egg has reaached final matureation and is released from the follicle (OVULATION), the luteal phase begins.  In the follicular phase the follicle produces primarily the hormone ESTROGEN, and in the luteal phase the follicle (now a CORPUS LUTEUM)  produces primarly the hormone PROGESTERONE. 

The best times to try to conceive in the cycle are in the days leading up to ovulation.  It is important to know that sperm can live up to 5-7 days inside the female genital tract, so if you have intercourse even 5-7 days prior to ovulation there is still a chance that you can get pregnant.  If you are trying to conceive however, I recommend having intercourse within the 2-3 days prior to ovulation.   Once ovulation has occured, the egg remains fertilizable for up to 24 hours.  However, since there are changes in the mucous in the CERVIX (the entryway into the uterus) - the cervical mucous becomes thick and sticky, making it difficult for sperm to swim through it into the uterus and the fallopian tubes- after ovulation, it becomes difficult to get pregnant if you wait until after ovulation to try to conceive.  (If you are having an artificial insemination however, you can still get pregnant for up to approximately 24 hours after ovulation, since the sperm is being inserted directly into the uterus, bypassing the cervix and the bad cervical mucous.)  Therefore, you should focus on having sexual relations in the 3-4 days leading up to ovulation.

There are 2 adequate ways for you to know when you are going to, or have, ovulated.  The first way is to use ovulation predictor kits (OPK's) which are kits that test your urinary LH concentration, and can be purchased in a pharmacy.  You should start testing about 19 - 20 days prior to your next expected period.  (For example, if you have a 31 day cycle, you should start testing on cycle day 11 or 12, or cycle days 31 minus 20 through 31 minus 19).  Once you begin testing, you should test daily until the kit turns positive.  The OPK's detect urinary LH.  LH is the hormone (luteinizing hormone) that spikes up higher just before ovulation happens.  Typically, one will ovulate approximately 36 hours after the LH spike.  Therefore, once the test becomes positive, indicating the spike of LH, you will likely ovulate within 24-36 hours.  Therefore once the test turns positive you should have intercourse once or twice if possible prior to the 36 hour lapse.

The second method, which I am a big fan of, is basal body temperature testing.  The idea is that once ovulation has occured, your basal body temperature (your temperature at rest) rises about 0.5 degrees.  That temperature rise is actually due to the release of progesterone from the ruptured ovarian follicle (the CORPUS LUTEUM).  Once your temperature has gone up you know you have ovulated.  The temperature remains elevated for approximately 10-14 days until your next period, when the corpus luteum stops producing progesterone.  If you happened to have conceived, that corpus luteum will continue to produce progesterone, and your temperature will remain elevated.  I will usually know just by looking at someone's basal body temperature chart if they are pregnant, if their temperature has remained elevated for more than say, 15 days!

I am a fan of the BBT charting because it is relatively easy to do, gives a lot of information, and is INEXPENSIVE!  You just need a digitial thermometer, and a chart.  You need to take your temperature immediately upon wakening since getting up and moving around will elevate your body's temperature and you will therefore not be recording your BASAL body temperature.  So just wake up, take your temperature right away, then record your temperature on your chart.  You can download the chart easily from many websites.  (There is a link to one on my website WestchesterReproductiveMedicine.com - go to patient resources - glossary - basal body temperature.)  There is a flaw to using this method however - the chart will help you to tell that you have ALREADY ovulated, not that you are GOING TO ovulate.  Therefore, I think it is useful for women who have very predictable, consistent cycles, to use this method for a few months just to ascertain when you are typically ovulating.  For example,  if you do the chart for 3 months, and your temperature always rises around cycle day 14 or 15, then you know that going forward, the best times to have sex are between cycle days 11-15.  You can still do the BBT charts every month to confirm that you have not YET ovulated, but once your temperature rises you will know that you don't have to continue to try that month anymore (you certainly can if you want to though!)  Then you keep your fingers crossed and wait to see what happens.

Hopefully this blog has answered some questions for some people about the basics of trying.  I am looking forward to responses and to answering any questions that may arise from this, my first blog!  Going forward, I will begin discussing the usual fertility testing, and then go on to treatments.