New Treatments for Infertility

Amongst the factors in women that one has to seriously consider are ovulatory dysfunction, the most common problem that we face, along with tubal disease. This varies in studies from forty to fifty percent, depending on who you read, but it is a large number of people. Unexplained infertility is a huge problem that is very difficult to deal with.

Why is this such a big problem now? It is even more of a problem now than it was years ago because of the aging demographics of the female population in the United States. Without a doubt, the number one type of patient that we see and probably most reproductive endocrinologists and general gynecologists see is the patient who has a career, who has delayed having children until the mid to late 30’s and is now faced with this dilemma of not being able to get pregnant or their sense of urgency increases and they just want to know if they can get pregnant.

If you look at the numbers from the Census Bureau, clearly the number of women who are older have increased and will increase as time goes on, by the middle of this century. The number one thing that we can absolutely document is that fecundity – the ability to conceive – decreases with age, independent of absolutely any other factor. The rate of impaired fecundity is pretty well in the young population, but as you get to the 35 to 45 range, it easily reaches thirty percent and in some studies, even higher.

We are beginning to try to talk about the perimenopausal period. Probably the best way to assess this is a day three FSH. On day three of the cycle, it may take 5 miu/ml to get a certain level of estrogen when you are 20 years old. To get that same level of estrogen when you are 40 years old might take 10 to 15 miu/ml of FSH. While phenotypically the person may still be ovulatory and may have no difference in anything other than this biochemical change, it clearly represents incipient ovarian failure as a woman ages. The other more recent test that people are doing is inhibin. What you need to know for the exam is that specifically, you want to measure inhibin B. I don’t know why inhibin B goes up in the follicular phase and inhibin A goes up in the luteal phase, but inhibin B is what you want to measure. Inhibin is a peptide that comes from the ovary. As the ovary fails, the level of inhibin B drops. So you are looking for low inhibin B and FSH when you are trying to document incipient ovarian failure. Clearly, phenotypically the length of the follicular phase is what changes; once the person ovulates, the length of the luteal phase is pretty sacrosanct at 14 days in humans. The big problem is accelerated follicular loss. You are born with a certain number of eggs and you just ovulate them down to zero; there are somewhere around 300 to 400 eggs in a woman’s lifetime. That means that not only do you have less as you get older, but that the quality is clearly going to be different as well.

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