FSH

AMH blood test- everything you wanted to know about this common blood test but were afraid to ask

AMH testing, a Q&A: Princeton IVF blog
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Common questions and answers about AMH testing

What is AMH?

Antimullerian hormone, commonly known at AMH, is hormone that is secreted by follicles in the ovary. It was initially studied for its role in reproductive development but is now widely used as a test of ovarian reserve.

What is ovarian reserve?

Ovarian reserve is a measure of the aging of the ovaries, and how many eggs the ovaries are likely to produce when given fertility medications. AMH, day 3 FSH and estradiol levels and antral follicle counts on ultrasound are commonly used measures of ovarian reserve.

What does a low AMH level mean?

A low AMH level, which most doctors consider a level of less than one, indicates that the ovary has fewer eggs available to stimulate. Women with low AMH levels, will usually make fewer eggs when given fertility drugs for IVF or insemination cycles.

Does a low AMH level mean that I am less likely to get pregnant?

AMH is a great test to determine how a woman will respond to medications, but it not as good at predicting pregnancy rates. It is true that women who produce more eggs are more likely to get pregnant, but particularly in young women, who do not need a large number of eggs, there does not seem to be reason to be concerned.

What does a high AMH level mean?

A high AMH level suggests that you are likely to respond very well to fertility injections and may be more likely to become hyperstimulated when taking them. It is also is considered a sign of polycystic ovaries (PCO) although AMH levels are not currently used to make the diagnosis.

Can the AMH level be used to predict if I will have trouble getting pregnant in the future?

Not really. Despite the early hope that AMH could help women know in advance if they might have infertility in the future, it turns out there is no evidence that AMH can predict future fertility.

Celebrities having babies over 40

Pregnancy in your 40s- how realistic is it?: Princeton IVF blog
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The media shows plenty of Hollywood stars having babies in their 40s, but are they telling the whole story?

For many it is exciting to hear about the celebrities they adore having babies. Like many women in the society at large, many celebrities have chosen to delay having children for a variety of reasons. It should come at surprise, then, that many of the celebrity moms depicted in the magazines are in their 40s.

Knowing how women trying to start a family (or growing her current family) as they get older face an uphill battle,  are the media who cover these stories doing a disservice to women's reproductive health?

To answer this question, researchers at New York University looked at all the issues of 3 popular magazines widely read by women of reproductive age over a 4 year period.

This is what they found:

  • There were 1,894 references to pregnancy or fertility
  • 1/3 of the issues had cover stories related to fertility
  • There 240 celebrities, who averaged age 35
  • Only 2 articles on 40+ year olds using donor eggs
  • There were 10 stories about adoption and 5 about using a gestational carrier. Not one of these mentioned that they had previously suffered from infertility

It is understandable that a celebrity (or anyone else for that matter) would not want to share the very personal details of what it is like to go through fertility testing and treatment.  Still, the stories presented to the public are far from complete. While there is nothing that appears to be inaccurate in the articles, they present an unrealistic view of normal fertility after 35.

Modern fertility treatments have revolutionized the ability of couples suffering from infertility to get pregnant, but it has not been able to eliminate reproductive aging. Implying that waiting to have children is not harmful to your fertility through human interest stories is doing a disservice to women. 

Dr Derman featured in Princeton Packet

Infertility causes and solutions in the Princeton Packet: Princeton IVF blog

YOUR HEALTH: Infertility: causes and solutions

By Stephanie Vaccaro

Dr. Derman talks about the causes and treatments for infertility

This article recently appeared in the Health Matters Column of the Princeton Packet...

   So You Want to Have a Baby?

   Infertility is defined as the inability to conceive after engaging in unprotected sex for one year, according to the Centers for Disease Control and Prevention.

   What causes fertility problems?

It can be a number of factors. Dr. Seth Derman of Princeton IVF and Delaware Valley OBGYN, said that approximately 40 percent of the fertility issues he sees are due to male problems, 40 percent are due to female problems, and 20 percent a combination of both partners.

   ”The exact cause of male infertility is a little harder to diagnose because it’s not well understood,” Dr. Derman said. “With female infertility, the most common cause is ovulation problems, which usually show up as irregular cycles. Polycystic ovarian syndrome is the most common of these.”

   Fertility problems can be caused by endometriosis. They also can be linked to damage to the fallopian tubes, which can be caused by previous sexually transmitted diseases. This is particularly a problem in women who have had prior Chlamydia infections.

   And sometimes infertility has no identifiable cause.

   What options exist for treatment?

   ”Well, it depends what’s wrong,” Dr. Derman said. “If there’s an ovulation problem, usually the treatment is fairly simple with fertility drugs. These are medications that induce ovulation, such as clomid or letrozole.”

   ”For tubal problems — the treatment is usually surgery or IVF (in vitro fertilization),” Dr. Derman said. “IVF is clearly the most effective treatment for these problems.”

   Oftentimes the most effective option involves treating the female partner. IVF allows for the sperm to be injected directly into the egg, and is the most effective treatment for male infertility. “The poorer the husband’s sperm the more likely the couple will need more invasive treatment such as IVF,” Dr. Derman said.

   A less invasive alternative to IVF is insemination, in which sperm is injected up into the uterus. In contrast, IVF involves fertilization of the egg outside of the body, and the transfer of that embryo into the woman’s womb. It is also much more effective than insemination. When patients have unexplained infertility, insemination is oftentimes done first, and if that doesn’t work then they may try IVF, Dr. Derman said.

   What are the odds of success?

Typical fertile couples have a 20 to 25 percent chance of getting pregnant each month. Infertile couples have a 3 percent chance when trying on their own. IVF increases the odds of having a child to twice what it would be in a fertile couple. Those numbers can vary based on age.

   IVF is very often successful in the first or second cycle, particularly in young women. If it isn’t successful, it’s not unusual for a couple to try three or four times, according to Dr. Derman.

   Who pays for IVF?

In New Jersey, the Family Building Act (August 2001) requires companies with more than 50 employees to cover fertility testing and treatment, including IVF. There are exceptions in the law, and since the passage of healthcare reform, those exceptions have gotten even larger.

   Some of the other treatments can be relatively inexpensive. “For instance, treatment using fertility pills and some monitoring is not terribly expensive,” Dr. Derman said.

   When should you go see a fertility doctor?

   ”Generally, over 35, we recommend coming after six months,” Dr. Derman said. “If they are under 35, one year is the right time.”

   What should you expect when you go see a fertility doctor? When patients go to see Dr. Derman for the first time, the first stage in the process is to try to understand why they are unable to conceive. After getting a detailed history, tests will be ordered, which include testing to make sure their eggs are not running out, to make sure their tubes are open, to make sure the ovulation process is going well and that the sperm is normal. After getting a clearer picture of what is going on, they can better determine the next steps.

   ”Not everybody with infertility needs IVF, even though it is the most effective treatment out there,” Dr. Derman said. “IVF is the last thing that we do, not the first thing.”

 

Egg freezing- the controversy continues

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Egg freezing- Is it effective and is it a "fertility insurance?"

Several years back the American Society for Reproductive Medicine declared that the freezing and storage of unfertilized eggs (oocyte cryopreservation) was no longer experimental. Reproductive science specialists have worked out the kinks and figured how to freeze, thaw, fertilize and grow these eggs, and from them get healthy live born children. The initial focus was to help women who wanted to have children, but were facing cancer treatment (surgery, chemotherapy or radiation) that might render them sterile. The data on pregnancy rates was very sparse but it in comparison to the alternative in these women, moving forward was a no brainer.

Now researchers in in Canada, have published on the outcomes in couples based on US data. The pregnancy rates range from 4-12 %, and that is in young women under 30.  The rates are likely much lower in women in their 30s and 40s. While not great, it does offer some hope where there was none before. The problems is that now egg freezing is being used to delay childbearing in women for social reasons. With the announcement by google that they will pay for the procedure in their employees and the advent of "egg freezing parties," this is becoming more widespread.

As reproductive medicine specialists, we all want to offer our patients reproductive freedom, the ability to have children at a time that works out in their lives. Undoubtably, freezing and storing eggs for future use will enable some women to have children well into their 40's and early 50's. However, those who are unsuccessful with frozen eggs, and there will be many of them, will be left little choice other than using eggs from a donor, knowing that their biologic clock ran out while they had other priorities in life.

The problem is this: Is egg freezing an answer to a real problem? or is it giving women false hope? It may be a little of both. Only time will tell as the technology moves forward.

How old is too old to try IVF ?

With stories of 45 year celebrities having babies (and sometimes even twins and triplets) with high tech treatments, most people think that age is not a barrier to successful treatment.  When using donor eggs from a young egg donor, that is definitely true. The chances for success with donor egg ivf is excellent, even for women in their late 40's. However that is not the case in women using their own eggs. Pregnancies in women undergoing fertility treatment without the use of a donor over 45 are very unusual.  A recent report from Florida describes a 46 year old woman who is reported to be oldest woman to conceive from IVF with her own eggs. Is this a major breakthrough? Not really. The main determinant over whether a fertilized egg will develop into a healthy baby is whether the embryo is genetically abnormal. Genetically normal embryos are common in 25 year olds but pregnancy rates are never 100%. Likewise, the vast majority of  45 year olds' embryos are abnormal, and so the pregnancy rates would be expected to be quite low but not exactly 0%. When confronted with these odds, most couples would chose not to try.