I’m Dr. Catha Fischer, the Medical Director at Spring NYC, a best-in-class fertility center that puts patient care first.
A couple of weeks ago we asked you what your questions about fertility, egg freezing, IVF and family planning were. The team and I over at Spring Fertility, want to thank you for posting such interesting and thoughtful questions!
In fact, there were so many questions we wanted to address, we’re going to be answering them throughout a three-part series.
In the first post of the three, Drs. Monica Pasternak, Peter Klatsky, and I are answering your questions about fertility, fertility tests, and assessing different services and technologies.
Q from @Selina120 : There are a lot of startups in the fertility space with things like take-home hormone tests, egg retrieval services, etc. How should someone like me without any medical expertise assess which tech-enabled fertility services are backed by science?
That’s a great question. There is no take-home test that is as valuable as a consult with a physician. Like everything, it depends on what information you are seeking from these direct-to-consumer tests.
If you want a generalized interpretation of a blood test, these at-home tests are fine.
If you are looking for an interpretation that applies to you, then an actual visit to a provider is the best path.
For egg retrieval and IVF, these are sophisticated and challenging services. You want to go to a center that has great physicians, scientists and outcome data, not a flashy marketing budget.
Some questions to consider: who is the provider? Where did they train and practice? What are the success rates of this service? And what are the complication rates? ALSO, how do they respond to your questions? We feel patients should leave an appointment feeling more empowered with more answers. If you are confused after a consultation, maybe it's not a good fit.
Q from @iammyr: Why do you think there is so little research and stats that are reliable and comprehensive, around IVF, fertility and related techniques? Do you think this situation is improving? If not, why?
A: There are a lot of studies and data out there. One of the challenges is understanding how the data in one study apply to a specific patient. And it can also be challenging for someone outside of medicine to access the better studies or to understand and appreciate the study limitations or strengths (some are not as well controlled as others). In general, it’s a good idea to start a conversation with your doctor and ask for publications or primary sources for what they are telling you. Most physicians have studies available to share with patients and we are always happy to review and discuss studies if you find something that applies to your goals.
Q from @Margurite151 : Can you talk about the differences between egg count, egg quality and the results of what they mean? What's the time window for having children if our AMH (ovarian reserve) results are above 51 percentile for our age group (are over 35), should we be worried about our ability to bear children in early 40s, or would it be impossible to get pregnant at 40 and after (meaning, do I need to rush to have kids within 3 years otherwise I'll never bear children)?
A: The distinction between egg quantity and quality is very important. The only thing fertility physicians can assess through our tests is egg QUANTITY. Female age is the best predictor of egg quality, there is no actual blood test we send out in our workup to determine egg quality aside from this. AMH assesses egg QUANTITY, and is not a reflection of fertility. AMH is made by our eggs at certain stages of their development. Although we have had all our eggs since birth, from our remaining pool of eggs we constantly have new groups being recruited on a cyclic basis throughout our reproductive years. AMH is produced by the groups of eggs that will be recruited and grow over the next upcoming few months. Hence, a woman with a higher AMH has more eggs being recruited on a month to month basis, and we use this as a surrogate marker for the amount of eggs we have remaining (higher AMH, more eggs remaining). But again, this absolutely does not predict FERTILITY, which is our ability to become pregnant naturally. Out of our eggs recruited on a monthly basis, only ONE (in rare cases, multiple) grows to the point of being released at ovulation and potentially fertilized by sperm, so the number of eggs that were “contenders” to grow but did not get chosen, is really not a predictor of fertility. To reiterate, the most important predictor of fertility is our age, and the presence of regular menstrual cycles.
Q from @teresaman: I've briefly looked into Spring Fertility before and signed up for a session where you could get your AMH count evaluated. Though upon my own research, it seems that those who are on birth control (which I am on currently - the pill) are not advised to get their AMH count as the results would always be lower than if they were not on birth control. Is that correct? What are some of the preconditions that should be true prior to getting AMH count tested?
A: AMH is a good (but imperfect) test. It is a screening test. IF it is low, you would follow that up with an ultrasound or consultation. We discourage stopping birth control pills before testing if you are interested in pregnancy (because it puts you at risk for an unplanned pregnancy). Egg freezing is to give you options for a future pregnancy, we hate to see patients trying to optimize for a test and give up an effective contraceptive.
Q from @iammyr: Is a high AMH an indicator of the fact that one will go into menopause much later?
Unfortunately, our current scientific understanding still does not permit an accurate assessment or prediction of when a woman will enter menopause (despite spending tens of millions of dollars in NIH funded studies). It’s a hard thing to determine. A high AMH can mean a lot of things. AMH is typically produced by the cells surrounding small follicles on your ovary and it means that your body has a higher reserve than an average woman your age. This most often translates into an ability to produce more eggs if you are going through the IVF or egg freezing process.
Q from @adriennesmith: I am a year postpartum and am thinking about the best way to regulate my body's cycle, hormone levels, and thus, fertility, again. I haven't gotten my period back yet other than the occasional spotting (I am still breastfeeding) and I am ready to reclaim my body's natural cycle!
While every woman is different, in general, breastfeeding particularly if you are feeding many times a day will suppress your cycle. Remember the menstrual cycle is set up to achieve a pregnancy, which takes a lot of energy. While your body is expending so much energy to produce milk, it doesn’t have the reserves to support a new pregnancy–so no cycles. If you scale back breastfeeding, your cycles should resume.
Q from @iammyr: Most women are recommended to "first try naturally". Here where I live, they recommend trying for 1 year or 7 months if you're over 35. However, I've talked to a gynecologist who admitted that this is done only because the health insurance (where I live) covers the cost of the fertility test and therefore pressures doctors not to prescribe any test for as long as possible, so that they can save money. Would you recommend instead, doing fertility tests immediately, rather than waiting for a while to try naturally? Which tests would you recommend?
A: Infertility is diagnosed based on time. About 85% of couples less than 35 years old will achieve a pregnancy within a year. This timeframe changes as we get older because it becomes harder to conceive, so between 36 and 39 we say try for six months before seeking evaluation. Built into the definition of infertility is the assumption that couples have no issues. If you have irregular cycles or your partner has low sperm counts, then you should seek guidance earlier and potentially before starting.
The idea of an evaluation prior to even trying has merits if you are concerned but know that these tests are validated, or we know how to interpret them, when couples have infertility. In the absence of the diagnosis, when tests return somewhat indeterminate it is challenging to counsel patients on what they mean.
Q from @Chelsey103: My spouse and I started trying when I was 36. You always hear concerns about being able to get pregnant and lower egg counts as you get older, however, I actually did get pregnant fairly easily twice. Unfortunately, both resulted in miscarriages. Are there any tests to understand if this would be an issue that would come up? This was not something I would've anticipated when everything else has seemed fine. I've also heard other women like me who have struggled with miscarriage. I wish this was something I would've known more about sooner.
I’m sorry to hear about your experience. Miscarriages are actually quite common. Approximately 25% of pregnancies will result in a miscarriage at age 35. Six years later that probability has increased to 50% (at age 41/42). Many times the challenge in having a baby is maintaining the pregnancy.
Miscarriage evaluation: It's worth seeing a specialist who can evaluate to make sure there are no treatable or diagnosable conditions that put you at higher risk for a miscarriage (eg. A uterine septum, antiphospholipid antibody syndrome, or balanced translocation). If those tests are negative, it may just be a higher risk due to age. In that case, IVF can help if you test the embryos before putting them back. An embryo with 46 chromosomes would have only a 5-10% risk of miscarriage, regardless sof the age of the woman receiving the embryo.
Q from @iammyr: The Preimplantation genetic testing for aneuploidy (PGT‐A) is another technique around which there isn't much studies/data. It is difficult to decide whether to go for it and risking to damage an embryo due to the biopsy, or to skip it and risking a spontaneous abortion or health issues in the child. Would you recommend doing it?
Testing to see if your embryo has 23 pairs of chromosomes (PGT-A) can be helpful in reducing miscarriage risk and reducing the risk of multiple gestations (twins/triplets) by transferring only a single embryo. Like any test, it is important to know that it is not perfect and there is a 4% false-positive rate and 1-2% chance that after the biopsy, the genetics lab will not be able to determine if the embryo is normal or abnormal. In spite of those recognized limitations, we feel that it is still a helpful test, particularly for women aged 35-42.
PGT-a is meant to assess the genetic composition of embryos and therefore allow physicians to select embryos for transfer. There are many studies showing that embryos are not damaged or harmed by the biopsy; however, the decision about doing PGT-A is individual. In general, we use a woman’s age as a factor in this counseling as we get older, our risk of miscarriage or abnormal pregnancies goes up. The decision on if this test is right for you really comes down to individual risk tolerance.
Q from @codev91: I am 31 years old and would like to have a family someday, however, my partner is three years younger and not sure he is ready to start a family yet. Since infertility runs in my family I spoke with my doctor and he said if I am planning to start trying to conceive in the next 12 - 18 months I probably don't need to worry about freezing my eggs, but if I wanted to wait longer he would suggest considering it more seriously.
1) Is it recommended to do any testing, prior to trying to get pregnant, to assess whether I may have any fertility issues? 2) Even if I wanted to start trying to conceive in the next 12-18 months, should I freeze my eggs in case I wanted a second child? Even if I started trying to have kids one year from now and everything went smoothly, I would likely not start trying for a second until at least 34-35).
AS we mentioned previously, there are very few tests of natural fertility and we do not recommend these. The difference in treatment outcomes between 31 and 24 is not meaningfully different and therefore we agree that you probably do not need to pursue treatment now.