Fertility Facts

The effect of age on fertility

Conception rates for normal healthy couples are, at best, 20-25% per menstrual cycle. Once a woman reaches the age of 35, her fertility begins to decline. By age 40, it is estimated that her conception rate is in the range of 8-10% per month and at age 43, the pregnancy rate is thought to be as low as 1-3% per month.

In addition to a reduction in pregnancy rates associated with increasing female age, there is also a significant increase in the risk of miscarriage and chromosomal (genetic) abnormalities.

"Reproductive Potential in Older Women"
by P.R. Gindoff and R. Jewelewicz. Fertility & Sterility. 46:989;1986

"Maternal Fetal Medicine: Practice and Principles"
Creasy and Resnick, eds. WB. Saunders, Philadelphia, PA. 1994:71

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Duration of infertility
The duration of infertility is also important both for choosing the appropriate time to initiate investigation as well as selecting the most appropriate treatment. In general, the longer the infertility, the smaller the chance of conception occurring spontaneously (without treatment), and the sooner treatment will be initiated.

How common is it to have a fertility problem?
It has been estimated that one out of six couples (15%) will have some difficulty conceiving. Some couples will have conceived a pregnancy together in the past yet will have difficulty in achieving another pregnancy. In other cases the female may have been pregnant with another individual or the male may have fathered a child with a previous partner.

Unexplained infertility
This diagnosis is reserved for those couples that have completed their fertility investigation and no cause has been demonstrated (approximately 15% of all infertile couples). In such cases once the duration of the infertility has exceeded 24-30 months, the chance of conception occurring on its own is approximately 3-5% per month and perhaps even less as the woman becomes older.

The relationship between weight and infertility
It has been shown that weight is closely related to the success of fertility treatment. Women who are excessively overweight or underweight have reduced conception rates and higher miscarriage risks than women of similar ages who are within their ideal weight range. The risk of stillbirth has also been shown to be increased when women are overweight. Weight stabilization prior to initiating any fertility therapy increases a woman’s chances of conception and live birth.

Smoking
Smoking has deleterious effects on a woman's eggs as well as on sperm. Smoking cessation is essential for maximizing a couple’s success with fertility treatment. This includes cessation of marijuana use, as marijuana has additional detrimental effects, especially on sperm function.

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Stress
It is virtually impossible to quantify stress and thus the effect of stress on fertility is also hard to correlate. What is stressful for one person may not be for another. Pregnancies still occur during high stress situations. e.g. wartime. However, it is always desirable to reduce one’s stress level to a minimum.

Lifestyle
The adage “everything in moderation” should be followed. This includes caffeine and alcohol consumption. Pregnancy is a natural process and thus, there is no good evidence that these two activities must be totally eliminated from one’s lifestyle. A balanced diet combined with regular exercise is healthy and helps prepare a woman for pregnancy, labour and delivery. We recommend a multivitamin supplement that contains folic acid (0.4-1.0 mg) for all women who are trying to become pregnant. This B-vitamin reduces the risks of some serious defects of the central nervous system in the fetus. It should be started a few weeks before treatment begins and taken until the 10th week of pregnancy.

Day 3 FSH
Measurement of the blood concentration of FSH (follicle stimulating hormone) on the 3rd day of the menstrual cycle is one of the best ways of assessing a woman's fertility potential (reserve function of the ovary and egg (oocyte) quality). The methods used to measure the FSH level vary from clinic to clinic and thus the level above which the FSH is considered to be elevated will vary among clinics. At the Genesis Fertility Centre, we consider the upper limit of normal to be 12 I.U.'s.

Women with elevated levels of FSH on cycle day 3 demonstrate a poor response to the medications and poor outcomes when receiving treatment with any of the assisted reproductive technologies (ART's) (superovulation, IVF, ICSI). In the few cases where pregnancy does occur in spite of an elevated level, pregnancy outcomes are also very poor.

When the day 3 FSH level is near the upper limit of normal, or in cases where previous ART treatment has resulted in poor stimulation of the ovaries, a test known as a "clomiphene citrate challenge test" may be performed to further clarify the situation. Although day 3 FSH levels may vary from cycle to cycle, it is the highest level of FSH on either day 3 or day 10 of the clomiphene challenge test that is associated with the potential outcome of treatment. As a result, a woman may be advised against undertaking ART treatment when the day 3 or day 10 FSH (during a clomiphene citrate challenge test) is elevated.

The Clomiphene Citrate Challenge Test
This test is referred to as "a provocative test" for assessing a woman's fertility potential (ovarian reserve function). The test involves measuring the cycle day 3 FSH and estradiol blood level followed by 2 tablets per day of clomiphene citrate (Clomid, Serophene) taken together each morning from days 5-9 of the cycle. The FSH and estradiol blood levels are then repeated on cycle day 10 (the day after completing the clomiphene tablets).

This test may be performed for a number of reasons including a borderline high day 3 FSH level, a history of poor response to the stimulation of egg growth in a previous cycle of an assisted reproductive technology or in cases of increasing female age.

When either the day 3 FSH or day 10 FSH level is greater than 12 I.U.'s, the prognosis for a successful outcome with one of the assisted reproductive technologies (superovulation, IVF, ICSI) is very poor.

Hydrosalpinx
Some women are infertile as a result of blocked fallopian tubes. When the blockage or obstruction occurs at the end of the tube furthest away from the uterus (fimbriated end of the tube), the tube may fill up with secretions. This distended, fluid-filled fallopian tube is known as a hydrosalpinx. Several studies have shown that the presence of a hydrosalpinx will reduce IVF (In Vitro Fertilization) success rates by as much as 50%. Removal of the affected fallopian tube(s) prior to IVF improves subsequent pregnancy and birth rates.

Antiphospholipid antibodies (APA)
The relationship between APA and IVF treatment failure is quite controversial. The American Society for Reproductive Medicine has suggested, “The assessment of APA is not indicated among couples undergoing IVF. Therapy is not justified on the basis of existing data.”

Prophylactic antibiotics
It has been suggested that antibiotics play a role in promoting fertility for infertile couples. There is no clinical scientific evidence to support:

1. That a 10-day course of antibiotics will help infertile couples conceive.
2. That antibiotic administration at the time of embryo transfer improves pregnancy rates in IVF.

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