Time is of the Essence: MUSC Expert on Age-Related Fertility Challenges

An MUSC College of Medicine professor has a message for older women contemplating pregnancy: "Time is of the essence."

"Many couples are not aware of how challenging getting pregnant can be as a woman ages," says Dr. Andrea Peterson, a reproductive endocrinologist and infertility specialist with Coastal Fertility Specialists in Mount Pleasant. She also works closely with MUSC's OB/GYN providers to ensure patients have healthy pregnancies.

Age 45 is when Dr. Peterson advises patients not to use their own eggs and instead use a donor egg to become pregnant.

According to a recent World Health Organization report, infertility is increasing worldwide, affecting one in six couples. That number is about one in eight in the United States. Dr. Peterson says her practice mirrors those numbers and that infertility is increasing for several reasons, particularly the decision by couples to start a family at a later age.

"More women are waiting and pushing back the time to start a family, and so much is driven by the woman's age," she says.

Infertility is defined as the inability to conceive after having unprotected sex regularly for a year when a woman is under 35 and at least six months if she is over 35.

"The quality of eggs declines with age, and age is all we can go off of in terms of quality of eggs," says Dr. Peterson, who herself has experienced infertility and conceived her son via in-vitro fertilization (IVF). "There are no blood tests to determine quality."

A Limited Supply of Eggs

Females are born with all the eggs they are going to have — five to seven million as a fetus inside of a mother's uterus and one to two million at birth. At puberty, they have 500,000. Every month a female loses about 1,000 eggs, and she ovulates only one egg per month.

"I tell my patients that their eggs are as old as they are," she says. "It is the egg's job to combine with the sperm and then divide to make a baby that has the right amount of genetic material. As a woman ages, the machinery in the egg starts to break down, which makes it more difficult to get pregnant, and the risk of genetic abnormalities rises."

Natural pregnancy occurs when egg and sperm meet in the woman's fallopian tube. A woman grows follicles in her ovaries every month. Each follicle contains one egg. The biggest (dominant) follicle

releases the egg, which is taken up by the fallopian tube, where it is fertilized by the sperm. It takes five days to travel down the tube and implant itself in the uterus.

What to Expect From an Initial Infertility Specialist Visit

When couples have been unable to achieve a pregnancy naturally, Dr. Peterson first gets a complete medical history, does a pelvic ultrasound and then performs a battery of tests to ensure that the patient is healthy and has no physical abnormalities that may be affecting her fertility. These include blood work and imaging of the uterus and the ovaries to determine egg reserves, as well as tests to check for any abnormality or blockage of the fallopian tubes.

Tests to find out the cause of infertility in women include:

• Ultrasound: Sound waves are used to produce images of a woman's uterus and ovaries to count the follicles that are produced that month.
• Anti-Mullerian hormone (AMH) blood test: Blood is tested for AMH, a hormone that can indicate a woman's egg reserve. A high amount of AMH means she has a higher egg reserve.
• Ovarian reserve testing: This blood test, which is done on the third day of the menstrual cycle, when a woman's hormones are at their lowest, measures the hormones FSH (follicle-stimulating hormone) and LH (luteinizing hormone) that the brain sends to stimulate the ovary to grow follicles. The follicles then release more estrogen as they grow. This blood work gives information on how the brain and ovary are working together.
• Thyroid blood test: The thyroid-stimulating hormone (TSH), which affects ovulation, is measured to determine if the level is within the normal range.
• Blood test for viruses and genetic conditions: Blood is tested for viruses for which a mom can't be vaccinated during pregnancy, such as rubella and varicella (chicken pox). Dr. Peterson also checks a patient's blood type before she gets pregnant. A genetic carrier screen is a blood test that tests for genetic conditions that a patient could have and not know that they carry.
• Sperm count test: The partner's sperm is tested for volume, motility (movement), concentration and morphology to find out if it is within the normal range.
• Hysterosalpingogram (HSG) is an X-ray dye test that shows if the fallopian tubes are open and if the uterus is normal or has scar tissue, fibroids, polyps\ or other abnormalities that could prevent the implantation of an embryo. The dye is injected through a catheter that is inserted into the cervix.

"Once we have all the test results, we discuss possible reasons for infertility with the couple, such as blocked tubes, uterine factors such as fibroids, diminished ovarian reserve or not enough sperm," Dr. Peterson says. "If the workup is normal, the diagnosis is unexplained infertility. One-third of the time, the problem is female-related, one-third male factor and one-third it is both. About 15 percent of couples are diagnosed with unexplained infertility."

Fertility Treatment Options

If tubes are blocked, or sperm count is low, she recommends moving straight to in-vitro fertilization (IVF). If the patient is not releasing an egg or not ovulating, Dr. Peterson recommends ovulation induction.

Depending on the diagnosis and cause of infertility, treatments may include:

• Oral medications: Ovulation induction medication prompts the woman's body to produce more follicle-stimulating hormone.
• Ovulation predictor kit: The at-home kit includes a stick that, when saturated with a woman's urine, can detect the surge in luteinizing hormone (LH) and predict when ovulation will occur. The couple should have sex on the night of a positive test and the following night.
• Medication with intrauterine insemination (IUI): Ovulation induction medications prompt the woman's body to produce more follicle-stimulating hormone. A trigger shot is taken to induce ovulation. At the time of ovulation, sperm is deposited through a catheter into the uterus. This method is used for three consecutive cycles.
  If medications fail and intrauterine insemination fails, IVF is recommended.
• In-vitro fertilization: The IVF regimen includes injection medication for 10 to 12 days, along with ultrasounds and blood work. When follicles appear ready to produce a mature egg, a trigger injection is given to finalize the maturation of the eggs.
  
  Before ovulation occurs, eggs are retrieved while the patient is under light anesthesia. With the guidance of an ultrasound probe, Dr. Peterson uses a needle to aspirate the follicles and collect the eggs, which are collected in the embryology lab and grown to develop into embryos and frozen until implantation. Before the embryos are implanted, estrogen and progesterone are administered to ensure the uterine lining is receptive to implantation.
  
  By the fifth day after retrieval, an embryo can be biopsied to determine the sex of the embryo and if it is genetically normal. The test, which examines five to seven cells that become the placenta, is 98 percent accurate, Dr. Peterson says.
  
  A couple has about a 60-percent success rate of taking home a baby after the first transfer of a genetically tested embryo, Dr. Peterson says.

Don't Postpone Seeking Help with Family Planning

In addition to infertility treatment, Dr. Peterson sees a variety of patients who want to have a family. These include LGBTQ couples who want to know their options for having a child, individuals who suspect infertility because of a prior illness or injury, women who are seeking elective fertility preservation, such as egg freezing, and infertile couples needing a third party, such as a gestational carrier or a donor egg to build the family that they want.

She reminds all her patients that time is of the essence and says most people are not aware of how much more challenging getting pregnant can be the older someone gets.

"It is a time-sensitive issue, and knowing that there are options, such as egg freezing for career women, should encourage people to act sooner and seek treatment rather than later. You're never as young as you are today."

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Dr. Peterson sees patients at Coastal Fertility Specialists' Mount Pleasant location and in Summerville. Other Coastal Fertility Specialists offices are in Columbia, Myrtle Beach and Savannah. To make an appointment, call 843-883-5800.