With changes in social roles and desires, postponement of marriage and birth to later ages, widespread use of birth control methods, legal right to evacuation, economic concerns, increased risk of exposure to sexually transmitted diseases and decrease in sperm counts, birth in our society, especially in urban areas, has increased. Birth rates are gradually decreasing.
Birth rate is calculated by multiplying the number of live births occurring in a society in a year by the ratio of the mid-year population of the same society by 1000. While the total fertility rate in Turkey was 6.3 in 1963, today this rate has decreased to 2.17.
Consultations to doctors with infertility complaints are increasing. The reasons for this increase are the social acceptance of the situation, the fact that the problem is no longer a taboo, the internet, newspapers, etc. The ease of access to information and doctors through the media, the increase in the level of education, and the development and spread of infertility treatment centers.
Girls are born with a certain number of eggs that they will use throughout their lives, while no new eggs are produced, the number of eggs gradually decreases over the years. . The number of eggs, which is around 7 million when the baby is 5 months old in the womb, decreases to 1 million at birth, 250 thousand at puberty, 100 thousand in the 20s, 30 thousand in the 30s, 8 thousand in the 40s and below 1000 at menopause. Approximately 300-400 eggs of women mature and become ready for fertilization and are expelled from their ovaries, once a month during their reproductive periods throughout their lives.
The highest chance of becoming pregnant is around the age of 25. Pregnancy rates gradually decrease towards the age of 30, and after the age of 35, they decrease with a very clear and significant difference. While it decreases further in the 40s, when the woman reaches the age of 45, it becomes almost impossible for her to become pregnant. In fact, she is menstruating, but menstruation does not indicate that she can become pregnant because there is no ovulation in menstrual cycles at this age.
While "Over reserve" refers to the number of eggs in a woman's ovaries at her age, "ovarian aging" refers to the decrease in the number of eggs and egg quality in the ovaries with advancing age. is used to define. A decrease in ovarian reserve is expected due to age. While it is a physiological condition, the decrease in ovarian reserve at a young age occurs as a result of some risk factors.
Risk Factors That Negatively Affect the Ovarian Reserve
Obesity
Medical Reasons
- Previous ovarian surgery (endometrioma)
- Single ovary
- Smoking
- Chemotherapy and radiotherapy
- Diseases that require treatment with medical agents that damage the ovaries
- Type 1 Diabetes Mellitus
- Severe endometriosis
- Pelvic inflammatory disease
- Thyroid autoimmune diseases
Genetic Causes
- Family history of early menopause
- X chromosome disorders (45 X Mosaicism)
- FMR1 (Fragile X ) premutation carrier
- Relevant gene polymorphisms (disorders related to E2 synthesis and metabolism, AMH and AMH receptor genes, etc.)
What is the Poor Ovarian Response to In Vitro Fertilization Treatment?
Poor ovarian response is accepted if at least two of the following criteria are present.
- Advanced female age (over 40 years of age) or any risk factor for poor ovarian response
- Less than three eggs obtained during in vitro fertilization treatments
- Ovarian reserve tests are not normal (AMH < 0.5-1.1 and the number of antral follicles is below 5-7 on ultrasound)
How is Ovarian Reserve Evaluated?
Hormone tests (FSH, E2, Inhibin B and AMH measurements) and measurement of antral follicle number (AFC) with ultrasound. It can give an idea about whether the response will be moderate or poor.
FSH Measurement
As age progresses, FSH values increase towards menopause. While FSH levels above 30 indicate definite menopause, increases in FSH levels above 10 indicate that the ovarian response will be low. Live birth rates are given in the table according to FSH values for people over and under the age of 38. As seen in the table, age is a very important factor; pregnancy rates are higher in young patients with high FSH, even if the number of eggs is low, as the egg quality will be good.
FSH< 1010.1-1515.1-20>20Live birth rate ( Under 38)32%22%20%17%Live birth rate (over 38 years of age)12%8%10%0%
E2 Measurement
E2 measurement does not provide additional contribution to FSH measurement. High E2 can suppress FSH. > 80 pg/ml may predict poor ovarian response. It has low value in terms of in vitro fertilization results. A cystic structure remaining from previous months may cause high E2 levels. Therefore, E2 levels can indicate whether ovulation treatment should be canceled or not.
Inhibin B
It is secreted from granulosa cells in developing follicles. Therefore, it gives an idea about the developing follicles. Serum inhibin-B levels decrease with age. Inhibin-B has become widely accepted for assessing ovarian function rather than ovarian reserve. Inhibin-B <45 pg/ml is associated with decreased egg number and decreased E2 level. Inhibin-B does not decrease gradually with age; it is a rather late marker of a reduced egg pool.
AMH
AMH is a protein hormone secreted from the granulosa cells around the developing eggs in the ovaries.
AMH <0.5 ng/mL
- decreased ovarian reserve, < 3 eggs in in vitro fertilization
AMH <1.0 ng/mL
- borderline ovarian reserve, limited number of eggs
AMH >1.0 ng/mL - <3.5 ng/mL
- Good response to ovulation treatment
AMH >3.5 ng/mL
- Take precautions for excessive response, in polycystic ovary syndrome
Antral Follicle Count (AFC)
Antral follicle count (AFC) and AMH are the strongest indicators of egg count and response to ovulation treatments. FSH and E2 measurement can also be used, although they are not as effective as AFC and AMH. The most important indicator for egg quality is the woman's age. However, it is not possible to predict that pregnancy will not occur with any test results. Low ovarian reserve is not a definitive indicator of inability to become pregnant, and it does not prevent infertility treatment on its own. Most women with low ovarian reserve have regular menstrual cycles, but since their follicle numbers are lower than their peers, their response to ovulation medications and their chances of getting pregnant have decreased. Over reserve Treatment can be personalized by predicting the response to ovulation treatments.
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