Diego and Susy Golberg are a couple in Argentina who began a yearly ritual in 1976. Every June 17th, they took portraits of themselves and their eventual family of three sons, producing a vivid photographic reminder of the reality of aging.
Age plays a very important role in reproduction, especially biological age. Chronological age is determined by what it says on your driver's license. Biological age is different, and arguably more significant. Do you know any athletic women in their late-30's who have the "body of a 20-year-old"? Have you ever seen a 35-year-old alcoholic smoker who looks like he's 50? When it comes to a woman's reproductive capability, it's important to consider her ovarian age in addition to just her chronological age.
Near one extreme, you can have a 43-year-old woman with enough quality eggs remaining that she conceives twins on her own. Or you can have a 19-year-old girl who goes into premature menopause. But for most women, their ovarian age stays fairly faithful to their chronological age with a gradual decline in fertility throughout their life until they reach their 30's at which point the decline accelerates. Then by age 40, the decline becomes very sharp.
It's not possible to tell someone's ovarian age with a single test. You can't tell based solely on how healthy and young she looks. There are a variety of clues about a woman's biological age provided by various methods, some of which are more important than others.
CHRONOLOGICAL AGE: Not surprisingly, the biggest predictor of ovarian function is someone's true chronological age. There is no getting around the fact that if you are 46, you still have poor reproductive outlook, even if you are in the biologically youngest 1% of all the 46-year-olds in the world.
FSH LEVELS: There is a blood test that is typically done on day 3 of your cycle. A high FSH (over 10 IU/l) is suggestive of advanced reproductive aging. A value over 15 IU/L is significantly worse. Consistent values over 25 IU/L indicate that you are likely menopausal. A bad test result is bad news. Unfortunately a GOOD FSH result (under ~9 IU/L) is not necessarily good news. If you are 46 and have a FSH of 5 IU/L, that still does not mean you have the fertility of a 26-year-old. Another warning about interpreting FSH levels involves the possibility that FSH results can look much better than they actually are if your estradiol levels are high on the day of the FSH test. This is why reproductive endocrinologists always know to test an estradiol level at the same time as the FSH level. For example, a day 3 FSH level of 6 IU/L with an estradiol of 53 pg/ml is more favorable than a FSH level of 5 IU/L and an estradiol level of 119 pg/ml. The final point to make about FSH levels is that they are a MARKER of ovarian aging and they are not the CAUSE of ovarian aging. Many patients when told they have a high FSH level often ask what they can do to make the FSH level lower. Making it look lower doesn't change the message that the ovaries are old. This is similar to having a red "engine warning" light come on in your car and inquiring what you can do to cut the wire so the light goes out. It still doesn't change the fact that there is a problem with the engine.
OVARIAN VOLUME: In general, younger women have large plump ovaries, because there are more stored eggs left in them. Menopausal women have tiny ovaries that are sometimes so small as to not be visible on ultrasound.
ANTRAL FOLLICLE COUNT: Every cycle, before a woman begins developing her eggs, the number of tiny pre-ovulatory follicles is higher in women with young responsive ovaries as compared to in women with older resistant ovaries.
RESPONSE TO CLOMIPHENE CHALLENGE TESTING: An old way of testing ovarian reserve or ovarian age involves giving Clomid pills and testing FSH levels before and after. Elevated FSH levels pre or post Clomid are signs of ovarian aging.
INHIBIN B: In contrast to FSH testing, higher levels of inhibin B are good and lower levels are bad.
ANTI-MULLERIAN HORMONE: The usage of this hormone to predict ovarian response is a fairly new concept. Again, as with inhibin, higher levels are good. Lower levels are bad.
ACTUAL PERFORMANCE: All of the previous mentioned tests and methods are just predictors of how the ovary MIGHT function. None of them beat actual performance in terms of importance. Even if your age, FSH level and all other testing predict bad news, if you undergo infertility treatment, make a surprisingly large number of good eggs and get pregnant, then you won't really care what the testing predicted. One patient who comes to mind is a woman with small ovaries and a documented day #3 FSH level of 22 IU/L, who came to me for fertility treatment. After I informed her that her chances of success would be low, she polite acknowledged my warnings and then wound up defying the odds, getting pregnant and delivering a perfectly healthy girl at age 41 with her own eggs!
Before asking your doctor to order this whole slew of tests, bear in mind the principle that tests are only of value if they can help us make better decision choices. Knowing that you might have a better or worse outcome may not necessarily change what you decide to do. For example, if you are applying to law school and your LSAT scores tell you that you have a 80% chance of being accepted, but your GPA suggests you have a 55% chance of being accepted, and you are going to go through with the application process anyway despite of which is more accurate, then knowing this additional information doesn't really change your actions. Think about it. I will share more on this very important concept of decision-centered thinking in future posts.
Photos by Bobby Neel Adams.