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Egg quality & quantity & the relationship to fertility, infertility and IVF success
Female age is very important in consideration of probability for conception because it is very much related to egg quality, which in turn is crucial in determining embryo quality.
Egg quantity - also referred to as ovarian reserve - is the number of eggs a woman has remaining for use in the future. In general, egg quantity is also closely related to age, but can also vary dramatically at any age. There are tests of ovarian reserve that are done by fertility specialists that help estimate how good a woman's remaining egg supply is.
Antral follicle counts on ultrasound, day 3 FSH testing, and AMH levels are probably the best tests of ovarian reserve.
Testing fertility potential in the general population (not infertility patients)
Patients often tell me: "My eggs are fine, I don't think I need any testing for that." When asked how they know that the eggs are fine, the most common answers are either; "Because I get my period every month." - or - "Because my gynecologist said that my eggs are fine."
However, the gynecologist has not performed any tests of ovarian reserve, so he or she is giving the patient information based on an assumption and not based on data, or perhaps the patient and the gynecologist did not communicate well and there was a misunderstanding about the "egg issue".
A 45 year old can have good quality eggs (for her age) and still possibly be fertile, although this is rare. At the other extreme, a 25 year old can have very poor quality eggs and be infertile (also rare). These are extreme examples, but the point is that egg quantity and quality declines significantly as women age.
The decline in fertility potential in women usually begins in the early 30s and accelerates in the mid to late 30's. Egg quantity and quality in an individual woman can be average for her age, better than average, or worse than average.
When women are trying to get pregnant on their own (yes, fertility doctors do approve of having a sex life and getting pregnant without assistance) a limiting factor will sometimes be her egg quality.
That means she may have regular monthly menstrual cycles and have sex with her man on the perfect day for the sperm and egg to have a date. But if the egg she ovulates that month is poor quality (a red dot in the figure below) then it will either:
1. Not fertilize
2. Fertilize, but not develop properly to become capable of implanting in the uterus
3. Implant - but then not be "healthy and normal" enough to be able to continue proper fetal development - resulting in a miscarriage.
When we perform ovarian stimulation and intrauterine insemination or in vitro fertilization procedures, the issues involved are similar. However, in these cases there is also an issue of egg quantity involved as well as egg quality. If only a few eggs develop in response to the ovarian stimulating medications, then we have a lower chance of having success because of a reduced supply (quantity) issue - and there may be an egg quality issue on top of that as well.
More on the number of eggs obtained and success rates with IVF
I have tried to help illustrate issues about the relationship between egg quantity, egg quality, age and fertility potential with the drawings and discussion below:
- Dots are eggs
- Green dots are eggs that are "good" enough to fertilize,
develop normally into a quality embryo and result in a healthy baby being born.
- Red dots are eggs that are not "good" enough to fertilize, develop into a quality embryo and jump through all of the hoops in order to become a healthy baby.
A sample from an ovary of a woman of advanced "reproductive age" - for example age 42
Few eggs and a low percentage of quality eggs
This represents a sample from an ovary of a young woman - for example, age 28
Many eggs and a high percentage of quality eggs
For example, if we are doing in vitro fertilization on 2 women as represented above in the "dots". One is 42 with low ovarian reserve, the other is 28 with good ovarian reserve. We give the ovarian stimulating drugs to both women. The 42 year old has a low remaining number of eggs - and therefore has a low response to the drugs - and we get 4 dots (eggs). The 28 year old has a lot of eggs remaining - and therefore has a high response to the drugs - and we get 14 dots (eggs).
Even more importantly, we need green dots instead of red dots. The response of the ovaries to these medications is random - the green dots (good eggs) are not more likely to respond as compared to the red dots (poor quality eggs).
If we (randomly - with our eyes closed) dip a soup ladle into the ovary at the top and get 4 dots - are any of them green? It is likely that they would all be red - which would result in a failed IVF cycle.
If we dip a soup ladle into the ovary on the right and get 14 dots - are any of them green? It is likely that at least some would be green - which would then be expected to result in good embryo quality, a successful IVF cycle and a live birth - and perhaps some frozen embryos that can be used later to have more children.
In my opinion, quite often, the reason IVF fails is as simple as "we didn't get a green dot".
The point is not that a 42 year old should not try IVF and a 28 year old should. This is simply meant to illustrate issues related to egg supply, egg quality, resulting embryo quality and success with IVF and other fertility treatments.
Treatment options for women with reduced ovarian reserve:
In vitro fertilization
Lupron "flare" protocol for ovarian stimulation in low responders
In vitro fertilization with assisted hatching
In vitro fertilization with donor eggs
