Last week a patient presented to my office with a question that made me feel like I was responding to a Dear Abbey letter requesting help to make some crucial life decisions that were related to her reproductive health. As I pondered her query that I had heard so many times before I wondered how terribly nerve racking it must feel like for this woman.
Dear Fertility Doc,
“I am 39 years old, single and I enjoy my career. However, I always dreamed I would have children. Unfortunately, I have not yet met a man that I would feel comfortable with to marry and with whom to have a baby. What should I do?”
At Reproductive Crossroads
The issues that this woman brings up are universal in my practice. She basically has to weigh her desire to have children now rather than delay, using her own eggs or potentially with an egg donor or to adopt. She needs to consider the ramifications of taking time off from her career as well as creating a child with donor sperm. She expressed concern to me that if she were to meet Mister Right how will he respond to this child? Are there any tests that I can perform that can help this woman make a decision?
First of all, it is imperative in cases like this to do a full fertility screen so that we understand from a fertility perspective how much time she has left and how urgent this patient needs to make a decision. To assess her fertility I do a Day 3 serum Estradiol and FSH, an AntiMullerian Hormone and a sonographic antral follicle count. The FSH is regulated by negative feedback from serum Estradiol and inhibin both of which are produced by the granulosa cells of the ovarian follicles. With diminishing ovarian activity there are fewer follicles, less estradiol and inhibin so with less feedback, the FSH level is high. Occasionally, in patients with low ovarian activity, often called reserve, a patient may have an ovarian cyst that produces estradiol. This will lower the FSH level to otherwise normal activity levels even when there is minimal ovarian activity and inhibin. One would misinterpret the low normal FSH in the presence of higher estradiol which is why this must be measured concurrent with FSH.
AntiMullerian Hormone is also produced by the granulosa cells and low levels therefore indicate depleted ovaries. Likewise, few antral follicles seen on ultrasound typically performed during the early follicular phase of the cycle will indicate low ovarian reserve.
Once we know a patient’s relative fertility through this screen we need to decide whether she is prepared to delay her career for pregnancy and motherhood or should she do IVF and freeze her embryos thereby freezing her fertility potential at the current state.
Since she is single without a participating partner we would be using the sperm from an anonymous donor. The specimens are obtained from sperm banks that are certified by New York State by virtue of their screening and testing for infectious and hereditary diseases. Patients may review what is available from the sperm banks. They can review on the internet the donor’s demographic information, physical attributes, educational and occupational histories, etc for the offered specimens.
If a woman does not have any infertility issues I would attempt donor insemination. However, due to her advanced age, I would progress to more aggressive therapies if we were not successful after a few cycles.
A common concern for women in this circumstance is that they may meet their soul mate in the future and he may not be comfortable with a child produced with someone else’s sperm. This is an issue that is very individual and I can only offer to support the patients as they decide what is best for them.
As she prolongs the decision her fertility is diminishing, and thereby risks not being able to have a child using her own eggs. If conceiving with one’s own eggs is crucial then she must weigh the downside of conceiving a child from an anonymous donor and if she does so, the potential problems associated with finding a man in the future who she may want to have a family with.
It is enormously stressful making these decisions at these reproductive crossroads.
I discuss these issues with my patients and help them arrive at the decision that is right for them.