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At Reproductive Crossroads

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a blog by David Kreiner, M.D., F.A.C.O.G., East Coast Fertility, June 14, 2010

Last week, I saw a patient with a question that made me feel like I was responding to a Dear Abby letter. As I pondered my patient's query (one I’d heard so many times before), I thought about how terribly nerve-racking the issue must feel for women.

    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 with whom I would feel comfortable marrying and having a baby. What should I do?

    At Reproductive Crossroads

These issues are universal in my practice: Women have to weigh their desire to have children now rather than delay, using their own eggs versus those of an egg donor, or adopting.

My patient needed to consider the ramifications of taking time off from her career, as well as creating a child with donor sperm. She wanted to know if she were to meet Mr. Right, how would he respond to this child? Were there tests that I could perform to help her make a decision?

Screen Your Fertility

First of all, it’s imperative in cases like this to do a full fertility screen so that we understand from a fertility perspective how much time a woman has left and how urgently she needs to make a decision. To assess 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 low ovarian 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.

Making a Decision

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 whether she should undergo IVF and freeze her embryos, thereby freezing her fertility potential at its current state.

Since she is single without a participating partner, we would be using the sperm from an anonymous donor. Sperm 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, reading on the internet the sperm donor’s demographic information, physical attributes, educational and occupational histories, etc.

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 my patients as they decide what is best for them.

As a woman prolongs the decision, her fertility is diminishing, and thereby, she risks not being able to have a child using her own eggs. If conceiving with her 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 with whom she may want to have a family.

It’s enormously stressful making these decisions at these reproductive crossroads. I discuss them with my patients and help them arrive at the decision that is right for them.

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