Dr Anne Clark, MPS, MBChB, FRCOG, FRANZCOG, CREI

Medical Director, Fertility First

Sydney, Australia

Female Reproductive Physiology*

Fetus at 7.5 weeks – germ cells already developing in fetal ovaries

*The science that deals with the

functioning of living organisms

or their parts’

1 in 6 couples have

a fertility problem

Infertility is a W.H.O.

medical condition,

it is not a choice!!

Normal Time to Conceive

Couples are usually advised to seek advice after 12 months of unprotected intercourse.

But sooner if known fertility issues exist, such as anovulation, sperm problems or age >35 years for either partner.

100%

80%

60%

40%

20%

0%

40%

20%

14%

11%

0 - 3 3 - 6 6 - 9 9 - 12

Cumulative

Pregnancy Rate (%)

Months or cycles of

treatment

Fertility Parameters: Even a mild reduction in fertility parameters,

particularly in combination, can reduce the

chance of pregnancy each month

Number of

mild factors

0

1

2

3

Typical

monthly chance

20%

5%

1%

0.2%

Estimated time

to a pregnancy

4 months

2 years

7 years

40 years

3. Ovulated oocyte

to be fertilized in

the fallopian tube

2. Sufficient normal sperm to

swim through cervical mucous into

the fallopian tube

4. Receptive Uterine lining -

endometrium

1. As oocyte

matures the

follicle grows

A lot goes on inside an ovarian follicle to make that happen ……

Fertility & Sterility Cover; July 2009, Vol. 92, No.1.

•to produce a mature

egg that can result in a

pregnancy

•to assist the sperm to

reach the egg

•to prepare and support

the lining of the uterus

to allow an embryo to

hatch out and implant

•continue to support the

pregnancy until it is

independent at 8 to 9

weeks gestation

A lot goes on inside an ovarian follicle to make that happen ……

Fertility & Sterility Cover; July 2009, Vol. 92, No.1.

Achieves this by

.Process of oogenesis to

produce female gametes

•Secretion of hormones

from the cells lining the

follicular walls

Maternal Age and Oocyte Numbers A woman has the most eggs she’ll ever have when her mother is

6 months pregnant

Folliculogenesis and Oocyte Development

At birth a woman’s oocytes

are halted at first meiosis

division with a diploid (46)

number of chromosomes for

up to 50 years – primary

oocyte

Folliculogenesis and Oocyte Development The development of a primordial follicle containing an oocyte to a

preovulatory follicle takes in excess of 120 days.

After puberty, if an oocyte

develops in a menstrual

cycle completion of first

meiosis I results in a

secondary oocyte (GV or MI)

with a haploid (23) number

of chromosomes and the

first polar body.

Follicle Stimulating

Hormone (FSH) and

Lutienising Hormone

(LH) production in an

orderly fashion in

the brain is key to

the development of

a mature oocyte and

endometrium that

can result in a

pregnancy.

Connection between the Brain and the

Female Reproductive System

A feedback system of hormones secreted by the ovary,

hypothalamus and pituitary

FSH and LH only act in the final weeks of the development of a mature oocyte Initiation of follicular growth is continuous and occurs independently of gonadotrophic stimulation. It cannot be slowed or increased by medical means in normal circumstances. But in IVF want all the recruited oocytes to have a chance to mature.

McGee and Hsueh (2000)

Oocyte Development

Meiosis II is completed at

fertilisation and a second

polar body created

- Metaphase II oocyte –

The LH surge is critical

for this phase - HCG or

equivalent used in ART cycles

Thecal Cells – make androgens

Antral Follicle

Granulosa Cells – convert the

androgens to oestrogen

Cumulus Cells

Egg - Oocyte

Science • Granulosa cells are the only

cells in the female body known

to possess FSH receptors

• Antral formation requires stimulation by FSH starting when follicles reach about 0.25mm in diameter

• The pre-ovulatory surge of

gonadotropins (FSH and LH) is

essential to induce the

resumption of chromosomal

meiosis and final maturation of

the egg

antrim

• LH receptors are present in

theca cells and granulosa

cells in the ovary.

• In response to LH, thecal

tissues are stimulated to

produce androgens that

are then converted,

through FSH-induced

aromatisation to

oestrogens in the granulosa

cells.

• Therefore, ovarian

steroidogenesis is LH-

dependent to a significant

degree i.e. granulosa cells

are dependent on

androgens from the theca

to make oestrogen.

antrim

Science

‘Two cell, two gonadotrophin’ theory

Only FSH is required

for follicular growth

but some LH is

essential to achieve

adequate follicular

steroidogenesis and

develop the capacity

of the follicle to

ovulate and luteinise

when exposed to hCG

• Inhibin B secreted by

granulosa cells in response to

FSH, directly suppresses

pituitary secretion.

• Activin originating in both

pituitary and granulosa,

augments FSH secretion and

action.

The ‘LH window’ concept

That there is a threshold and a

ceiling for ideal LH levels to

maximise normal oocyte development

during the follicular phase.

The threshold has to change once the

oocyte is mature to ensure normal

oocyte maturation and ovulation.

LH Surge >20IU/l required for Ovulation

OVU

LATIO

N

LH E2

14-24 hours

10-12 hours

• The LH surge initiates the continuation of meiosis in the oocyte, luteinisation of the granulosa and synthesis of progesterone and prostaglandins within the follicle

• Progesterone enhances the activity of proteolytic enzymes responsible, together with prostaglandins, for digestion and rupture of the follicular wall.

• The progesterone-influenced midcycle rise in FSH frees the oocyte from follicular attachments and ensures sufficient LH receptors are present to allow an adequate luteal phase.

• If progesterone appears too early then premature luteinisation occurs, adversely affecting oocyte and pregnancy potential

In an IVF cycle need to first prevent ovulation before the eggs are collected with down regulation but ensure they have completed their maturation with a trigger injection

Progesterone (ng/ml)

Estrogen

Progesterone

LH

FSH

100 100

0 0

0 14 28

Ovulation

Follicular Phase Luteal Phase

FSH (mlU/ml) LH (mlU/ml)

500 20

0 0

Estrogen (ng/ml)

Endocrine Testing

Egg growth – oestrogen

Timing Ovulation – LH

Luteal phase and/or

ovulation - progesterone

Assessing a Woman’s Fertility

Potential: The Holy Grail Ultrasound assessment of antral follicle

count – normal number is 6 to 12

Ultrasound can only detect the number of oocytes

that have developed an antral follicle. It cannot

detect the total number of eggs available.

Assessing a Woman’s Fertility Potential:

Anti Mullerian Hormone (AMH)

Text goes here ….. As anti-mullerian hormone is

secreted by granulosa cells

in theory, the more eggs,

the more follicles so the

more AMH

Antral

Follicle

The primary physiological function of AMH in the ovary is inhibition

follicle recruitment into the antral follicle pool, so a woman’s egg

number lasts until her normal time of menopause.

AMH also reduces the sensitivity of growing follicles to FSH.

Assessing a Woman’s Fertility Potential:

Anti Mullerian Hormone (AMH)

From 2005, measurement of serum levels of anti-Müllerian hormone

emerged as a potential way of assessing ‘ovarian reserve’.

The higher the AMH, the more eggs a woman was believed to have in

reserve and therefore the better her fertility potential and also her

response to fertility treatments.

Anti-Müllerian Hormone (AMH)

Testing in Women

The levels are not reproducible. There is up to a 48%

significant variability of AMH results when the same woman

was tested.

Being on the oral contraceptive pill lowers AMH levels.

So sample variability in AMH results should be taken into

account when advising patients on their future fertility.

Most importantly, the test does not reflect egg quality or the

ability to conceive!

AMH could stand for “Anxiety Making Hormone”

Rustamov et al, Eshre, July 2012 108 women who had 2 or more AMH measurements within a median time gap of 3 months

However there are problems in relying on

AMH testing alone to advise a woman on

her reproductive potential.

AMH is Not a Useful Predictor of

Live Birth?

Extremely low levels of AMH do not mean a

woman cannot get pregnant naturally or on

treatment and therefore deserves the same

workup as any other fertility patient.

Effect of Maternal Age on Live Birth Rates

after IVF Using a Woman’s Own Oocytes

40

Live Births (percentage)

35

30

25

20

15

10

5

0

23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

Woman’s Age (years)

There are significant factors besides the woman’s age and

ovarian reserve that contribute to reducing fertility potential,

that can be corrected.

Vitamin D

100

90

80

70

60

50

40

30

20

10

0

Percent

conceived

0 1 2 3 4 5 6

Sufficiency

At risk of inadequacy

or deficiency

Adjusted for age, race, BMI category, alcohol consumption, smoking

status and physical activity score. At risk of inadequacy or deficiency

is defined as serum 25(OH)D <50nmol/L; sufficiency is defined as

serum 25(OH)D >50nmol/L. Fung. Vitamin D and Fertility. Fertil Steril 2017.

Months from baseline

Women’s time to conception for

pregnancy by serum 25(OH)D status

Vitamin D Deficiency and Latitude:

Vitamin D deficiency

during pregnancy is

associated with an

increased risk of

multiple sclerosis,

asthma, schizophrenia

and autoimmune

diseases when the

child reaches

adulthood

Lucas et al., 2008 26x higher risk of developing multiple sclerosis if born in

Tasmania, 10x higher risk if born in Victoria cf if born in

Queensland

Serum and follicular fluid levels of Vitamin D

are highly correlated.

Vitamin D is from sunlight, fish, dairy and

sun exposed mushrooms.

As well as reducing fertility for men and

women, Vitamin D deficiency increases the

risk of miscarriage and pregnancy

complications, including stillbirth.

Ozkan et al Vit D and Reproductive Success Fert Steril 2010

Lowest Highest

Clinical Pregnancy (%)

IVF Pregnancy Rates and Vitamin D Levels

Lifestyle Factors Known to Improve Pregnancy Rates – Adequate Vitamin D levels

Nutrition: Mushrooms and Vitamin D

Similar to humans, mushrooms produce

Vitamin D naturally following exposure to

sunlight or a sunlamp.

All mushrooms contain vitamin D, but

growers have the ability to

increase levels by exposing mushrooms to

ultraviolet light.

Three to four Vitamin D mushrooms are

sufficient to supply daily needs.

http://www.fungi.com/blog/items/place-mushrooms-in-

sunlight-to-get-your-vitamin-d.html

Iodine: Adjusted Probability for Not Becoming Pregnant

0

0.25

0.55

0.75

1.0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Time to Pregnancy in Menstrual Cycles

Percent Remaining Non-Pregnant

Iodine to Creatinine Ratio <50mg/g

50 mg/g <= Iodine to Creatinine Ratio < 100 mg/g

Iodine to Creatinine Ratio >= 100mg/g

Women who are iodine deficient are 46% less likely to get pregnant over each menstrual cycle compared to women who have sufficient iodine

Mills et al, Hum Reproduction, March 2018

Maternal Age:

Fertility and Miscarriage Rates

Miscarriage

Fertility

20-24 25-29 30-34 35-39 40-44 >45

500

450

400

350

300

250

200

150

100

50

0

100

90

80

70

60

50

40

30

20

10

0

Fertility Rate (per 100 women)

Miscarriage Rate (percentage)

Maternal Age (Years)

As a woman’s age

increases her fertility

decreases and her risk

of miscarriage

increases.

Fertility is a couple

issue, NOT a

woman’s issue.

They both have a

biological clock

A woman is only half the baby… ‘It takes two to tango’

An egg and sperm contribute an equal amount of genetic material to a pregnancy. The placenta is largely dependent on the expression of genes from the paternal chromosomes.

Miozzo and Simoni, 2002, Biol. Neonate; 81:217-228

Normal: >15 million per ml; >40% motile – 32% progressive;

>4% normal forms

Not all sperm are created equal!

0

20

15

10

5

25

Time to Pregnancy (months)

Time to Conception for a 25 year old Woman vs. Male Partner’s Age

<25 >40 35-40 30-35 25-30

Male Partner’s Age (Years) Hassan et al, F&S 2003, 2006

2x longer

4x longer

Dunson et al, Hum Reprod 2002:

Impact of a Man’s Age on the Chance of

Natural Conception plus Importance of

Timing Intercourse

Pregnancy

Probability

Halved

Likelihood of conception following IVF is halved for women 38 to 40

years if their partner is aged 40 years or older.

Rochebrochard et al, Fertil Steril; 85:5 May 2006, 2017

How to maximise fertility potential? Choose a younger partner

Check for and treat if

required increased sperm

DNA damage if the man is

over 35 years of age

Collette Dinnigan, pregnant naturally aged 46, and her husband, Bradley Cocks, aged 36

Paternal Age

20-29 yrs

30-34 yrs

35-39 yrs

40-64 yrs

Maternal Age

20-29 yrs 30-34 yrs 35-44 yrs

Standard Risk Zone

Standard Risk Zone

Standard Risk Zone

Standard

Risk Zone

High

Risk Zone

High

Risk Zone

High

Risk Zone

High

Risk Zone

Highest

Risk Zone

SRZ

HRZ

HjRZ

1.00 (Reference)

2.87 (1.86-4.45)

5.65 (3.20-9.98)

A man’s age, as well as a woman’s,

impacts on the risk of a miscarriage

de la Rochebrochard and Thonneau, 2002

Incidence of Downs’ Syndrome Related

to Paternal Age as well as Maternal Age

Maternal age uncorrected

for paternal age

Maternal age corrected

for paternal age

<24 25-29 30-34 35-39 40>

Maternal Age (years)

700

600

500

400

300

200

100

0

Rate per

100,000 births

Harry Fisch, Grace Hyun et al, Journal of Urology; Vol.169, 2275-2278, 2003

So what else can women do to maximise antral follicle count and fertility potential?

Know their family’s reproductive

history e.g. endometriosis, earlier

menopause and seek early

intervention if concerned

Don’t smoke

Use the pill for contraception

Minimise ovarian surgery that

reduces ovarian reserve

Maximising Fertility – Stop Smoking!

Women who smoke will have their

menopause 1 to 3 years earlier.

Up to 13% of infertility is attributable

to cigarette smoking, more than tubal

disease

Cigarette smoking increases the risk of

an ectopic pregnancy by 3-4x, more

than chlamydia

Miscarriage is 3-4x more likely.

Women who smoke ~ 20 cigarettes a day

expose their bodies to the radiation

equivalent of one chest X-ray a day!!

ASRM Practice Committee, Smoking and Infertility, Fertil Steril;

Nov 2006

Protects against ovarian cysts, endometriosis, PID

and premature ovarian failure

Prevention of Diminished Ovarian Reserve

Take the oral contraceptive pill

Maximising Fertility Potential – Marry!

Percentage without children

Age Range (average of first child is 30 Years*)

*Australian Bureau of Statistics 2011

A woman who is partnered but not married is 2 to 3 times

less likely to have children.

0

10

20

30

40

50

60

70

80

20-24 25-29 30-34 35-39 40-44

Married Defacto Partner

Average

age 1st child

women

Average

age 1st child

men

• Understanding the menstrual cycle is key to understanding how to assess and treat a woman’s fertility issues.

• Fertility is a couple issue, NOT just a woman’s issue

• Just as care needs to be taken to not give women unrealistic fertility expectations, it is just as important to assess each woman individually and not be unnecessarily negative.

• A woman should never be advised

she is unable to have a child or

treatment on the basis of an AMH

level alone.

To Conclude:

Fertilised egg in fallopian tube

Questions and Feedback

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