If you’re over thirty-five and hoping to get pregnant then this is for you. This is not my typical Egg Whisperer show. Instead, it’s a conversation I had with Shannon M. Clark, MD who is the Founder/CEO of Babies After 35.
What follows is a recap of our conversation in question and answer format. I hope this is helpful to you, whatever your fertility journey may be. As always I encourage you to discuss your fertility with your doctor or to reach out to me directly, [email protected], if you have any questions. I want you to know that you are supported!
Okay, here it goes! And you can watch it here.
What is AMH?
It’s a hormone. It’s secreted by cells that surround your eggs. It’s normal for it to go down over time. What can be really confusing for people is that it can meander. So I also call it the “always meandering hormone”. Or the always mean hormone, as sometimes when your level doesn’t show what you want it to then people feel like they’ve now been labeled with something that’s low or bad. The way I like to think about the test is that it’s a great way to help you plan your future family. Make no mistake. There is NO test that can definitively tell a woman that she has good eggs or that she can or cannot get pregnant. Simply put, it’s more of an egg quantity test than anything else.
For example, if you’re twenty-eight years old and your AMH is 0.3, it doesn’t mean you have the eggs of a forty-two-year-old. However, you should consider freezing your eggs or embryos so that you have secure future options for yourself.
Similarly, if you’re forty and your AMH is 0.3, it generally means that the egg supply is low, but each egg still has a 10% chance of being genetically normal. Age is more predictive of pregnancy outcomes than anything else.
Low AMH levels don’t mean no. Consider being as aggressive as you want to be. Know there is nothing you can do to control AMH levels. It’s just a diagnostic tool that guides us. Knowing your AMH level can help you and your doctor determine what treatments to consider, how many eggs you’re going to get through IVF and what your pregnancy chances are.
Is there an optimal AMH?
Not exactly. Although, I will say there are AMH levels that will indicate to us that you are likely to get 15 eggs or so eggs retrieved if you were to do IVF. 15 eggs tend to give us the highest chance for pregnancy. Certainly, there are AMH averages by age, but I have patients who have an AMH of 3 at the age of 42 and don’t have a single normal embryo. I have patients with an AMH of .3 at the age of 42 and get one normal embryo. So there’s not a hard and fast rule.
More than anything, it’s important that you work with a doctor that believes in your fertility. You want to be supported by someone that sees the options and opportunities to get you pregnant vs. the barriers.
Dr. Clark:
What I’m hearing you say is that there’s no special sauce to make your AMH better. That it can change over time, and it is somewhat predictive of what your future fertility might be, but it’s not absolute.
For me what I tell patients is that it’s not going to hurt to get an AMH level, especially if you’re going to delay child-bearing. It may help women determine if they want to freeze their eggs.
Dr. Aimee:
Yes. I will say that there are some things that can impact the AMH level that you can control. Such as a low vitamin D level or being on birth control pills. In general, you want to take good care of yourself and taking a supplement such as CoQ10 can help. That’s what I tell my patients.
Advanced maternal age, like it or not, is the medical diagnosis for a pregnant woman over 35. Is there much of a difference between a woman over 35 trying versus one that’s 40?
I think that there is. I have what I call the Egg Whisperer Golden rules. Part of that has to do with age and fertility.
If you’re 32 and you think you want two kids, consider freezing embryos. If you’re 37 and want two kids then consider going right to IVF. The reason is that our egg viability changes pretty rapidly as we age. These are things that we don’t really learn in medical school so I always tell people when you go to your annual exam or postpartum visit talk to your Obgyn about future pregnancies and your options.
Dr. Clark:
Yes. Just to talking from my personal experience, I started trying a few months after I turned 40. After 5 cycles of IVF, only one embryo was genetically normal.
This leads me to another question.
Can you talk about the difference between egg quality and egg quantity?
Dr. Aimee:
Sure. My slogan is “your mom’s fertility is not your own”. The other thing is that “your fertility is not skin deep.” It only takes one egg. Quality is way more important than quantity.
We all want definitive answers. But when you’re over 40 it doesn’t work that way because each egg has a 10% chance of being genetically normal.
Dr. Clark:
Assisted Reproductive Technology (ART). This is something that many women are turning to.
I personally think I went too far and did too many IVF cycles before changing course. Do you steer patients to stop?
Dr. Aimee:
Sure, we talk openly about how there is a plan for them to be a parent and there are many options to do so.
Dr. Clark:
Yes, I went through egg donor. Every family has to determine along the way how aggressive or far they want to go.
I think it’s really important for open conversations to be had.
Dr. Aimee:
I think people are surprised to hear what the chances are when they try naturally.
Dr. Clark:
Seeing a fertility specialist at any age does not mean you’ll be doing IVF.
Dr. Aimee:
Exactly. Seeing a doctor just means you’ll be educated about your fertility.
Dr. Clark:
Tell us what do you mean when you encourage women to get their TUSHY checked?
Dr. Aimee:
Sure. I find that people don’t really know what the simple steps are that they can do to learn more about their own fertility. So I came up with a very simple nemonic. T is for fallopian tubes, U for uterus, S for sperm, H for hormones, and Y for your genetics. These are the steps (and things) that every fertility doctor goes through and checks with and for their patient.
Anyone can get more information about the TUSHY method here.
Dr. Clark:
Eggs do have an expiration date. Why doesn’t the uterus?
Dr. Aimee:
Well, there are some conditions that can make it more difficult to get pregnant that are more common when we get older. Something like endometriosis. With endometriosis, you can also have a condition called adenomyosis.
Both of these contribute to it being harder to get pregnant, especially as you get older.
In general, for a woman that’s forty-five, we just worry about the general pregnancy complications like high blood pressure, early delivery, diabetes, etc.
Otherwise, if you were to in theory place the same embryo in a uterus of a woman who is thirty-eight vs. someone that’s forty-five, the pregnancy rate in both women should be about the same (with the same embryo). That’s true unless there are other conditions there like endometriosis or fibroids.
Dr. Clark:
So that’s why you hear stories about women in their 50s having babies. For example, I didn’t have any viable eggs, but I had a uterus that was healthy. ASRM.org is a great resource for women and their fertility.
Dr. Aimee:
That’s right. There are plenty of women that run out of eggs but their desire to be a mom doesn’t run out. That’s okay, in fact, it’s very common for women to still seek out options even after menopause and that’s why there are other creative ways to get pregnant.
Dr. Clark:
What is the IVF attrition pyramid?
It helps you learn about what your expectations should be from IVF. Understanding what your pyramid looks like for you at your age and with your follicle count should then help you plan your fertility treatment. It may take another egg source if you are of a certain age and it may take more than 1 cycle.
Dr. Clark:
Yes, I had 36 eggs, but only 1 embryo that didn’t take.
When do you recommend that a woman consider an egg donor when she’s not getting pregnant with IVF?
Dr. Aimee:
When she feels like she has IVF closure — when you feel like you’ve done everything possible to feel you can move on without any regret.
It’s such an individual thing and sometimes working with a therapist can be helpful too.
We can talk about other options early on. Sometimes for patients over forty, we can parallel path between IUI, getting pregnant naturally, and planning for IVF with and without an egg donor.
Dr. Clark:
Great. So always ask your doctor what your options are and know that IVF isn’t always the endpoint.
Dr. Aimee:
Sometimes I tell patients to just look at egg donors and see how they feel. For some people they have the reaction, “yes — this will work. I just want to be a mom.” Others will have the opposite reaction and only want to use their own eggs and to keep trying.
Dr. Clark:
Yes, and we are allowed to change our minds.
What is pre-implantation genetic (PGS) screening? Who is a candidate?
Dr. Aimee:
I recommend it to all of my patients regardless of their age. Every clinic will have its own philosophy. I refer to it as the murky crystal ball. It doesn’t tell you everything, just chromosomes. It doesn’t tell you if you’re going to get pregnant or not. Embryo quality is just as important.
Talk to your doctor about PGS and also talk to your doctor about embryo quality so you know what the implantation rate is for your embryo.
What do you do if IVF isn’t working and you’re not ready for other options?
Take some time off! Build your team. Build your own mind and body center if you don’t have one at your fertility clinic. If you really want to be a mother depending on your age, you get to a point when it’s more important to be a mom and less concerned about your own DNA.
Women are getting pregnant after menopause. How does that happen?
Yes, I call it menopausal pregnancy and it’s because you don’t need fallopian tubes or ovaries to have a baby. As long as we have options like egg donation then we can prepare the uterus in the same way that we prepare for an embryo transfer. You don’t need ovaries or regular periods for pregnancy.
If you’re over age thirty-five, then seek help within 6 months. If you’re over 40 then wait 3 months. This assumes you’re having regular menstrual cycles. That is a likely indicator that you’re ovulating. If that’s not the case then you may want to see someone sooner than the general rules above.
If a woman can’t afford IVF, what supplements can she take to try and get pregnant?
There are always other options. Back to the TUSHY, go through the steps and make sure that you’ve got everything checked.
Taking CoQ10 is something that I think every woman should start, even in their 20s. I have my patients and egg donors take it.
Otherwise make sure that you have a healthy BMI, are timing intercourse correctly and you aren’t drinking too much alcohol.
Some treatment facilities offer something called Invocell. That’s where you extract the eggs and you put the eggs and sperm in a little vaginal chamber which then goes in your vagina. The pregnancy rate is about 10–15% higher than an IUI cycle. This may be a good option for someone that can’t afford IVF.
If the cost of living is high then the IVF cost will be higher so consider going somewhere else in the US where treatments are more affordable for you.
How long can you take COQ10 and at what dose?
I tell patients to take 300–600 mg a day, and if they can tolerate it even up to 900 mg.
Talk to your doctor about the dosage they recommend.
ASRM made a recommendation for all fertility treatments to stop unless they have an emergency situation.
So what that means is if someone has cancer and needs to go through chemotherapy then that’s a threat to their fertility. That’s a type of cycle that someone can start right now, otherwise, treatments have stopped. It’s less to do with pregnancy being dangerous, but it has more to do with resources and we are looking at shortages of needed resources in certain areas of this country.
Dr. Clark:
Unfortunately, patients with diminished ovarian reserve are not considered urgent under the current guidelines.
Dr. Aimee:
There is no reason to lose hope. Nothing bad will happen. Use the time to prepare.
What do you think of acupuncture?
I think acupuncture is a great complement to fertility care because patients feel better, have fewer side effects, and recover better from IVF.
I tell my patients to go see an acupuncturist and tell them, “make my eggs look good for Dr. Aimee.” (laughs)
Dr. Clark:
Yes, I did not believe in acupuncture at all, but at some point in my own process, I decided to do it. I did it for 5 months before we transferred our donor embryos. I don’t know if that’s what ultimately helped me get pregnant, but it definitely helped decrease my stress levels.
We need to do what we can to minimize our stress.
Dr. Aimee:
Yes, see the acupuncturist as a part of your team. They are just another person there to cheer you on.
Will they help improve egg quality? I don’t know, but if they help with your stress then there’s a possibility you will see some improvement.
During an IVF cycle, how do you get eggs to grow at the same rate?
Not every egg will grow at the same rate just like not every egg will be viable. That goes back to the IVF pyramid that we mentioned in that every cycle will have a certain number of mature eggs that you’re meant to get out of it and so my strategy is to see patients frequently and early during their IVF cycle so I can adjust things as needed.
I like to monitor my patients closely. I prefer natural cycle starts for several reasons, but there are some good reasons to use birth control pills. My concern for women starting birth control, is that they can also suppress your ovaries and this could work against you if you’re starting with a low number of eggs.
Why is a thin endometrial lining a concern when progesterone can be given until the desired thickness is achieved?
You need a nice landing pad for that embryo. Studies show that having a certain texture, we call it the trilaminar texture, gives patients the best pregnancy rate along with a certain thickness.
Am I allowed to do a transfer right now?
There are some doctors that are finishing cycles that they started a couple of weeks ago. I think it has to do with what’s happening in your specific community.
Can you pass COVID-19 to your eggs or baby?
Based on other viruses like SARS or MERS there was no indication of verticle transmission (meaning a mom passing to a baby during pregnancy or delivery). However, this is a novel virus and we don’t have enough data to know that. We heard a small study out of China that said there was no transfer. We simply don’t know.
As far as transferring to eggs, you probably can’t.
Any recommendations for recurrent miscarriages?
Low dose aspirin is recommended in certain situations but talk to your doctor to get specific guidelines and determine if you’re a candidate for low dose aspirin that’s ideally started around 12 weeks of pregnancy.
Is it okay to continue taking supplements during IVF treatments?
Yes, absolutely. I tell my patients not to stop until they get the family size they want.
Can we talk about DHEA?
DHEA can help some patients who have a low egg count. This may help them grow the follicle count maybe by 1 egg, but we know it can increase testosterone levels and I’ve had one patient experience irreversible voice changes from it. If you’re starting to get acne, unwanted hair growth or oily skin then you may want to stop the DHEA. Based on your body size you may not want to start at a dose that people normally start at (75mg).
Dr. Clark:
I want to put this out there for all women. Let anyone that’s taking care of your know what you’re putting into your body. Your doctor needs to know what you’re taking as they may have their own personal views or opinions of what they like or don’t like.
If you’re spending the money on fertility treatment it’s better to be 100% transparent with what you’re doing with your body.
Is IVF a MUST if you’re over 40?
Dr. Aimee:
No, not at all. There are people who find themselves pregnant as they get ready for IVF or a transfer.
You don’t always need IVF to get pregnant, nor does doing IVF always mean you’ll get pregnant.
Dr. Clark:
Yes, one of the things that I always caution women is to consider IVF as a plan B. It may not work for you. You can’t assume it’s a safe option.
If you are anticipating delaying childbearing for any reason (typically after 35, or sometimes 40). Start to have conversations with your OBGYN so you know what your plan is.
I think we highly underutilize doctors during our regular check-ups to discuss childbearing. We need to take advantage of these visits to ask questions.
Dr. Aimee:
Yes, and test..don’t guess. Don’t make assumptions. Don’t worry thinking you’re going to find out you’re infertile. Instead, you may learn you have a fibroid that needs removing. Those are important things to learn at the start of your fertility journey.
If I started to go down the path of IVF, but due to COVID-19 am not able to continue, how can I continue to try naturally? Is that okay to do?
Yes, and I have a checklist of sorts. If you have a history of ectopic pregnancy or hyperemesis gravidarum (where you’re nauseous and throwing up frequently) — then maybe hold off from trying. You want to avoid going to the hospital right now so if there’s nothing that may put you in that situation then it’s probably okay to go ahead.
Other than that I would recommend timing intercourse around your ovulation every couple of days. And hold off if the current environment is making you very stressed and anxious or you can’t stay home from work if you get pregnant.
Dr. Clark:
With COVID-19 and the current state of affairs if you’re a woman trying to conceive I’d ask you to just consider what the knowns are. Right now if you do get pregnant you’re likely to have reduced or minimal prenatal care as many OBGYN offices are seeing patients on an essential-needs basis only. You may not get the same frequency of ultrasounds, etc. This is all because doctors are trying to protect you and reduce your risk of exposure to COVID-19.
Consider this as you compare this to the option of waiting to conceive. You may want to consider waiting. Or if you don’t know then consider a telemedicine visit with your doctor.
If you’re pregnant and have medical conditions nobody is going to deny you care, but it’s something important to consider if you’re actively trying to get pregnant at this time.
If I’m 39 and just miscarried my first pregnancy, is this normal?
Dr. Aimee:
When you have a miscarriage people are often given bad advice. They may say, “oh just try again. You know you can get pregnant so just keep trying.”
I think the real answer is to get your fertility levels checked. Often after you talk with a fertility specialist you’ll learn that there is nothing wrong, but it’s incredibly helpful to know that before wasting time and potentially experiencing the heartache of another miscarriage.
Learn what you can from that miscarriage to ensure there’s nothing you need to do — like remove a polyp or a fibroid, which may prevent you from having a healthy pregnancy.
Dr. Clark:
I would add to that if you have a miscarriage and you’re older then get the genetic testing of the pregnancy that miscarried done to know more about what’s going on.
What about minimal stimulation IVF. Have you seen better success rates in doing this?
The answer to this is dependent on your situation, but my general thinking is that in this case more is more and less is not more. In other words, if you can get 10 eggs, then you want 10 eggs. If you knew you could get 10 eggs, but only get 2 because you choose minimal stimulation and none of those turn into embryos, then you’ll be pretty upset. Just think carefully about your options.
If I’m trying to conceive or want to do IVF should I first get tested for COVID-19?
Dr. Clark:
No, you should only get tested for COVID-19 if you have the symptoms, have traveled recently, or have had direct exposure.
If I stopped taking medication as my fertility treatments stopped, can I still try and conceive? Will I ovulate?
Yes — it depends a bit on what medication you were on, but your ovulation should come back and yes, you can get pregnant if your doctor thinks it’s right for you.
Are there any birth defects or complications for women pregnant and who test positive for COVID-19?
A high fever we know is associated with birth defects. So if you get pregnant (or are pregnant) and get COVID-19 during your first trimester that would be something to watch.
There are women who have had COVID-19 who have delivered early and we don’t know if there’s a relation there.
There are not any definitive answers about COVID-19 and pregnancy as we simply don’t have enough information at this time.
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Thank you for reading this recap of my conversation with Dr. Shannon Clark.
You can catch more of me and fertility topics like this through The Egg Whisperer Show. The episodes are live-streamed on YouTube, Facebook, and Twitter and on Wednesdays at 7 PM PST. Subscribe to the podcast too!
