Understanding Hormonal Infertility: Causes, Risks, and Solutions

Why does a long-awaited pregnancy not occur? Continuing the topic of hormones from our previous issue, we delve into hormonal infertility and other crucial aspects with Alena Strazdina, a top-tier obstetrician-gynecologist and reproductive specialist.

The Portrait of a Patient

When looking at patients who come for consultations, can we outline a general portrait of them—age-wise or psychologically?

Alena Strazdina

We can start with definitions. According to the World Health Organization (WHO), hormonal infertility is defined as the inability of a sexually active couple, not using contraception, to achieve pregnancy within a year. Why a year? Studies show that under these conditions, approximately 78% of couples achieve pregnancy within a year, while the remaining may take longer. However, this is a general definition. Many factors depend on age, past illnesses, and surgical interventions. Women over 36 should start evaluating their health and fertility after six months of trying to conceive.

Age and Fertility

Contrary to popular belief, patients should not attribute the delay in pregnancy to their age. Instead, they should be more proactive. Waiting longer can result in missing the precious time that becomes more valuable each month. For women of advanced reproductive age, the ovarian reserve—the supply of eggs in a woman’s ovaries—is always assessed. This reserve indicates how long a woman will remain fertile, how long her menstruation will continue, and when menopause will occur.

Markers of Ovarian Reserve

Markers of ovarian reserve include the number of antral follicles, which can be counted during an ultrasound of the pelvic organs in the early follicular phase (days 2-5 of the menstrual cycle), the level of Follicle-Stimulating Hormone (FSH) in the blood, and the Anti-Müllerian Hormone (AMH). Surgical interventions, radiation or chemotherapy, and autoimmune processes can reduce the ovarian reserve. If pregnancy does not occur, assisted reproductive technologies can be considered to achieve pregnancy sooner. In cases of extremely low ovarian reserve or early menopause, the only option may be using donor eggs.

Quality Over Quantity

Age is a crucial factor. It’s not just about the quantity of eggs but also their quality. Unfortunately, we cannot effectively influence these parameters at this stage. However, it is proven that as women age, the likelihood of de novo mutations in the embryo increases. These mutations can lead to implantation failure and miscarriages. Older women experience more such pregnancies, which is something to consider when delaying motherhood.

Planning Motherhood

There was a time when it was believed that having the first child around the age of 20 was the healthiest and most advisable, and completing the family by 30 was ideal. Is this still the position of doctors today?

Alena Strazdina

Times have changed, and women now have many opportunities: building careers or self-improvement. However, if a woman plans to have children, there should be limits to these pursuits. Ideally, having a child by 30 or at least by 35 should be a goal. This is my position as a doctor. I am not suggesting that modern girls should marry at 17 like their great-grandmothers, but we must acknowledge the reality around us. There are circumstances we cannot bypass. Reasonable limits should be set, including for career growth. If you want to focus on self-improvement until 40, then we should plan for a ‘Delayed Motherhood’ program—freezing young eggs and waiting until 49.

The Myth of Pregnancy at 40

There was a trend among women to discuss the ‘beauty’ of giving birth at 40, claiming it rejuvenates. How much do you agree with this as a doctor and a woman?

Alena Strazdina

Pregnancy is a natural process, not an illness, but it has nuances. As we age, we acquire various health deviations: heart, vascular, liver, kidney issues, and more. Pregnancy involves the entire body, adding extra strain. The immune system also changes with age, and pregnancy is a form of immune deficiency. How a woman will cope with this is unpredictable. The appearance of another circulatory system increases the load on the heart and kidneys. Older women are more prone to gestosis in late pregnancy, characterized by high blood pressure, protein in urine, edema, and other complications.

Regarding rejuvenation, when a woman who has already achieved career success returns to the feelings and experiences of youth—first smiles, first words—it can be psychologically refreshing. However, this is only if everything goes physiologically normal.

Realities of Motherhood at 40

Life is unpredictable. The first pregnancy could have been 20 years ago, followed by a second marriage or a longing for children’s laughter. The desire for motherhood is understandable at any age. However, objectively, getting up 25 times a night at 40 is much harder than at 20. At 40, your mother is at least 60, and you cannot rely on her help as you could when she was 40. You will have to manage independently, adding extra strain on your body and mind.

Endocrine Infertility

Let’s return to endocrine or hormonal infertility, which are the same. What are its causes?

Alena Strazdina

The endocrine factor is usually based on ovulation disorders, known as anovulatory infertility. What causes it? The most common condition is Polycystic Ovary Syndrome (PCOS). Menstrual irregularities can start from the first period or later, around 17-20 years. Besides irregular menstruation, symptoms may include obesity and signs of excess male hormones—androgens. Hormonal profiles may show elevated levels of certain hormones.

For further reading, visit the World Health Organization website.