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Tan Xiaojun
·Senior reproductive medicine expert
·Postdoctoral fellow at Peking University
·PhD candidate at Xiangya School of Medicine, Central South
University
·Master’s tutor at Central South University
· Master's degree candidate in reproductive
medicine at the University of South China
· Professional training at Huazhong University
of Science and Technology and Tongji
Hospital Reproductive Center
Expertise:
diagnosis and treatment of infertility, first/second/third generation IVF (including
egg/sperm donation), microsperm retrieval, embryo freezing and resuscitation, artificial
insemination (including husband's sperm and sperm donation), paternity testing, chromosomal
disease
diagnosis, high-throughput gene sequencing, endometrial receptivity gene testing and other
clinical
technology applications. Many of these technologies are at the leading level both domestically
and
internationally.
47-year-old ovarian reserve decreased but menstruation was normal, Beijing assisted reproductive assessment, AMH test, fertility assessment process, can you still get pregnant at 47 years old, pregnancy preparation test for the elderly, IVF assessment, ovarian function decreased with normal menstruation.
47-year-old with decreased ovarian reserve but normal menstruation: 6 judgment points to see whether it is "window period" or "misled by appearance"
At the age of 47, the ovarian reserve is declining, but the menstruation is normal, which is a stage that many women are prone to misjudgment. Focusing on this core keyword, this paper analyzes the relationship between menstruation, ovarian reserve, pregnancy probability and inspection process, helping readers to look at the current fertility evaluation results more objectively.
Let's start with the conclusion: normal menstruation does not mean normal ovarian function.
The 47-year-old with a decreased ovarian reserve and normal menstruation is usually closer to the state of "still having menstrual performance, but the fertility has obviously decreased" than the evidence of good ovarian function.
Many people will interpret "menstruation is still coming and the cycle is still regular" as "ovulation and egg quality should be ok". This inference is not rigorous. Medically, ovarian reserve mainly reflects the number of eggs, and the increase of age will also affect the quality of eggs simultaneously; Whether menstruation comes, more reflects that the hormone axis is still running, and can not directly prove that fertility is in an ideal state. ASRM clearly pointed out that ovarian reserve is the concept of oocyte number, and "quantity" and "quality" are not the same thing; ACOG also pointed out that female fertility declines with age and accelerates after 35 years old.
From the first-principles point of view, the essence of this problem is not "whether there is menstruation", but three things:
Whether there are follicles that can be recruited, whether the quality of eggs can support the formation of usable embryos, and whether uterine and systemic conditions allow pregnancy.
Therefore, seeing "normal menstruation" at the age of 47 can be regarded as a signal that endocrine activities have not completely stopped, but it cannot be directly equated with "the chances of natural pregnancy are still considerable".
Why do some people have normal menstruation, but the examination suggests that the ovarian reserve is declining?
Ovarian aging is not "menopause overnight", but a gradual change process. STRAW+10 mentioned about the stages of female reproductive aging that the cycle, hormones and ovulation state will change gradually before and after entering perimenopausal period, but these changes do not occur in the same way and at the same time for everyone. That is to say, when the ovarian reserve has decreased, menstruation may still temporarily maintain the surface regularity.
Clinical common situation is:
Menstruation still comes, but AMH is low.
Basal FSH elevation
AFC (sinus follicle number) decreased.
Even with ovulation, the risk of egg aneuploidy increases significantly with age.
ESHRE's data on women's fertility and age point out that natural pregnancy is rare after entering the 40 s, and by the middle and late 40 s, the chances of success are obviously reduced regardless of natural pregnancy or self-assisted reproduction. The data of HFEA also show that the live birth rate is at a low level for a long time when people aged 43 and above use autologous eggs.
Expert tip:
"Normal menstruation" can only show that the body is still bleeding periodically, which is not enough to judge the ovarian reserve and egg quality alone. What really has reference value is the comprehensive evaluation of age, AMH, FSH, AFC, previous pregnancy history and accompanying diseases.
Who are more likely to mistake "normal menstruation" for good news
From the perspective of assisted reproductive clinics, the following groups of people are particularly prone to misjudgment:
1. People who only look at menstruation, not age.
Age is an unavoidable core variable. Both ASRM and ACOG emphasize that the decline of female fertility is first driven by age. Even if it is the same as "normal menstruation", the reproductive meaning of 37 years old and 47 years old is not the same. At the age of 47, the problem is often not only the decrease in the number of follicles, but also the decrease in the probability of forming normal embryos.
2. People who only look at AMH without looking at the overall clinical background.
Another misunderstanding is just the opposite: as soon as you see the low AMH, you will directly assume that there is no chance at all. This is also inaccurate. ASRM pointed out that the prediction of ovarian reserve index for short-term natural conception ability is not the same as the final birth outcome, especially it can not be explained separately from age, medical history and treatment goal. In other words, low AMH is not evidence of "immediate despair", but at the age of 47, when low AMH is superimposed with age, its clinical significance will be even heavier.
3. People with regular menstruation but complicated with uterus, metabolism or chronic diseases.
The evaluation of pregnancy preparation or assisted reproduction in the elderly has never only looked at the ovaries. The 47-year-old people often need to assess the risks of endometrium, hysteromyoma, adenomyosis, thyroid function, blood pressure, blood sugar, weight and pregnancy complications at the same time. ACOG's data on advanced pregnancy indicate that the increase of age is related to the increased risk of pregnancy complications. In other words, even if there is still ovulation, it does not mean that the risk of pregnancy is low.
How is this kind of situation usually evaluated technically?
If the core question is "is this good news or illusion", medicine will not rely on sensory judgment, but on hierarchical inspection.
The first layer: basic fertility examination
Usually includes:
AMH
Basic FSH, LH and E2 on the 2nd-4th day of menstruation.
AFC viewed by transvaginal ultrasound
Ovulation monitoring
Uterine evaluation
Male semen analysis
ASRM pointed out that AMH, basic FSH and the number of ultrasonic sinus follicles are all commonly used indicators to evaluate ovarian reserve, but these tests mainly help to judge the ovarian response to stimulation and treatment expectations, and cannot define whether a person can "naturally conceive" alone.
The second layer: pregnancy feasibility assessment.
Even if the 47-year-old population is still menstruating, it usually needs to be evaluated simultaneously:
Basic information of endometrial receptivity
Whether there is uterine space occupation or chronic inflammation.
Blood pressure, blood sugar, liver and kidney function
Coagulation, thyroid and autoimmune related indexes
Cardiovascular risk of pregnancy
The significance of this step is that assisted reproduction is not about "laying eggs", but about whether there are relatively acceptable pregnancy conditions.
The third layer: scheme diversion evaluation
The common clinical shunt ideas are roughly as follows:
Can you still try natural pregnancy?
Is it suitable for short-term active pregnancy assistance?
Whether to enter the self-ovum test tube for evaluation.
Is it necessary to discuss the egg donor path?
Should we focus on health management instead of continuing to pursue pregnancy?
According to the published data of HFEA, the live birth rate of self-fertilized eggs at the age of 43 and above is low for a long time, and the outcome of egg donor route is obviously better than that of self-fertilized eggs at the same age. This fact does not mean that everyone must choose to donate eggs, but it shows that the older you are, the more you need to face the realistic boundary in making decisions.
Expert tip:
PGT-A/ embryo chromosome screening can be used as an embryo level evaluation tool for some people, but it can not reverse the aging of eggs, nor can it replace the influence of age itself on the outcome. Whether it is necessary to use it should be judged by the doctor in combination with the number of embryos, past history and medical indications.
The core of this point is not "the more technology, the better", but "whether it can really improve the overall outcome when there are few embryos available". This judgment needs to be individualized.
From the process point of view, what should I do when I am 47 years old?
If this matter is divided into action steps, the reasonable process is generally not to "continue to wait", but to complete the closed loop of judgment as soon as possible.
The first step: first confirm what kind of "normal menstruation" is.
Some people just have a roughly regular cycle, but the menstrual flow is obviously reduced, the cycle is shortened, and ovulation is unstable; Some people are seemingly regular, but in fact the anovulatory cycle increases.
Therefore, menstrual records should at least combine:
Period length
Variation of menstrual quantity
Is there any advance or delay?
Is it supported by basal body temperature or ovulation test paper?
Step 2: Complete the core inspection within one cycle.
Old age assessment is not suitable for delaying for too long. The reason is straightforward: this age group may change faster than expected.
It is suggested that AMH, basic hormones, ultrasound AFC, uterine cavity and man examination should be completed in a short time as far as possible, and then comprehensive judgment should be made, rather than repeated observation of menstrual status alone. ASRM's assessment of infertility points out that older women should start the assessment earlier rather than wait for a long time.
Step 3: Decide whether to continue the self-egg attempt according to the goal.
If the goal is to "use your own eggs as much as possible", you need to accept a reality:
At the age of 47, the self-egg path emphasizes "whether there is still room to try" rather than "whether the success rate is optimistic".
ESHRE data pointed out that by the middle and late forties, the chances of successful natural pregnancy and self-assisted reproduction decreased significantly. HFEA also showed that the live rate of self-fertilized eggs over 43 years old was at a low level.
Step 4: Discuss the physical risk together with the birth goal.
Many people only focus on "can you conceive" and ignore "whether it is safe after pregnancy". At the age of 47, pregnancy-induced hypertension, abnormal glucose metabolism, abortion, chromosomal abnormalities and other risks need synchronous communication. ACOG clearly pointed out that advanced age is related to pregnancy complications and increased fetal risk.
Frequently asked questions: Is this good news or illusion?
Q: After 47 years of normal, does it mean that you can still get pregnant naturally?
A: Whether you can get pregnant naturally cannot be judged by menstruation alone.
Normal menstruation means that ovarian activity has not stopped completely, but it does not mean that the number and quality of eggs are still at an ideal level. It is not absolutely impossible to get pregnant naturally at the age of 47, but it is usually classified as a group with low chances in medicine and needs to be evaluated as soon as possible.
Q: AMH is low, but menstruation is accurate. Is it not allowed to check?
A: Not necessarily.
AMH reflects the reserve of collectable follicles in the ovary, while menstruation is the expression of the overall hormone cycle, and they are not the same dimension. Clinically, it is entirely possible that "menstruation is still regular, but AMH has declined".
Q: Does the 47-year-old self-ovulating test tube still make sense?
A: This is not a question with a unified answer, but a question of management by objectives.
According to the population data, the chances of using self-fertilized eggs for live births at the age of 47 have been obviously limited; But whether an individual still has the value of trying depends on AFC, FSH, previous reaction, embryo formation ability and my acceptance of time, cost and expected results. According to the published data of HFEA, the live rate of self-ovum at the age of 43 and above is low for a long time, so doctors tend to discuss the realistic boundary of self-ovum path more cautiously.
Q: If your menstruation is normal, can you wait for another half year?
A: From the perspective of medical logic, it is not recommended to take "waiting" as the default scheme.
At the age of 47, time itself is the key variable. Waiting for half a year will often not make the ovarian reserve better, but may further reduce the choice space. It is more reasonable to evaluate first, and then decide whether to continue the natural attempt, enter the process of assisted pregnancy, or adjust the birth plan.
Summary box
Summary: At the age of 47, the ovarian reserve is declining but the menstruation is normal, which is more like the stage of "the appearance is still stable and the internal fertility has changed significantly".
The good news is that the body may still have periodic functions and has not completely stopped menstruating;
The risk is that it is easy to overestimate the realistic chance of natural conception or self-fertilization
What really matters is not whether menstruation will come or not, but to complete the comprehensive judgment of age, AMH, FSH, AFC, uterine condition and systemic pregnancy risk as soon as possible, and then decide the next step.
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