Most modern women in their thirties and forties are full of energy, with personal and career ambitions and suddenly might be informed that their reproduction time is limited, and they must rethink all personal, social and working plans.
At birth, a certain number of eggs are embedded in a women’s ovaries. Thereafter, a few of these are consumed in each menstrual cycle and by menopause that egg pool becomes depleted. Therefore a women’s reproductive life is directly related to the availability of eggs. This, so called ovarian reserve, gradually declines and physiologically zeros at menopause, the median time of which is around 50 years. An indicator of the ovarian reserve is serum AMH, a hormone that is produced by cells from small ovarian antral follicles.
The ovarian reserve can be low from the beginning at birth, or begin to decrease at faster rate at any time during reproductive life, or may decrease to reach a plateau for a period of time, and then decrease again, or decrease rapidly approaching early menopause. Such impacts can be summarized under the term Premature Ovarian Insufficiency (POI). This might be the most shocking information for women at reproductive age without children yet.
Premature Ovarian Insufficiency might be the most shocking information for women at reproductive age without children yet.
Women usually are not aware about their ovarian condition. A discussion about low AMH and POI initiates anxiety, even anger and sense of helplessness. Today most modern women in their thirties and forties are full of energy, with personal and career ambitions and suddenly might be informed that their reproduction time is limited, and they must rethink all personal, social and working plans.
The etiology of POI is variable and heterogeneous. It can be due to genetic and hereditary factors, environmental factors, a virus infection, endometriosis, ovarian surgery, radiotherapy, chemotherapy, and even unknown factors, or sometimes a combination of factors. As we know, the major destruction of ovarian eggs happens at fetal life about 20-25 weeks of gestation. Therefore, is unusual to identify precisely the cause of POI.
A campaign must be initiated for all women to be aware of important issues such as low ovarian reserve and POI, and their role in reproduction. It is critical that these conditions are explored well before the time of diagnosis. Being informed of this complex and unpleasant condition at that late stage can be very emotional, and decision options become limited and harder to make.
It is wise that women from early on are educated about he importance of subtle menstrual cycle changes associated with POI. These might be a gradual decrease of menstruation volume, a shortening of cycle duration, frequent presence of ovarian functional cysts, and low counts of antral follicles observed by vaginal ultrasound. All women must inform themselves of the time of menopause of their mother, sisters and other maternal females relatives. In case of an ovarian surgery women must extensively discuss the possible consequences on the ovarian reserve, and apply an appropriate cost – benefit analysis regarding reproductive options.
A low AMH is definitely an alarm that forces women to reconsider social, personal and family plans to succefully confront POI
The encounter with a low AMH is not the end of the world. It does not mean that a woman cannot have a baby. In most cases the cause or the course of POI is not known. Maternal age weighs as the most significant factor. A low AMH is definitely an alarm that forces women to reconsider social, personal and family plans to succefully confront POI. After the initial surprise and anger, an acceptance of the new situation must lead to a solution plan.
Another subtle issue is that the male partners, most of the time, seem reluctant to understand fundamentals of female reproduction and empathize, particularly in the situation of POI. It is difficult for them to realize that women have a certain time period for reproduction which coincides and interferes with personal, social and professional ambitions, and that in some cases this time period can suddenly be far shorter.
Taking all these into consideration, a case of POI is a complex and very emotional issue. Ideally, educational tools should be available early on to understand female reproductive dynamics. Discussion and management must embrace all reproductive alternatives and consultation must involve women and their partners.