AMH: The Little Hormone That Can (Help Predict IVF Outcomes & More!)

AMH-Secreted-by-Growing-AF copy

Anti-Müllerian hormone (AMH) is a new biomarker that may be the most cost effective marker for women who are trying to get pregnant.

AMH is a hormone produced by small ovarian preantral follicles. As the quantity of eggs in the ovary diminishes, AMH levels also fall. In the ovary, AMH directly affects ovarian follicle growth, as it reduces sensitivity to follicle-stimulating hormone (FSH). Excess AMH may inhibit the ovaries from ovulating, which is a common cause of infertility.

This means that AMH is a solid marker of ovarian reserve. For women trying to get pregnant, knowing their AMH levels can help direct them to the best approach to conceiving. For other women who want to ensure that they don’t end up waiting too late to conceive, AMH is also an ideal indicator.

Here are some of the ways AMH is an efficient, effective fertility gauge of ovarian reserve:

  • It can be measured any time: Your doctor can test its levels any day of your menstrual cycle.
  • It is a stable marker: There is little change in the marker between cycles.
  • It is consistent: Accessing AMH will not vary significantly from lab to lab.

Other markers of ovarian reserve are available, but they have more limitations than AMH, including:

  • FSH: This hormone needs to be obtained on the early days of the cycle (day 2,3 or 4), and it needs to be evaluated with estradiol (estrogen) levels. FSH also varies between cycles, so it can be falsely reassuring when drawn by itself or not viewed in conjunction with estradiol levels or with ovarian sonography.
  • Antral follicle count (AFC): During an ultrasound of the ovaries, the small 3-6mm ovarian follicles (inside of which should be an egg) are counted in each ovary. The AFC also accurately predicts ovarian response to fertility treatments, but it too is cycle dependent (early is best). Also, it can be falsely reassuring because the small follicles visualized on ultrasound may be either small antral follicles ready to grow OR they could be small atretic (dying) follicles that can no longer grow.
  • AMH has been shown to correlate with ovarian response in fertility treatments. Here are some of its implications:
  • Very high AMH levels > 3.0 can predict a high risk of Ovarian hyperstimulation syndrome (OHSS) in a cycle. This is a complication seen with injectable fertility medications and can be serious and life threatening. Prevention is key. In addition high AMH levels may be used to diagnose Polycystic Ovary (PCO) syndrome.

Many women have irregular periods, but sometimes the precise reason for the irregularity is hard to determine. High AMH levels may help to diagnose PCO syndrome.

Low levels of AMH can predict cycle cancellations with accuracy. IVF cycles are often cancelled if less than three or four follicles are seen on ultrasound after fertility medications are taken. Although AMH by itself does not correlate directly with live birth rates, it appears that AMH >1.0 is more likely to be associated with successful fertility treatment cycles (no cancellation) and live birth rates.

In contrast, low levels of AMH are associated with higher cancellation rates. In one study, if AMH was <0.7ng/ml, two thirds of the cycles were cancelled.
In an IVF cycle, it appears that AMH is inversely proportional to the following:

  • Number of follicles aspirated
  • Estradiol levels
  • Number of total oocytes retrieved
  • Number of total mature oocytes found ( only mature eggs/oocytes can be fertilized and become embryos.

AMH is more significant as a predictor of good outcomes (or bad outcomes), when age is combined with AMH level. It is not a good predictor of implantation and pregnancy rates. Age is still the best marker of quality and of percentage of viable embryos, but together age and AMH can be used to predict outcomes, and in particular cancellation rates.

To summarize, AMH is a great single marker to help tailor treatments and to reliably counsel women who are in the following situations:

  • Young women contemplating egg freezing or when to start a family
  • Young women with cancer (AMH can be used to measure ovarian reserve before chemotherapy as well as after.)
  • Young women with irregular menstrual cycles
  • Older women who wish to conceive

For more information about AMH and how it might be the best indicator for your fertility situation, please CONTACT US.

All About Egg Donation

golden-eggIn vitro fertilization (IVF) was designed to help women with fallopian tube blockage or structural damage – known as tubal factor infertility – which accounts for as much as a 25-30% of all infertility cases. Corrective tubal surgery was not very successful if there was severe tubal damage from prior infections, endometriosis, or scar tissue from prior surgeries. Frequently in these cases, the ovaries, eggs, sperm, and uterus were normal, but without a functioning fallopian tube (or tubes), the gametes could not meet and form embryos. IVF took fertilization out of the bedroom and into the laboratory – more than 35 years and five million babies later, the process has answered many parents’ prayers.

Once fertilization could be done in the laboratory, procreating was no longer synonymous with intimacy and sexuality. This has allowed third party reproduction to be possible. From the first successful egg donation in 1983 through to today, Assisted Reproductive Technology (ART) has become hugely successful.

The process of egg donation is fascinating. First, the donor takes fertility medications to ensure multiple follicle (egg) development. During this stimulation, she makes frequent visit to the reproductive medicine office to monitor the growth of her follicles and estrogen production. Simultaneously, the parent-to-be (know as the oocyte recipient) takes estradiol to prepare her uterus for implantation.

The process kicks into high gear in the middle of the donor’s cycle when ovulation is triggered by the application of an injectable hormone. Thirty-six hours later, the follicles are aspirated via a needle attached to a vaginal probe ultrasound. Later that same day, the eggs and sperm are mixed together either with conventional IVF where sperm are overlaid on top of the eggs or via intracytoplasmic sperm injections (ICSI), when the sperm head is injected by needle directly into the egg. (ICSI is used for men with abnormal semen parameters or for couples who have never had any conception or prior natural fertilization.) Five days later, an embryo is implanted into the uterus of the oocyte recipient after adding progesterone to her estrogen regimen.

Egg donors go through a rigorous screening process. Egg donors have tests to ensure that they have no sexually transmitted diseases or infections. They are also screened for drug use. In addition, their medical and family history is reviewed. Genetic tests are often done to make sure that they do not carry gene mutations that might lead to children with specific disorders. Finally, donors are also required to have psychological screening.

Egg donation opened up fertility to many women. Older women whose ovaries no longer make quality eggs – even those who are in menopause! – are now able to conceive. Younger women who have gone through an early menopause (i.e., due to surgical removal of their ovaries from chemotherapy or unknown causes) can now get pregnant and carry a baby to term. Genetically, these babies do not have their intended mother’s DNA, but they do have their father’s DNA.

Egg donation success rates are better than standard IVF, with pregnancy rates per cycle often as high as 60% per stimulation. Moreover, young egg donors frequently make many eggs, and often yield multiple embryos – thus after one stimulation, several attempts at conception are possible. Frequently there are surplus embryos that may never be used.

Recently, using a newer technique called vitrification, the ability to freeze eggs is now possible and successful. For years past, egg donation required the synchronization of two women’s cycles. Optimal success was achieved with fresh embryo transfer less than a week after oocyte retrieval. With vitrification, the embryologists can now freeze egg donor’s eggs and store them in egg banks. Very soon, there will be egg banks similar to sperm banks, and the collection of eggs will be separated from the recipient’s transfer cycle. The recipient will be able to choose six eggs from a single donor. The eggs will then be thawed and inseminated prior to transfer. Over time, this may prevent the production of numerous surplus embryos without compromising success rates.

Young women now can consider the prospect of freezing their eggs to ensure that if someday they need an egg donor, they can use their own stored eggs. Many women are considering egg freezing (check out The Pros of Fertility Preservation and The Cons of Fertility Preservation), but most who consider it are already in their mid to late 30s. Now that egg freezing is a reality, more young women in their mid 20s may want to consider one cycle of egg freezing as an insurance policy against unforeseen circumstances. These same women would make excellent egg donors. It may even be possible to combine a cycle as an egg donor and also as a personal egg freeze.

For more information about this combination cycle, CONTACT US.

How Paternal Age Affects Fertility

old spermNowadays, many couples are delaying becoming parents until their mid 30s and beyond. This choice is not without conception consequences; data has been available for years about the adverse affect of advanced maternal age on childbearing. There is an increase in miscarriages and a decline in fertility rates, as well as increased incidences of chromosomal abnormalities in the first and second trimesters of pregnancy.

But what about advanced paternal age?

Recent evidence suggests that just as age affects female fertility, so can it affect male fertility. The following are common conditions and situations that older men may experience that inhibit their ability to impregnate their wives or partners:

1) Urologic disorders and prostate problems. While these conditions alone don’t necessarily impact fertility, the medicines prescribed can have a negative effect. When they enter the seminal fluid, the meds can be harmful to pregnant women.

2) Erectile dysfunction, loss of libido, and problems with ejaculation. All of these conditions inhibit sexual function and activity. Further, if relief entails surgical treatment, then it may lead to scarring and obstruction.

3) Cancers, such as bladder and prostate cancer. Treatment may lead to a lack of ejaculate, which means that surgery may be required to aspirate sperm from the testes. The only option in that case for insemination, then, is In Vitro Fertilization (IVF).

4) Testosterone supplementation. As men age, many complain of fatigue and are prescribed testosterone to improve mood, performance strength, and libido. Testosterone, however, depresses sperm count and should NEVER be prescribed to men trying to conceive. While doctors know this, frequently men take over the counter supplements or otherwise ingest testosterone unwittingly. What men should know is that the alternative to testosterone supplementation is exercise — this increases lean muscle mass and energy, while also providing a man with a sense of well-being and improved bone health. Rest and avoidance of stressful situations also helps.

5) Natural decreases in sperm count. As men age, research supports the idea that there are subtle declines in semen analyses over time. Semen volume decreases 0.3cc per year, and sperm motility decreases 0.7% per year. Progressive motility declines by 3% per year, and total motile count appears to decline 4.7% per year. Compared to men under the age of 25, adjusted odds ratio for conception within a 6-12 month period is as follows:

  • 0.62 (age 30-34)
  • 0.5 (age 35-39)
  • 0.51 (age >40)

So the odds rate for conception within one year decreases by 3% annually. When intrauterine insemination data was analyzed, it revealed that pregnancy rates clearly declined with advancing paternal age. IVF data, however, is different, and there is no clear correlation between older men/advance paternal age and rates of fertility, implantation, pregnancy, miscarriage, and live births, and embryo quality in the early states.

Despite this reassuring news, with advancing paternal age there are also fewer blastocyst embryos. Also in donor egg cycles, there is a steady decrease in live birth rates, and an increase in spontaneous miscarriages. And intrauterine fetal death rates do appear to rise when the man is over 40 and over 50 — the odds ratio is 5.65 over 40, and 1.88 over 50.

Additionally, data shows that when the man is older there is a related increase in birth defects, fetal death, and stillbirth. There is also a notable increase in Caesarian sections, pregnancy-induced hypertension, preterm labor, placenta weight, and low birth weight infants. Experiments have shown there may also be greater DNA damage in sperm and increased incidences of rare disorders including imprinting and congenital malformation. Studies have shown more cleft lips and palates, complex disorders, and syndromes. There is even more childhood lymphoma and leukemia.

While most children born to older fathers are normal, the greater the paternal age, the greater the risk of issues related to fertility and conception. Just as it is with females, male peak fertility years are when they are in their 20s.

If you have concerns about the age of your male partner and your chances of conception, CONTACT US for more information.

Diminished Ovarian Reserve & How it Differs From Age-Related Infertility

eggsDiminished ovarian reserve and age related infertility are NOT the same.

Mary Smith (not her real name) recently came to the office requesting egg freezing. She was thirty years old with regular menses but no lifetime partner, and she wanted to preserve her fertility. She had heard that in one month she could store up to 20 eggs to be used later at her discretion. Her friend Amy was married but wanted to delay childbearing due to career concerns. A third friend had irregular menses for two years, and no gynecologist could explain why. We evaluated each of these women, and the results revealed that each had diminished ovarian reserve.

What does diminished ovarian reserve really mean for a young woman who has yet to try to conceive and does NOT have a diagnosis of infertility? How should these women be counseled?

Now that egg freezing is NOT considered experimental, more and more women are inquiring about it. The first step includes an assessment of ovarian reserve. We start with a history of menstrual cyclicity, and perform an ultrasound to measure antral follicle count (the number of small eggs/follicles seen in the ovary at the start of menses). Lab tests look at hormones including Anti-Müllerian (AMH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH), and also measure estradiol. We then begin a discussion of the process, which includes eight to twelve days of injectable gonadotropin hormone to help the antral follicles grow to maturity and ovulation, followed by transvaginal aspiration of the follicles to retrieve the eggs.

Diminished ovarian reserve is a term coined to explain the situation when a woman has few (less than five) antral follicles in her ovaries each month. The diagnosis may also be made when AMH levels are below one (suggesting a decreased chance of conception) and FSH is elevated.

I liken ovulation to a horse race — each month a certain number of eggs line up in the corral at the beginning of the menstrual cycle. For some women, there are twenty eggs at the starting gate, and for others there are less than five. At menstruation (or a few days before), the starting gun goes off and the race begins as the pituitary gland signals the ovary to release hormones; FSH to help the eggs grown and LH to help the cells surrounding the eggs make estrogen. Usually by Day Five of the cycle, the largest egg has enough machinery in its cell to continue growing without the extra input from the pituitary gland’s hormones. This message from this “lead” follicle to the pituitary gland is, “I have this race won, I don’t need any more juice.” The pituitary subsequently stops feeding the ovary with FSH and LH hormones. Over the next week, that lead egg grows, survives, and wins the race to ovulation, leaving behind the other eggs that were too small to make it to the finish line.

Women with diminished ovarian reserve have fewer eggs at the starting gate. Typically until perimenopause, ovulation continues unabated – so unless investigation is undertaken, a woman may have no indication that there are changes happening in her ovary. As time progresses, a woman with diminished ovarian reserve may notice changes to her menstrual cycles: first subtle changes, which are the shortening but increased regularity of her periods, and then on to later changes which are much less subtle, such as months of delayed or missed menses. She may also notice hot flashes and night sweats.

Response to fertility medications is markedly different in young women with diminished ovarian reserve, and so it is critical that changes to menstrual cycles, no matter how seemingly minor, should be noted.

In women with a healthy ovarian reserve, the extra FSH and LH in the form of injectable gonadotropins provided at the outset of fertility treatments gives smaller eggs the extra juice needed to reach maturity and achieve ovulation. For women with diminished ovarian reserve, since the additional eggs were not in the starting corral at the onset of menses, the extra drugs do NOT recruit any additional eggs.

Diminished ovarian reserve and infertility/subfertility are not one and the same. Egg and embryo quality is most closely associated with age, not embryo number. Women who are under 35 usually have a larger percentage of their embryos that have a normal chromosome number and thus have a very high chance of pregnancy.  A young women in her 20s or early 30s with diminished ovarian reserve may not have significant fertility issues if she tries to conceive naturally.

If a young woman with diminished ovarian reserve chooses to freeze her eggs, she may not develop a significant number of mature eggs to put away in the freezer. This means that delayed childbearing that relies on egg freezing to preserve fertility may not be as successful or financially feasible for all women.

Population-based studies to see what percent of young women in their 20s and early 30s have diminished ovarian reserve have not been done. Most studies have focused on women presenting to the infertility clinic. It is not known if young 20-somethings with few antral follicles have similar or reduced pregnancy rates when trying to conceive naturally. Biologically, since egg quality and subsequent embryo quality is most closely associated with age, the presumption is that these women should have similar pregnancy rates as their age-related cohorts. The difference is as they age and there are fewer eggs in the ovary, they will reach the critical juncture to the perimenopausal transition sooner, which means they might start having anovulatory cycles (bleeding without ovulation) and infertility issues sooner.

For women like Mary Smith and her friends with diminished ovarian reserve and a desire to delay childbearing by freezing eggs, fertility options are somewhat limited and may be relatively expensive. Realistically Mary can expect two to five eggs in the freezer per cycle, and it may take several cycles (and much expense) to store the desired 20 eggs or more. For those with means, this may still be worthwhile as their alternative prospects are not favorable. The diminished ovarian reserve diagnosis is NOT synonymous with infertility; it only implies a poor response to fertility medications. A woman already in perimenopausal transition should be counseled that ovulation induction may already be a required treatment, and her symptoms combined with diminished ovarian reserve may yield much lower changes of conception. For these women, donor egg and adoption always remain a viable option for building a family.

For more information about diminished ovarian reserve and how it affects your fertility, CONTACT US.

How Age Affects Fertility

age_infertilityIt’s a well-known fact as your age increases, fertility significantly diminishes over time. Aging is also associated with higher miscarriage rates. Unfortunately these changes are intrinsic to the egg, and today’s fertility technologies can’t alter the egg’s integrity.

The connection between age and fertility has been proved over and over again from data derived from earlier populations that didn’t use contraception. The evidence shows that the later a woman married, the fewer children she had, and as time went on, it was also less likely that she would have children at all. Age-related infertility is therefore not a problem of modern society. The issue with modern society is that a large percentage of women are waiting to marry and are delaying childbearing until their thirties and forties. This translates to a larger percentage of women who face fertility issues.

A classic French study in which women underwent insemination with donor sperm yielded 75% pregnancy rates for women under 31 after 12 months of insemination. For women ages 31-35, this figure decreased to 64%, and then again to 54% for women over 35. In IVF cycles, pregnancy rates markedly decline according to the age of the woman — for details about national IVF stats, check out this Clinic Summary Report.

Age is also associated with a corresponding decline in egg number and ovarian follicle count. Simply put, this means there are fewer eggs in the starting gate. Response to fertility medications is markedly different in women with a diminished ovarian reserve (which is the ability for the ovaries to provide eggs that can be fertilized and that will result in successful pregnancies). Age-related infertility describes the changes in quality of eggs with the aging female. Diminished ovarian reserve describes a decreased number of eggs. Unfortunately for women over the age of 38, these two factors frequently compound each other and can make it especially difficult for older women to become pregnant.

During treatments with fertility medications, providing women with extra hormones provides the necessary juice to fortify the smaller eggs in the race and allows them to continuing growing, reach maturity, and achieve ovulation. For women with diminished ovarian reserve, if the additional eggs are not in the starting corral at the onset of menses, extra drugs don’t yield additional eggs. Hence diminished ovarian reserve is associated with a poorer response to medication.

While pregnancy rates have been proved to decrease as a woman ages, miscarriage rates conversely have been shown to increase as the mother ages. Whereas a woman under the age of 35 has just a 15% chance of miscarriage, the rate increases to 20-35% from ages 35-45, and in women over 45, that rate leaps to 50%. (Source: So as we age, most women also have a decline in their egg quantity as well as egg quality. This makes the likelihood of having even one normal embryo much lower over time.

Additionally, there are several other factors that support the decline in reproductive rates in aging women including:

  • An increased likelihood of endometriosis (a painful condition caused by the appearance of endometrial tissue outside of the uterus), adenomyosis (also painful with excessive bleeding; this is caused by endometrial tissue existing within and growing in the muscular wall of the uterus), or fibroids (benign tumors made of muscular and fibrous tissues in the pelvis).
  • Since older women may have had more sexual encounters over time, there is potentially more exposure to sexually transmitted diseases or pelvic inflammatory diseases.
  • Over a woman’s lifetime, an abnormal Pap smear may have been treated surgically with a resulting change in the cervical mucus.
  • Older women are also more likely to have other illnesses related to infertility and/or health risk during pregnancy including thyroid dysfunction, hypertension, diabetes, and even a cancer diagnosis.
  • Older couples also report fewer sexual encounters, which also may contribute to decreased fertility.
  • New data supports the theory that there is a mild but real decrease in sperm quality with the age of the male partner, which may have a subtle effect on fecundity rates as well.

All of this is not meant to scare you, but to provide you with the knowledge to plan your life and make educated reproductive choices. Having a regular menstrual cycle is not synonymous with fertility, and although menopause may not occur until 51 or older, the ability to have a child beyond the age of 43 is rare. Egg donation has made the possibility of childbearing up to age 50 a reality for many women, but women of all ages need to understand the real facts of reproductive aging in order to make educated decisions and choices in their twenties and thirties.

If you have questions about age and fertility, talk to us!

What You Need to Know About The Affordable Care Act

acaThe Affordable Care Act (“ObamaCare”) was signed into law to reform our healthcare system in 2010, upheld by the Supreme Court in 2012, and began its big rollout last year with the most significant aspects of the legislation in place by January 1, 2014. This controversial new law was made even more complex by the issues related to the launch of the website. Consequently, you may not be clear on all of The Affordable Care Act’s benefits. While we healthcare providers are also in a period of adjustment – which will continue to evolve as reforms continue to rollout, the initial changes have already made significant impacts.

The good news is that 47 million women now have access to preventative health services and the law also makes it illegal to charge women different rates from men.  (For more on benefits specifically geared toward women, click here.)

And from our standpoint as your OB/GYN provider, here are some key points about how The Affordable Care Act affects you:

1) It is a blessing to many women due to the fact that many preventative services are now guaranteed by the law. Annual well-woman exams (i.e. pap smear, pelvic exams, associated lab tests, and annual checkups with no additional issues) are now a covered benefit on all insurance plans. This means that you are entitled to visit the gynecologist once per year without a co-payment. Similarly, if you are over 40, recommended mammograms are now covered without a copay. After age 50, screening colonoscopies, which are recommended every five to ten years, will also be covered without a copay or deductible. Altogether, this coverage offers a significant savings to individuals and helps prevent women from opting out of preventive care due to cost.

2) Birth control is now required to be covered by insurance plans. My official response to this aspect of The Affordable Care Act is: HOORAY! Now birth control may be cheaper than Viagra for men, and that is a tremendous advance =) Please note that insurance companies are still allowed to require generics, so if you need a specific oral contraceptive that is not yet in generic form, insurance may not cover it or may require a higher copay. If possible, the doctor can request prior authorization from the insurance company for payment or coverage, but it is unclear how coverage decisions are actually made. Our office will do our best to help get you the contraceptive pills that work best for you.

Additionally, another excellent birth control option that’s now covered and one that I particularly recommend is the intrauterine device (IUD). Both the ParaGard (copper) and Mirena (progestrone) IUDs are fabulous, efficient methods of birth control – 99% effective, reversible, and very well tolerated – that in the past were often too expensive for young patients. Now that the IUD is covered, I hope more and more women choose this option.

3) “Ten Essential Benefits,” which are provided with no out-of-pocked limits to the amount of care you can receive, must now be included under all insurance plans in the Marketplace. The following will not have any lifetime or annual dollar limits:
• Maternity and newborn care
• Pediatric care, including vision and dental care.
• Preventive care, wellness services, and chronic disease treatment
• Prescription drugs
• Emergency services
• Hospitalizations
• Laboratory services
• Mental health and substance abuse treatment
• Outpatient, or ambulatory care
• Rehabilitative and rehabilitative (helping maintain daily functioning) services

4) The Affordable Care Act does not replace private insurance, Medicare, or Medicaid. It also doesn’t regulate your health care – it just regulates health insurance practices.

5) Young adults can now stay on their plan until age 26.

Like you, our office is also adjusting to the new healthcare provisions starting with the new healthcare exchanges and covered care of California. Connecting to routine insurance plans has always been a complex process for our office staff, and the new plans present new challenges. Change is difficult for everyone, and we promise to do our best to make the transition for you as smooth as possible as we continue to work to provide the highest level of gynecological and fertility care possible.

And speaking of providing the highest level of healthcare possible, we would appreciate your feedback about our office and also your current insurance coverage. Please take this survey, and thank you!

If you have questions about how The Affordable Care Act affects you, CONTACT US.

Sex & Women of a Certain Age: The Sex Trifecta, Part III

feet_facingFinally the kids are grown and the house is empty— you can have sex whenever you want it, wherever you want…  but you no longer want it. What’s that all about?

As I mentioned before, female-initiated sexual encounters peak around ovulation and new relationships, so what’s a girl to do when she has neither of those anymore?  The first thing she needs to remember is that women are DIFFERENT from men. Sexologist Alfred Kinsey described the male sexual response as a linear equation: desire leads to arousal, then to plateau, and finally to orgasm and satisfaction. But Kinsey never studied women, and if he had, he would have found that they are very different sexual beings.

The female sexual response is a complicated and dynamic process that is influenced by physiologic, psychological, sociocultural, and interpersonal factors. Rosemary Basson, M.D., director of the University of British Columbia Sexual Medicine Program, has put forth an alternative, intimacy-based model in which complex factors motivate women to actively seek sexual stimuli and/or are receptive to the sexual advances of their partners, and then they experience responsive desire and arousal until satisfaction is attained. In other words, women respond in a circular fashion— desire leads as much to arousal as arousal leads to desire. This means we can either forego sex because the natural instincts for desire have lessened or we can listen to our bodies and decide that sex is exactly what we want and need!

Additionally, women are intelligent beings with a strong frontal lobe (for thinking) AND a strong hippocampus/amygdala (for emotions). We certainly know that sex feels good. We also know that sex can create greater closeness between two individuals. We love to be loved, and we enjoy giving love, too. In our busy, complicated, modern lives, the key to have a fulfilling sex life is to make the space to connect, relax, and enjoy time spent with your partner. And it is very important to candidly discuss your changing sexual needs and desires.

I often hear from women in midlife that they have no sex drive. I always advise my patients that instead of raising a white flag, they should fight for a sex life with their partner that will help change that dynamic. It’s a joint decision, not a unilateral one. How much sex a couple has together has to be agreed upon. Some couples even schedule sex; for example, Monday-Wednesday-Friday, weekends only, during vacations only, and even every day … the point is to make an agreement that works for both partners.  Discuss ways to enhance your sex life, including trying lubricant and sex toys or changing the patterns of your normal sexual engagement. The point is to work with your partner to figure out how to have a more fulfilling intimate life.

Hormones may play a role in diminished sex for women as well. The reproductive hormones estrogen, testosterone, and even progesterone all increase desire. Oxytocin has a beneficial effect on orgasm. Lack of estrogen after menopause can be associated with painful sex, inadequate lubrication, thinning vaginal mucosa, and a narrowed vagina, as well as increased vaginal pH with associated increased risk of infections. Low estrogen has also been associated with reduced sensory perception, including vibratory sensation, diminished peripheral blood flow (required for the arousal response), and altered ability to develop pelvic floor-muscle tension (required to have an orgasm). Androgens (testosterone and DHEA) have also been looked at for their effect on sexual response. Losing the ovaries surgically, which may lead to a significant decline in testosterone levels, can also negatively affect sexual response. In numerous studies, however, scientists have not been able to prove direct correlations between testosterone levels and sexual dysfunction. Among all the androgens studied, only DHEA (which can be converted to testosterone) showed a weak correlation with sexual desire in the aging woman.

Neurotransmitters may also affect the sexual response. The neurotransmitter serotonin has a negative effect on sexual desire and downstream arousal. Dopamine increases desire and subjective excitement. Norepinephrine increases sexual excitement and orgasm. This explains why depression, as well as treatments for depression, can affect sexual response.

The following medical issues and medications can lead to sexual dysfunction:


  • Depression: Decreased desire
  • Diabetes: Impaired arousal and orgasm
  • Thyroid disease: Decreased desire
  • Cardiovascular disease: Impaired arousal
  • Neurologic disease: Impaired arousal and orgasm
  • Androgen insufficiency: Decreased desire
  • Estrogen deficiency: Impaired arousal


Psychotropic medications

  • Antiepileptic drugs
  • Antipsychotic medications
  • Benzodiazepines
  • Monoamine oxidase inhibitors
  • Selective serotonin reuptake inhibitors (SSRIs) & Serotonin-neurotransmitter reuptake inhibitors
  • Tricyclic antidepressants


  • Alpha-blockers
  • Beta-blockers
  • Diuretics

Cardiovascular medications

  • Digoxin
  • Lipid-lowering agents


  • Antiandrogens
  • Estrogens
  • Gonadotropin-releasing hormone agonists
  • Oral contraceptives
  • Progestins


  • Amphetamines
  • Histamine H2-receptor blockers
  • Narcotics

(Source: Modified from Basson R, Schultz WW8; Kingsberg SA, Janata JW.)

Sex can be a lot of things to individuals but it is often about stress reduction and a release of tension. It is about love. It is about caring. It is about being loved, and loving. It is about being vulnerable and respecting that your partner is also vulnerable. It is about pleasure, both giving and receiving.  As you age and things change, communication is essential. Talk to your partner, and consider talking to your doctor or therapist if you need additional help getting your sex life back on track.

Love, Sex & Baby Making: The Sex Trifecta, Part II

feet_smSex is a miraculous and fantastic aspect of life, and as an OB/GYN, it never ceases to fascinate me as I watch the point of sexual engagement evolve from recreation to procreation.

For women especially, our approach to sex, as well as our need for it, changes over time. For example, female-initiated sexual encounters peak around ovulation and also with new relationships. While men need a place, women need a reason. This usually means that at the start of a relationship there are more frequent sexual encounters, as both people want to learn about each other. But as time goes by and the novelty fades, new patterns set in. Maintaining a healthy relationship may take time and effort both inside and outside of the bedroom. External variables, like contraceptive pills, can suppress ovulation and lower free testosterone levels. So while the Pill is a great way to prevent pregnancy (not to mention treat acne and prevent facial hair growth), this form of contraception may also lower sexual desire.

When a young couple decides that they are ready to start a family, it is essential that both partners be on board so that they can ensure sexual frequency at the right time in the cycle to conceive. If one partner is too involved in his or her career path or educational goals, then s/he may not make the time to be together and thus fertility may suffer. Delaying having children may also mean lowered fertility for a number of biological reasons, but there is one additional reason that you might not guess: couples who are older and have been together longer often have sex less frequently.

So when it comes time to start a family, the role that sex plays in a relationship naturally evolves. Whether the couple finds that having unprotected sex is freeing and exciting so they want to have it more often, or whether having sex becomes more frequent simply in order to achieve a pregnancy, the period of time when couples are trying to get pregnant is a particularly sexually active phase of life.

Infertility can put a special burden on couples, as the precise schedule of intercourse can make having sex feel like hard work. I always remind my patients that sex should be fun, and when it becomes only about procreation, it may actually negatively impact a woman’s ability to get pregnant. I recommend several strategies to keep sex feeling as engaging and emotionally satisfying as it is at any other time in life. I tell my patients to designate one bed in their home for conception and another for relationship rejuvenation. And when the emphasis on procreation becomes too much, I tell couples to take a month or two off from fertility treatments to reconnect and appreciate each other. Shifting the emphasis from stress and worry to deep emotional connection helps support both partners during this transitional phase of life.

Once the baby arrives, many aspects of parenthood conspire to tamp down sexual interest. From sleep deprivation to struggles with time management and making child care fit with the normal routine of life and work can leave little or no time for sexual connection. Adjusting to a new body image and also a new self-image as a mom or dad can also radically shift the dynamic in couples’ sex lives.

During this crucial transitional phase, it’s extremely important that both partners make conscious efforts to maintain an emotional and physical relationship their significant other.  It is also essential to give the primary caregiver a break by hiring a baby sitter or having a friend or family member watch the baby so that there is time for romance. For “date night” and beyond, I advise making physical space in your home for intimacy. If you believe in a family bed, then find another room in the house or elsewhere to have the privacy necessary to relax and enjoy sex. If you want to lose the baby fat, remember sex is exercise — so it can help. And if you are having issues changing the post-childbirth sexual dynamics, then consider reaching out for therapeutic help.

While fertility is the focus of my practice, I also want to help support my patients in having a happy, healthy, and fulfilling sex life. At this precious stage where procreation is the focus, it’s important to remember that having sex has many essential side effects beyond making a baby including stress reduction, greater intimacy and closeness, and above all, a continued connection with your partner.

Next time we’ll talk about Part III of the Sex Trifecta: Beyond the childbearing years: from procreation back to recreation.

Let’s Talk About Sex – The Sex Trifecta, Part I:

pillow talkThere are many people in your life with whom you might talk about sex with: your partner, your friends, your kids… maybe others, too – but how often do you talk to your gynecologist about sex?

If you answered, “NEVER – she’s just there for my health,” then stop a moment and consider the disconnection in that statement.

My specialty is, in many ways, all about sex. My training started in college when I helped run my campus’ Peer Informational Services and Education on Sexuality (PISCES). From a young age, then, I have been giving advice and information about sex and its consequences. This experience may be why I ended up in the field of OB/GYN. My residency and fellowship included talks about the fundamentals, but what we really studied were the outcomes of sex.

Doctors are the ones who see it all firsthand; the gamut runs from the bad (i.e., sexually transmitted diseases (STDs), cervical cancer from HPV, unwanted pregnancies, infertility, sexual dysfunction, etc.) to the good (i.e., wanted pregnancies, assistance in regaining sexual function, support in sexual health, etc.). In my opinion, sex should be natural and easy, and yet it is also natural to have issues around sex. Some of my most gratifying work is helping people get what they need to have the active, healthy sex life they desire.

If sex is everywhere – in the media, in our entertainment, in the giggles and whispers that we all indulge in from the time we’re young—then why is it also seen as forbidden and a topic only to be discussed by adults? Perhaps because the consequences of being sexually active are best handle by adults, and responsible sex is the only really safe sex. Yet it also naïve to think that teens are not having sex.

So an important part of my job is talking about sex to many of my patients, particularly to young adults who need education and support around avoiding issues like STDs, unwanted pregnancies, and even emotional and perhaps physical harm from sexual relationships.

Taking my doctor self out of the equation, my view on sex is this: it’s ultimately all about getting and giving love and care. It’s also about opening yourself up and being vulnerable. And it’s about being desired by and desiring of your partner. Sex can relieve stress and anxiety. Sex can be an enjoyable activity that is good for your health, both physically and mentally. We all crave to be loved and to give love —sex can be that or sex can be just an action with no love involved. Nobody should ever be pressured to have sex; it should always be a personal choice. And ultimately, sex is best as an expression of intimacy in a loving situation. These are all messages that I believe any one – teens to seniors – should take to heart.

Now that we’ve laid the groundwork from my experience as a doctor AND a woman, next time we’ll talk about the changes in our sex life once we partner up and settle down.


From Fertility to Menopause: Part III — Beneficial Botanicals

black_cohoshHave you heard that black cohosh alleviates hot flashes? Or that soy (isoflavones), gingko bilboa, and ginseng help improve sex drive, memory, and other related symptoms of menopause?

While Hormone Replacement Therapy (HRT) has long been considered the first line of defense, more and more women are turning to botanicals and dietary supplements for relief, probably because these treatments are “natural,” over the counter, and perhaps less intimidating that HRT. But how effective are botanicals?

The Natural Medicines Comprehensive Database divides botanicals used for menopause into two groups:

1) Those that are purportedly hormonally active, binding to the estrogen receptor and having actions similar or opposite to estrogen.

2) Those that alter the function of central neuroreceptors, thus mimicking the mode of action of selective serotonin reuptake inhibitors (more commonly known as antidepressants).

According to the Study of Women’s Health Across the Nation (SWAN), which is dedicated to improving health for mid-life and older women, the most commonly used botanical medicines are soy, glucosamine, flaxseed oil, gingko biloba, black cohosh, and ginseng.

Additionally, the following dietary supplements are also often used to alleviate a variety of physical menopausal symptoms including hot flashes, night sweats, vaginal dryness, etc.

Aniseed, Dill, Fennel, Fenugreek
Dong Quai
Evening Primrose
Gotu Kola
Green Tea
Milk Thistle
Red Clover
Wild Yam

And these botanicals are said to help with mood and memory:
St. Johns Wort
Valerian Root

Although there have been many studies about botanicals and natural remedies for menopause, there is not much conclusive evidence to support that most are much better than placebo.

Black cohosh is the most popular botanical for menopause symptoms, and the formulation most used in the U.S. is Remifemin. Numerous clinical trials have been published, but most reach the same conclusion — there is insufficient conclusive data documenting the efficacy of black cohosh for menopause symptoms. Red clover (found in Promensil) similarly found a decrease in hot flashes, but the decrease was not clinically relevant. Similarly, in a randomized trial of 71 postmenopausal women, Dong Quai did not reduce hot flashes and did not have any physiologic changes similar to estrogen (blood hormone levels, vaginal changes, and uterine changes). Evening primrose may help with perimenopause, but was no different than placebo for post-menopause hot flashes. Ginseng showed slightly better symptom relief and is considered safe and well tolerated by most people; nonetheless the decrease in hot flashes was also not statistically significant. Maca, a foodstuff from Peru, may also help with perimenopause by affecting hormone receptor dynamics, but it too is less helpful after the last menses.

A few studies, however, have shown some botanicals can be quite effective. The North American Menopause Society published a report on the efficacy of soy (isoflavones) for menopause. After reviewing hundreds of papers, the conclusions reached were that soy isoflavones are at best modestly effective— and that Genistein and S-Equol may be the best of these.

Siberian rhubarb contains molecules that do bind to the estrogen receptors. Studies suggest this botanical acts like a selective estrogen-receptor modulator (SERM) and may provide activity both estrogenic and anti-estrogenic. In Germany, this rhubarb is available as Phytoesterol, and studies show a reduction in hot flashes with few adverse side effects.

While I support the scientific data associated with studies, many women anecdotally report feeling better when they used botanicals to alleviate symptoms of menopause. If you want to try such dietary supplements, remember first to ensure that your kidney and liver functions are normal (this is especially important before using black cohosh). Also check the US Pharmacopeial Convention (USP) website for a listing of verified products. The USP sets the standard for the quality, purity, identity, and strength of medicines, food ingredients, and dietary supplements. You can also check This website performs independent testing at the manufacturer’s request and expense. Products from Europe, where the botanicals are more tightly regulated, may also offer more consistent quality.

And finally, if you are considering taking botanicals to alleviate symptoms of menopause, please be sure to tell us what you’re taking – dietary supplements might interact with medications, and it’s always smart to keep your doctor in the loop!