their risk of attaining early menopause. Women who have responded poorly to controlled ovarian hyperstimulation during IVF treatment indicated by a low number of retrieved oocytes have a compromised ovarian reserve and are at risk of becoming menopausal earlier (Case History 2) than women who have had a normal response. Women should be informed that all procedures involved in the IVF treatment process are generally safe and do not put the woman at risk of premature ovarian failure.
Key points
Challenge: IVF treatment and the risk of early menopause.
Background:
The question is frequently raised by women undergoing IVF treatment.
Women with fertility problems have a higher background risk of reaching menopause earlier than fertile women.
Gonadotropin stimulation does not cause depletion of primordial follicles.
Women with a compromised ovarian reserve (indicating ovarian aging) are at risk of becoming menopausal earlier than women with a good ovarian reserve.
Management options:
Reassure women that the procedures involved in the IVF treatment cycle do not put them at a risk of reaching earlier menopause.
There is no association between the number of attempts at IVF treatment and the age at menopause.
Answers to questions patients ask
1 Q1 Will having ovarian stimulation for IVF make me get early menopause? A1. No, it wouldn’t. Ovarian stimulation is a routine part of IVF, aiming to increase the number of eggs available for treatment, compared with what happens in a spontaneous menstrual cycle. During a menstrual cycle, several follicles start to grow initially, but only one follicle and sometimes two follicles become dominant and release an egg following ovulation. The remaining follicles die out, as they require a higher level of follicle stimulating hormone for their continued growth. During ovarian stimulation, this hormone is given in the form of injections to recruit and mature these follicles so that they do not die out. Therefore, ovarian stimulation is only salvaging follicles that would have otherwise perished in a natural menstrual cycle. Hence, ovarian stimulation for IVF does not lead to early menopause.
2 Q2 I have had seven IVF cycles, and each time they collected about 10 eggs. Does that mean that I will run out of eggs in my ovaries earlier? A2. No, it doesn’t. Studies have shown that the number of IVF cycles and the number of eggs collected do not affect the age of menopause.
References
1 1 Te Velde ER, Pearson PL. The variability of female reproductive ageing. Hum Reprod Update. 2002; 8:141–54.
2 2 Richardson SJ, Senikas V, Nelson JF. Follicular depletion during the menopausal transition: evidence for accelerated loss and ultimate exhaustion. J Clin Endocrinol Metab. 1987; 65:1231–7.
3 3 Te Velde ER, Dorland M, Broekmans FJ. Age at menopause as a marker of reproductive ageing. Maturitas. 1998: 30:119–25.
4 4 Kok HS, Van Asselt KM, van der Schouw YT, Grobbee DE, te Velde ER, Pearson PL, et al. Subfertility reflects accelerated ovarian ageing. Hum Reprod. 2003; 18:644–8.
5 5 Elder K, Mathews T, Kutner E, Kim E, Espenberg E, Faddy M, et al. Impact of gonadotrophin stimulation for assisted reproductive technology on ovarian ageing and menopause. Reprod Biomed Online. 2008; 16:611–16.
6 6 de Boer EJ, Den Tonkelaar I, Te Velde ER, Burger CW, van Leeuwen FE; OMEGA Project Group. Increased risk of early menopausal transition and natural menopause after poor response at first IVF treatment. Hum Reprod. 2003; 18:1544–52.
7 7 de Boer EJ, Den Tonkelaar I, Te Velde ER, Burger CW, Klip H, van Leeuwen FE. Low number of retrieved oocytes at IVF treatment is predictive of early menopause. Fertil Steril. 2002; 77:978–85.
3 The HIV‐positive female
Mark V. Sauer and Shelley Dolitsky
Department of Obstetrics, Gynecology & Reproductive Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
Case History 1: A 37‐year‐old woman presents for reproductive counseling. The patient has a history of substance abuse and contracted HIV from a contaminated hypodermic needle at age 27. She states that for over 8 years she has not used illicit drugs and now wishes to conceive with her husband. She has no significant medical or surgical history. She has never been pregnant, and her gynecologic history is notable for irregular periods, with her menstrual cycles occurring from 30 –58 days. The patient’s husband is also HIV‐seropositive. He acquired HIV from a sexual relationship with a male partner when he was aged 23. He has one child from a previous partner and no other significant medical or surgical history. Both the patient and her husband are under the care of an infectious disease specialist, and they are compliant with their highly active antiretroviral therapy. They have both achieved an undetectable viral load with CD4 counts of 800 and 600 cells/mm3, respectively.
Case History 2: A 27‐year‐old woman presents for reproductive counseling. The patient acquired HIV from a sexual relationship when she was 18 years. Since diagnosis, she has been cared for by an infectious disease specialist, and as a result of compliance with medical treatment, she has achieved an undetectable plasma viral load; CD4 has always been >400 cells/mm3. Her boyfriend is HIV‐seronegative, and they have always practiced safe sex with condoms. She has no significant medical or surgical history, but she was hospitalized for pelvic inflammatory disease twice in her early 20s which resolved with antibiotic therapy.
Background
According to 2017 data from the USA, approximately 1.1 million people are infected with HIV, of whom 23% (258,000) are females [1]. Nearly 20% (7,401) of newly diagnosed HIV in the USA and nearly half of people living with HIV worldwide are females [2]. The majority of the female HIV burden is borne by reproductive‐aged women (15–44 years old).
Prior to the widespread availability of effective HIV therapy (specifically, highly active antiretroviral therapy: HAART), the impact of HIV disease on maternal health, as well as the alarming rates of vertical transmission (7–71% [3]), generally rendered childbearing an unreasonable and unsafe consideration in HIV‐seropositive women. The risk of horizontal transmission to serodiscordant partners was simply addressed by advocating universal condom use in these couples.
The introduction of HAART has transformed both patients’ and providers’ perspective on HIV disease. Maternal morbidity and mortality now resemble rates seen in many other chronic diseases and if appropriate steps are taken (medical treatment for mother and newborn, cesarean delivery and avoidance of breastfeeding), vertical transmission can be reduced to 2% or less [4]. The CDC developed a framework to guide organizations to reduce the risk of vertical transmission [5], and studies show that the vertical transmission rate can be less than 1% if HAART is started in the first trimester [7]. According to 2019 UN AIDS global statistics, 82% of pregnant women had access to antiretroviral medications, compared with 47% in 2010 [2]. These developments have created the need for recommending various safe approaches to childbearing in HIV‐serodiscordant couples.
While genital HIV shedding generally correlates with plasma HIV RNA concentration, a significant proportion of women will harbor HIV in the genital tract even at low levels of plasma HIV RNA [7]. Therefore, even in HIV‐seropositive women on HAART and/or with undetectable plasma viral load, the risk of horizontal transmission during unprotected intercourse is difficult to quantify, and natural efforts at conception via unprotected