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Dr. Eric Daiter

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Dr Eric Daiter has served Monmouth and Middlesex Counties of New Jersey as an infertility expert for the past 20 years. Dr. Daiter is happy to offer second opinions (at the office or over the telephone) or new patient appointments. It is easy, just call us at 908 226 0250 to set up an appointment (leave a message with your name and number if we are unable to get to the phone and someone will call you back).


"I always try to be available for my patients since I do understand the pain and frustration associated with fertility problems or endometriosis."


"I understand that the economy is very tough and insurance companies do not cover a lot of the services that might help you. I always try to minimize your out of pocket cost while encouraging the most successful and effective treatments available."

NJ Center for Fertility and Reproductive Medicine - Infertility Tutorials

Ovarian Reserve
Decreased ovarian reserve indicates that there is a significant reduction in the amount of eggs that are able to mature in the ovaries. A "significant" reduction in ovarian reserve can be defined as one which results in a reduced fertility rate. Woman with a regular menstrual cycle still have some residual number of eggs that will mature. One important question is "what test results for ovarian reserve suggest a reduction in fertility?"

Tests available to determine ovarian reserve include

  1. * the cycle day 3 FSH concentration,
  2. * the cycle day 3 estradiol concentration, and
  3. * the clomiphene citrate challenge test.

The "cycle day 3 FSH" blood levels can be drawn anytime of the day on cycle day 2, 3 or 4, with the first day of a full flow being cycle day 1. Research suggests that the difference in FSH concentration between cycle day 2, 3, and 4 is small so that the patient can have a sample drawn on the most convenient of these days. The study demonstrating this used only a small number of women (20 women under 40 years of age) and reports a less than 20% coefficient of variation between FSH values determined for the same women over the course of these days. A second study from another infertility center confirmed these findings.

Multiple reports since 1989 have correlated the cycle day 3 FSH concentration to pregnancy rates (usually at the time of In Vitro Fertilization). IVF success (pregnancy rate) is reported to be independently associated with both the woman's age and the cycle day 3 FSH concentration. In other words, both are important. The early classic studies from the Jones Institute in Norfolk, Virginia revealed a 17% success rate per IVF cycle (very high at that time) when the cycle day 3 FSH concentration was less than 15 IU/L, 9% when 15-25 IU/L and 4% when greater than 25 IU/L. Generally, a cycle day 3 FSH level of less than 15 IU/L (using the Leeco assay, see next paragraph) is considered reassuring.

The cycle day 3 FSH concentration depends on the assay used to determine its value. In the USA there are several different assays with 2 different assay systems in common use (Leeco and Becton Dickenson). These assays use different standard solutions for the test, and therefore give different results for the same samples. When compared head to head in one preliminary report, the Leeco assay yielded values 2.4-2.5 fold higher than the Becton Dickenson assay at three different points (concentrations) along the standard curve in the range expected for reproductive age women. Therefore, a value of 25 IU/L on the Leeco assay correlates roughly to 10 IU/L on the Becton Dickenson assay. This has led to confusion and occasionally misinterpretation of results. The system used in the early studies on cycle day 3 FSH concentrations is the Leeco assay and has a normal range of 5-20 IU/L. The Becton Dickenson assay has a normal range of 1.5-6.3 IU/L.

Recently (1995), the "cycle day 3 estradiol" concentration was reported to predict the pregnancy rate at IVF. As with most hormonal assays, knowledge of the assay used is critical since the available estradiol assays are varied and appear to give different values for the same samples. The physician must become familiar with the assay that (s)he uses to establish clinically relevant cutoff values. The report introducing estradiol as a useful parameter in assessing ovarian reserve (from one of the most successful IVF centers in the USA) found no pregnancies in women undergoing IVF if the "estradiol concentration on their assay was greater than 75 pg/ml" or if "the FSH was greater than 17 IU/L and the estradiol was greater than 45 pg/ml" in 600 IVF cycles. Since the estradiol assay used in this study was established in their own hospital the comparison to other assays may show significant differences. Once standard data within a lab system is established the estradiol level may be a predictable and valuable parameter helping to predict fertility treatment outcome and ovarian reserve.

The clomiphene citrate challenge test uses this fertility medication (100 mg per day for cycle day 5 to 9) to provoke an ovarian response. The test usually involves checking hormone levels (such as FSH, estradiol, progesterone) on cycle day 3 and again on cycle day 10. Most often, the FSH response to the clomiphene citrate is used to determine ovarian reserve. In several reports from a diverse number of infertility centers, an abnormal FSH concentration on cycle day 3 or 10 heralds a poor success in ovarian response to fertility medication and lower fertility rates. The FSH concentrations that should be used for cutoff values are not well standardized, with some large groups using 10 IU/L on the Becton Dickenson assay (equivalent to roughly 25 IU/L on the Leeco assay). Progesterone has also been proposed as another predictive variable in the clomiphene citrate challenge test. One report on this challenge test demonstrated no pregnancies in women whose progesterone concentration was greater than 1.1 ng/ml on cycle day 10 compared to a 19% pregnancy rate if the progesterone concentration was less than 0.9 ng/ml on this day. It seems that these findings remain to be confirmed and standardization must still be established for this test to gain widespread acceptance.

A decreased ovarian reserve suggests a poor prognosis in terms of fertility. If a woman with a decreased reserve is very committed to persuing fertility using her own eggs, a frank discussion with an experienced infertility specialist should focus on the likelihood of success given the findings from her ovarian reserve evaluation. Age and the reason for the ovarian dysfunction should be considered.

Donor egg programs are becoming increasingly available and are an alternative that some women might want to consider if their own ovarian reserve is very low. The fertility rate is roughly predicted by the donor's age, and the recipient carries the pregnancy from the time of embryo transfer (prior to implantation). An experienced donor egg program will most likely have the type of support and counseling often found helpful in this situation.

The in vitro maturation of immature eggs, that is the possibility of harvesting immature eggs from the ovaries and maturing these eggs to the point of becoming fertilization capable in culture (in vitro) has been the subject of a great deal of recent discussion and research. Although there have been a few pregnancies that have carried to term with this technique (in 1997 I believe there have been only 3 liveborn deliveries from this technique in the world literature), the technique is still in its infancy. Once the "bugs have been worked out" of this technique, the in vitro culturing of immature eggs will most likely revolutionize IVF. It is possible that at that stage, infertility specialists will also be able to select the few best eggs from thousands of eggs matured in culture from ovaries with decreased ovarian reserve and improve the fertility of these couples.


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Eric Daiter, M.D. - Edison, NJ - E-Mail: - Phone: (908)226-0250

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