- April 19, 2016
- Posted by: emobile
- Category: Uncategorized
Emobileclinic Trending Topic:Ovarian Reserve
If you personally have had difficulty understanding what your test results mean you should know that as a professional group IVF practitioners are also conflicted about what the test results mean and how to appropriately apply them in a given situation.
Understanding the term Ovarian Reserve
The aim of any stimulation regimen for IVF is several good quality eggs and a healthy uterine environment. It refers to the ease at which an individual’s ovaries can be successfully stimulated with fertility drugs. Ovarian reserve is the pool of eggs present in the ovaries at any given time. Low ovarian reserve is when there is a physiological decrease in the number of eggs, resulting in an insufficient number to ensure a reasonable chance of pregnancy. Generally, it is caused by aging ovaries. Patients can have diminished ovarian reserve but intact ovarian function.
The single most consistent variable affecting ovarian reserve is the woman’s age. This is because a woman is born with all the eggs she will ever have. In most women a majority of the eggs are genetically normal or balanced. However, there will be some that are genetically abnormal or unbalanced. It appears that the best eggs are ovulated first.
The older a woman is, the fewer genetically balanced eggs she has left to respond to fertility drugs. This age relationship holds true even in the fertile population. In older women fewer normal embryos are available for implantation into the uterus. Hence, healthy women over 35 are less fertile than their younger counterparts. Women of 40 and over may have only a 20% live birth rate with IVF treatment using their own eggs. This is why donor egg therapy has become so popular in this age group.
Unfortunately, there are some young women who respond poorly to attempts at ovarian stimulation. Perhaps these so called “poor responders” are born with more genetically unbalanced eggs such as in a Turner’s mosaic syndrome patient or they may have fewer eggs or poor quality eggs because of past surgical treatment, pelvic infections, cancer treatment, cigarette smoking, ovarian scarring associated with endometriosis, or unexplained infertility, etc. It is this group of patients that has presented the biggest challenge to IVF practitioners. Some young woman may have fewer eggs, but are they all of poor quality?
Ovarian reserve tests ?
There are several clinical markers used to identify the so called “poor responder”. Today the most commonly used ones in the United States are the basal follicle stimulating hormone (FSH) and the clomiphene citrate challenge test (CCCT) Measures of inhibin, mullerian inhibiting factor, and a variety of provocative response tests have been used less frequently. More recently, ultrasound has also been used to anticipate stimulation response.
The basal FSH test is a blood test drawn on the second or third day of the menstrual cycle. FSH released from the pituitary gland stimulates the ovaries to recruit and select eggs so that one will grow and eventually ovulate. When there are few eggs available the pituitary gland has to send a much stronger signal so the FSH level will be higher in those circumstances.
Unfortunately, test results may not be that accurate because it matters when blood is actually drawn during the menstrual cycle. An estradiol level may be drawn at the time of the basal FSH to help verify the fact that the patient is having the test drawn on the correct day. This is because if the estradiol level is elevated, the FSH level will be suppressed. Sometimes women in early menopause will have elevated day three estradiol levels with suppressed FSH levels giving false negative results.
Those women who demonstrate an exaggerated FSH release after clomiphene stimulation are said to have failed the test. Some women with normal basal FSH levels will be identified as poor responders when they are given the CCCT test. Unfortunately, as more individuals are assigned the “poor responder” label, more normal patients are inaccurately assigned to the abnormal group.
What does an abnormal result mean?
A true “poor responder” will have a lower chance of conception and live birth compared to members of the normal responder group regardless of the age. The problem lies in assigning patients to the wrong response group on the basis of pre-treatment testing alone.
What do I do if I have an abnormal result?
Age is one of the most important factors to consider. The implications are vastly different when a 35-year-old woman only produces one to two (1-2) eggs than if a 45-year-old woman produces the same number. Unfortunately age not only affects the number of eggs but more importantly affects the quality of the egg.
The doctor needs to lower the day 2 FSH level if it is higher than 15.
It is very important to be realistic about the chances of success so that the couple/individual can make the appropriate treatment decision or to use alternative options like donor eggs or adoption.
First, try to establish how important having a child with your own DNA is to you and your partner. Seeing a mental health provider familiar with assisted reproduction can be helpful. Remember that oocyte donor therapy is a wonderful option associated with high success rates. You can still have a baby with your partner’s DNA long as your uterus is receptive.
If you decide that you would like to attempt fertility treatment using your own oocytes despite a lower chance for success, make sure that your doctor is fully onboard with this approach and that you are financially and psychologically able to handle the stress of, perhaps, several failed treatment attempts. Get a second opinion if you have any lingering questions. Be aggressive. Continual pursuit of insemination cycles is costly and such an approach does not address fertilization issues. A properly planned IVF cycle can lead to answers and may help a couple with the closure process. And, there will be some patients who actually take home miracles when given the opportunity for a treatment cycle despite dismal treatment pre-screening test results.
Low Ovarian Reserve and IVF Success
Low ovarian reserve only becomes an issue when a woman has problems getting pregnant. Other women experience this condition in their 30’s and 40’s, but may have had their children earlier in life, so it does not negatively affect them. IVF success for all age groups is extremely dependent on how many eggs the doctor can obtain at the egg retrieval.
Many times poor responders are older so the quality of their eggs is poorer, which decreases the chance of pregnancy and increases the chance of miscarriages. The patient’s response to ovarian stimulation is usually proportionate to their ovarian reserve.