QuestionQUESTION: Hi there, I have just turned 37 years old and this year have been through two IVF cycles both of which were abandoned prior to egg collection due to lack of response to the drugs (only 2 follicles matured and they would only go ahead with 4 min). My consultant has diagnosed low ovarian reserve without further testing. My FSH level was 7.5 in January when the cycles began and I have not been tested since (they wanted to but I was going on holiday so they used my previous result). The first IVF converted to IUI but did not work. The next month I fell pregnant naturally but miscarried (very early so was probably a clinical pregancy). The second cycle we did not convert to IUI as my consultant wanted to wait until I developed a LH surge and then we would have gone to IUI but I didnt surge (probably due to my poor body having had so many drugs!). Anyway, now I am left feeling very down about the whole thing and I think the next meeting I have with the consultant (2nd Sept) will be the donor egg discussion. I just wanted to know whether you agree with all of this or whether I should try something else first? Please ask if you need more details but I seem to be rambling on here.
ANSWER: Dear Adrienne,
Thank you for your question. Where are you writing from?
You diagnosis of low ovarian reserve is based on the poor response to stimulation during your IVF cycles. We call that "poor responder." Despite a relatively low FSH level, your ovaries did not respond well. This could also be dependent on the amount of medication that you received. I presume you received a high protocol? I go up to 600IU per day with my poor responder patients. Some physicians will not use this high a dose, however.
There are differing philosophies regarding whether or not to proceed with the IVF cycle if there are only a few follicles. Some physicians, like yours, will cancel the cycle if there are not sufficient numbers. I, on the other hand, always complete the cycle. I have had many pregnancies with only 1 egg/embryo. In a natural cycle you only ovulate one egg anyway. IVF is definitely more efficient at achieving pregnancy than a natural method such as IUI so I proceed. I think it gives the patient a better chance for pregnancy. I have heard that in the states where IVF benefits are mandated, such as in Massachusetts, the physicians will cancel because there is a limit on the number of IVF cycles that can be done. In this case it is not the patient's best interest that is being served but economics. That is the problem with government regulations.
Certainly, if your doctor has determined that because you are a poor responder you should not continue trying on your own, then donor eggs is the only option. It is really your choice as to what is the best option for you. I think that each individual has to be emotionally and psychologically ready to go to donor eggs. That is, you have to have resolved that you cannot do it with your own eggs. When my patients have not reached this point, I allow them to continue trying on their own (with their own eggs). You see, my feeling is that I am here to HELP patients achieve their goal, not to dictate what they should or should not do. I don't want to force them into a choice that they are not prepared for or want (some IVF clinics do mandate the choice).
I hope this answers your questions.
Sincerely,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
---------- FOLLOW-UP ----------
QUESTION: Thank you for your reply. I am writing from Hampshire, UK. The first cycle was on 300IU per day and the second was 450IU. Because everything else seems absolutely fine (regular periods, clear tubes, low fsh, not overweight, non-smoker) I just wonder whether there is something else that could cause a poor response? Could someone respond really well to the downregulating drugs and not so well to the stimulating ones hence a poor response? Is "low ovarian reserve" the only reason for the poor response and if so is there anything I could do about it?
AnswerHello Adrienne,
You are the second patient from the UK.
As I mentioned previously, the diagnosis "low ovarian reserve or low responder" is a title given based on the response to stimulation. It is not a diagnosis of a disease state. In reality, we use "low ovarian reserve" only for patients that have an elevated FSH level, which you do not fit. You are a "low responder". Why one person is a low responder versus another, is unknown. There are many qualities about the ovary that are still not understood. Therefore, it is difficult to figure out how to treat low responders. For this reason, there are various protocols that Physicians have tried to increase the response. In my case, I do two things: First, I do not use a long protocol. That is where a patient starts on a GnRH agonist (lupron) two weeks prior to the start of the cycle. The Lupron suppresses the ovary too much. Second, I use a higher dose, 600 IU per day.
In addition, each cycle would be different. That is, the ovary responds differently each month. If you've been on birth control pills for a longer period of time, then your response may be decreased. In that case, you might want to have a natural cycle before restarting on the birth control pill prior to your IVF cycle. Another method is not using the birth control pill at all prior to the IVF cycle and not using the Lupron so that you begin stimulation on a natural cycle.
Other than that, there is nothing else that will increase the ovarian response. it is totally up to the ovary at that specific time.
Sincerely,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
