IVF & Diminished Ovarian Reserve
Fertility Treatments in San Diego
After months of failing to conceive on your own and countless tests and
consultations, you have been told that you have Diminished Ovarian Reserve
(DOR). Women receive this diagnosis when tests indicate that they have
a low Antral Follicle Count (AFC), a low Anti-Mullerian Hormone (AMH)
level and/or an elevated Follicle Stimulating Hormone (FSH) level.
What Do You Do?
For those of you who have been told that DOR is the
sole reason for your infertility, this is usually not the case. If you are
cycling regularly, there is probably another reason for your infertility,
and that needs to be explored.
Despite what you may have been told, IVF success is not impossible in the
presence of DOR. There are numerous studies that show that there is very
little difference in the rate of live births from eggs retrieved from
women with DOR vs. women with normal reserve. The younger you are, the
more likely you will succeed, as is the case with all fertility treatments.
The key challenge is accessing your eggs.
Traditional IVF Treatments for DOR
The traditional approach to IVF is not necessarily the optimal way to access
your eggs if you have DOR. Traditional IVF protocols are designed to stimulate
as many eggs as possible in the hope that some of these eggs will produce
normal embryos. The rationale for this approach is based on the observation
that women who respond well to IVF medications and subsequently produce
many eggs have higher live-birth success rates.
Unfortunately, women with DOR are at a significant disadvantage with traditional
IVF protocols because they have fewer eggs available. IVF clinics routinely
cancel cycles if patients do not demonstrate a minimum number of follicles
during ultrasound examination. Therefore, women with DOR have a significant
risk of IVF cycle cancellation at these clinics.
Reproductive endocrinologists and infertility specialists (REIs) use several
techniques for their patients with DOR who are undergoing IVF:
- The most common technique is to compensate for fewer follicles by increasing
the dosage of medications for stimulating follicle/egg development
- Another common technique is to administer birth control pills or estrogen
therapy to lower the FSH level prior to Day 1 of the cycle, then start
- Another technique is to try to improve the quality of the egg reserve with
various supplements and medications such as DHEA, CoQ10, human growth
hormone (HGH), and corticosteroids.
Unfortunately, none of these techniques work consistently and, in the case
of using super stimulation protocols, numerous studies have shown that
more medication is
The Problem with the Traditionalist Approach
All of these traditional treatment options revolve around traditional super-stimulation
protocols. It is not uncommon to hear stories of women with DOR whose
follicles do not grow no matter how heavy the stimulation. Alternatively,
too few follicles develop, and the cycle is canceled. These women are
then labeled “non-responders,” and it becomes a hopeless situation.
It is also not uncommon to hear stories of women with DOR whose follicles
started to develop when their stimulation medications were discontinued,
or who produced comparatively more follicles when they received much lower
medication doses for an IUI cycle.
The traditionalist will argue that is not just an access issue. They will
point out that when they do not cancel a cycle for a woman with DOR and
proceed with the egg retrieval, the outcome was poor, which was the reason
they were inclined to cancel in the first place.
Benefits of Mini IVF When Treating DOR
natural cycle IVF and low stimulation protocols have been around since the advent of IVF
(the first successful IVF pregnancy was a natural IVF cycle), these protocols
only started to become more popular about 20 years ago in Japan. This
rise in popularity was in response to the risks and complications associated
with traditional superstimulation IVF. For quite some time, doctors who
practiced minimal stimulation IVF observed that in cases of DOR, lower
stimulation protocols were often superior to higher stimulation in gaining
access to eggs.
Since these initial observations, we have found that follicles do not mature
properly at very high levels of FSH. At Hanabusa IVF’s San Diego
Fertility Center, we refer to this as “over-stimulation” syndrome.
The medications used in IVF to stimulate eggs are essentially pure FSH.
These medications are driving FSH closer and closer to (perhaps over)
the level associated with menopause. While there is no conclusive evidence
concerning the effects of over-stimulation syndrome on fertility, we believe
that the correlation between this phenomenon and sub-optimal access to
eggs cannot be ignored, and is a salient reason that super-stimulation
protocols are deleterious to women who wish to conceive a child.
Minimal stimulation can be effective for the following reasons:
No cancellation. The basic foundation of minimal stimulation is that there is a natural
progression with regard to egg quality. The lead follicle which occurs
in nature is the egg that is most likely to result in a pregnancy for
that particular month. Each additional egg that is stimulated in conjunction
with the lead follicle is increasingly less likely to result in a normal
pregnancy. There is no need to cancel due to low quantity since the quality
of the eggs that develop in a minimal stimulation environment are most
likely to be the best of the group.
No overstimulation syndrome. Less medication means lower FSH levels, so over-stimulation is less of an issue.
Preservation of the dominant follicle. This is an esoteric concept, but an important one. In minimalist philosophy,
the lead follicle is the best one. It may not be the only egg that could
result in a healthy pregnancy, but it is the most likely one. A common
practice in traditional IVF protocols is to “sacrifice” the
lead follicle (i.e., let it over-grow and over-mature) in order to allow
more follicles to reach maturity. This practice may be fine for a woman
in her early thirties with a normal egg reserve, but it is risky for a
woman with DOR. It is also a poor treatment strategy for women over 40
years old. But, once again, that will be addressed elsewhere.
At Hanabusa, we achieve optimal results in the setting of DOR by:
- Using less medication than traditional IVF protocols
- Following a protocol that does not over-mature the lead follicle
- Aiming to retrieve eggs (regardless of the number) rather than cancel cycles
- Flushing the follicle during egg retrieval. There is a small chance that
an egg will not be retrieved using the typical single aspiration technique.
This may not be an issue when there are a dozen follicles, but it is a
major issue when there are only one or two.
- Utilizing ICSI for fertilization
Egg/embryo banking. DOR rarely improves. If you have a successful cycle,
it will only get more difficult later on. Embryo freezing is very reliable now.
Collect your eggs and embryos now to optimize your chances for success by preparing for the future.
In DOR, success is often a matter of opportunity. Unfortunately, the traditional
IVF approach often limits those opportunities. By following a minimalist
protocol, patients with DOR have many more opportunities for success.