Despite being across the country, a number of patients from my prior IVF
center still consult with me regarding their treatment. One of these patients is AD.
AD came to me when she was 32 years old. She had been diagnosed with premature
ovarian failure (POF) and her last natural period had been 5 years earlier.
As with many others who have POF, AD is a carrier of the pre-mutation
of the Fragile X gene. Except for 1 REI (Dr. A), all the specialists she
saw recommended that she go the donor egg route. Dr. A is one the few
physicians that I know who understands how to manage POF/DOR (diminished
ovarian reserve). He was able to manipulate her hormones to allow her
to ovulate and perform 2 IUI’s. Unfortunately, Dr A does not perform
IVF in these cases.
With DOR/POF, the problem with more conservative treatments such as timed
intercourse or IUI is that the treatments that help with follicular development
do not necessarily also help with the development of an ideal implantation
environment. With IVF and embryo freezing, we
can focus on optimizing each step separately.
AD came to me because I am able to perform IVF in these situations. As
is to be expected in this situation, AD’s FSH was elevated (over
50 mIU). While this could simply indicate that there were “no eggs
left,” if there
were a few eggs remaining, an elevated FSH could result in Overstimulation
syndrome, when FSH is so elevated that viable follicles shut down and
stop growth. Unfortunately, there are no tests that can definitively determine
whether or not viable eggs still remain, so I started her on a hormone
suppression treatment to bring down her FSH levels. Responses to this
kind of treatment can be unpredictable, sometimes taking days, sometime
taking months, and sometimes not working at all. Fortunately, after 2
months, a follicle developed and we were able to retrieve an egg under
Since AD was relatively young, the egg fertilized well and developed into
a 4-cell embryo which we froze on Day-2. As you may know, we usually recommend
culturing embryos for 5-7 days so that they can reach a the blastocyst
stage and we can better ascertain embryo quality. However, because this
could have been AD’s last egg, there was no way I was going to take
We could have easily done a transfer at this point, but there was still
a risk that AD could enter menopause at anytime and we would not have
another opportunity to retrieve an egg, so we continued this process for
the next year and were, encouragingly, able to freeze 2 more embryos at
Day 2. AD decided that it was time to transfer. Although I prefer natural
cycle transfers, for a patient like AD, that wasn’t going to be
the most optimal route, so we decided to treat with a minimal hormone
replacement cycle using oral estrogen and vaginal progesterone…
and success! Well, almost. AD got pregnant, but ended up miscarrying at
8 weeks. At this point, AD needed a break, but, fortunately she had 2
more opportunities left.
At this point, I left for San Diego.
About 6 months into my tenure here at Hanabusa IVF, I received an e-mail
from AD. She had been trying to transfer but her doctors were unable to
achieve an adequate lining so she contacted me for advice. I reviewed
the notes that she sent me and saw that, although her current treatment
was similar to the treatment we had used, it had some small differences.
Now, I know that not every treatment plan (even normally successful ones)
is necessarily going to be successful for everyone. In AD’s case,
we had a treatment that worked for getting her pregnant the first time
we tried and there was no reason to change it. “If it ain’t
broke, don’t fix it.”
I gave AD a recommended treatment plan that replicated our first transfer
cycle… and lo and behold, her lining developed as it did before
and a few weeks later I received the good news that AD was well into her
pregnancy. Of course, there are still a number of hurdles that must be
overcome, the primary one being Fragile X expansion, but so far so good
and I am rooting for you, AD!