IVF & Premature Ovarian Reserve
San Diego POR Fertility Treatment
Although it sounds unlikely, pregnancy is possible when one is in Premature
Ovarian Failure (POF). Stories of women diagnosed with POF, “giving
up,” and then suddenly conceiving naturally are not uncommon. However,
pregnancies from IVF are significantly less common in women diagnosed
with POF. This is because traditional high stimulation treatments don’t
work very well, if at all, so few women and their physicians attempt it.
Even minimal stimulation protocols for women with POF may not produce results.
However, with expert clinical guidance, persistence and lots of luck, IVF
can be successful in POF.
Determining Your Eligibility for Pregnancy:
The most important determining factor is a
proper diagnosis. POF indicates that few or no eggs are present in the
ovarian reserve, resulting in an elevated FSH. It is critical to rule out conditions such
as Hypogonadotropic Hypogonadism (HH), a rare syndrome in which the pituitary
gland is unable to produce FSH to stimulate the ovaries. As a result,
the ovaries appear inactive and antimulerian hormone (AMH) levels may
be low. While FSH is elevated in POF, FSH is low or entirely absent in
HH. The treatment for HH is completely different from the treatment for
POF, so an accurate diagnosis is essential.
Another important determining factor is the
severity of POF. Despite the fact that “failure” implies complete non-function
of the ovary, the diagnosis of POF is often used when, in the presence
of elevated FSH, the period still exists but is very irregular. The presence
of a period indicates that there is still egg development and ovulation,
and as long as there is ovulation, the possibility of pregnancy still exists.
It is also important to understand that the absence of a period may also
indicate another condition:
Ovarian Hyperstimulation Syndrome (OSS). OSS occurs in some women who receive high doses of fertility medication,
causing an extreme elevation in their FSH levels. Their ovarian follicles
subsequently develop an insensitivity to FSH.
The other major factor isage. As with all fertility treatments, the younger a patient is, the higher
the chance of success. There are numerous studies that show there is very
little difference in live birth rates from eggs retrieved from women with
DOR vs. women with normal reserve. This applies to POF as well. If a patient
is still menstruating (and occasionally when she does not) and is “young
enough,” baseline FSH or AMH will not determine outcome.
Dr. Lyndon Chang, Medical Director of Hanabusa IVF, has had successful
cases in his clinical practice whose FSH levels were as high as 166 pg/ml
and AMH levels were imperceptible. Most of these patients were in their
late 20s or early 30s.
Proceeding with Fertility Treatments
First, there must be a commitment to the cycle no matter how few ovarian
follicles are present. Physicians who follow a traditional IVF protocol
cancel cycles and convert to intrauterine insemination or intercourse
when there is not an “acceptable” number of ovarian follicles.
In POF, there may never be an ‘acceptable” number of ovarian
follicles, but this does not eliminate the possibility of success. Many
practitioners will argue that they have attempted to continue these “inadequate”
cycles in the past, but were unable to retrieve eggs or retrieved eggs
that were of very poor quality. However, at Hanabusa IVF, we believe that
this need not be the case.
There are circumstances when the best strategy is to skip an egg retrieval
and wait for a more optimal cycle. A patient’s estradiol may be
too low, ovarian follicle growth too slow, and/or LH persistently too high.
Natural Cycle IVF
In some cases,
natural cycle IVF (NIVF) is the best option. When FSH levels are too high, follicles will no longer
respond to fertility medication. In POF, even minimal stimulation may
be too much stimulation, and in DOR, no stimulation is often the only
option. For patients with severe POF, NIVF may take some time. FSH levels
are often naturally over 30 mIU/ml and follicle recruitment is often delayed,
resulting in a menstrual cycle that is significantly greater than 28 days.
In these cases, FSH suppression may help in the recruitment and development
of follicles. Certain medications or supplements can lower FSH from excessively
high levels to ideal stimulation levels, thereby increasing the likelihood
that ovarian follicles will develop.
Estradiol is a well-known suppressor of FSH, but any substance that has
estrogenic/progestational qualities will achieve similar effects, including
estriol or progesterone. Supplements touted to improve fertility in POF/DOR
such as DHEA may also suppress FSH, although to a much lesser degree.
Patients with POF/DOR who follow an NIVF protocol must receive frequent
monitoring of both serum hormone levels and ovarian follicle growth. An
ultrasound evaluation of the patient’s ovaries indicates ovarian
follicle size, which helps a physician determine the optimal time for
egg retrieval. The evaluation of serum hormones levels including FSH,
LH, progesterone, and estradiol is also critically important. Here are
a few points about hormone levels that the fertility specialists at Hanabusa
IVF take into consideration when managing patients on an NIVF protocol:
- An FSH level between 5 and 30 pg/ml is ideal; because assays vary from
lab to lab, it is up to the physician to determine what level is optimal.
- An elevated LH (>10 mIU/ml) during the follicular phase of a cycle can
slow egg maturity.
- Progesterone can be helpful in determining the time frame of the cycle
(whether it is the follicular phase or the luteal phase)
- Serum estradiol levels are indicative of ovarian follicle quality. A mature
follicle produces about 200-250 pg/ml of estradiol; levels below this
threshold suggest that the egg quality is sub-optimal. In this case, the
best course of action is often to cancel the retrieval and wait for a
more optimal cycle.
At Hanabusa IVF, we have developed a
set of guidelines for egg retrievals that maximize success in our POF/DOR patients. Because retrievals involve
few follicles, local anesthesia may be preferable to IVF sedation, a procedure
that is both more invasive and more expensive. The use of a 20- or 21-gauge
retrieval needle minimizes patient discomfort. We use the follicle flushing
method, which makes it easier to collect hard-to-reach eggs. Once the
egg is retrieved, we recommend ICSI for fertilization.
In conclusion, at Hanabusa IVF’s clinic in San Diego, our fertility
specialists have developed a rigorous set of guidelines for the clinical
management for our patients with POF/DOR, giving our patients an edge
when striving for a successful pregnancy.