Patients With Low Ovarian Reserve
There are several tests to estimate the "time on hand" by assessing the ovarian
(egg) reserve. These are:
-
Serum FSH level on 2nd or 3rd
day of your periods.
-
Serum Anti Mullerian Hormone (AMH).
-
Antral follicle count – number
of eggs seen on transvaginal ultrasound on the 2nd day of your period.
The egg reserve is considered to be decreased after the age of 37 and in patients
who show elevated FSH levels ( > 8 miu/ml) or greatly reduced AMH levels ( < 2).
The most accurate test which can be done by patients of all age groups and at any
time during the menstrual cycle is the serum AMH level. Levels of 2-6 are ideal.
More than 6 is usually seen in patients with mild-severe Polycystic ovarian disease.
Levels of < 2 are usually seen in patients with reduced egg reserve.
Irrespective of age, a reduced AMH level indicates that the egg reserve is depleted
and the patient needs aggressive treatment.
Several therapeutic measures have been suggested for these patients such as:
-
Use of Testosterone gel 1% - for
20 days pre-IVF.
-
Use of antioxidants such as coenzyme
Q, L-arginine, etc
-
Use of regenerative agents such
as resveratrol
-
Long agonist protocol with hMG
(for better synchronization and more top quality embryos)
-
Short antagonist protocol with
combination of rFSH and HP-hMG
Other strategies for treatment include:
-
Ovulation induction with high
dose FSH.
-
IVF using mild stimulation with
clomiphene citrate and small doses of HMG injections. With this approach, our clinic
recommends 2- cycles of stimulation with egg retrieval, IVF and freezing of all
embryos.Once we have a stock of 3 grade I embryos we would plan the embryo transfer
with optimal endometrial preparation to increase the chances of pregnancy. You can
expect a 22% chance of pregnancy with this approach even with a very low ovarian
reserve.
-
IVF using high dose hMG stimulation
with a GnRH antagonist.
-
IVF using down regulation with
a GnRH agonist and hMG stimulation.
-
The novel Duostim – Dual stimulation
implies two stimulation cycles within one menstrual cycle. The first is called follicular
phase stimulation and the second is luteal phase stimulation. This not only helps
to accumulate maximum number of embryos in a shorter time span but research and
our own experience has shown that the luteal phase often gives more eggs and better
quality embryos in almost 50% of patients with a reduced ovarian reserve.
If all fails, then egg donation is usually recommended.