Fertility Topics Explained from the Experts at SFS
Malia (33y) and her husband, Paul (41y), presented to me a few months back. with 3 years of primary infertility (she had never conceived in the past). Paul had initiated 3 pregnancies in a previous marriage and by all tested parameters, was fertile. Malia on the other hand, was menopausal with absent ovulation and menstruation. She had been diagnosed with and treated for Leukemia 12 years prior and had been in full remission for the last decade. However, her chemotherapy had caused progressive ovarian failure such that her basal [E2} was <5 pg/ml, her [FSH] was >40MIU/ml, and her AMH, 0,02ng/ml. Her last menstrual period had occurred about 18 months prior. Malia tested “negative” for immunologic implantation dysfunction (IID). Malia, understood that her chance of propagating viable eggs of her own, was extremely small. However, I tried unsuccessfully to persuade the couple to use an egg donor. She insisted on first trying IVF with her own eggs and only if this was shown to be an exercise in futility, she might reconsider the egg donor option. Given the fact that Malia was hypoestrogenic (menopausal with a blood [estradiol] of <5pg/ml and likely had been so for several years, I was concerned that her uterus would be involuted and that her endometrium (uterine lining) might have become unresponsive to estrogen. Ultrasound examination confirmed the presence of a small uterus, and a failure to develop an adequate endometrium following a trial of estrogen therapy, confirming my suspicion. I suggested a 2 months trial of cyclical estrogen/progesterone hormone replacement therapy (HRT) followed by another ultrasound evaluation to look for a positive change. This was undertaken, following which her uterus was found to have had regained its size and her endometrium having responded well to estrogen. She presently continues on the same cyclical HRT to keep her in a holding pattern in preparation for an aggressive stimulation protocol using a robust agonist-antagonist conversion protocol (A/ACP) with estrogen priming (LA10-E2V) along with with human growth hormone (HGH) and steroid (dexamethasone) augmentation. Thereupon, if expanded blastocysts are propagated, my recommendation would be to transfer them fresh to her uterus without subjecting them to biopsy and preimplantation genetic testing (PGT). Frankly, I do not hold out much hope for Malia and Paul being successful IVF using this approach with own eggs, and I fully expect that we will in the future again have tore visit on the need of using donor eggs. I will update you as this case evolves!
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