CASE REPORT: A woman in her Early 40’s who has Diminished Ovarian Reserve Requiring IVF with Embryo Banking and PGS.

Dr. Geoffrey Sher - October 12, 2016
CASE REPORT: A woman in her Early 40’s who has Diminished Ovarian Reserve Requiring IVF with Embryo Banking and PGS.

Hi Dr Sher, I’m 42 years of age. Until very recently, I knew nothing about IVF, and I now find myself in a scramble to optimize my chances with it. Despite a lifelong dream of having a healthy baby and happy family, it has taken me this long to find a great man/dad I can believe in for my unborn kids, so prior, I always used protection and never tried to get pregnant. Since my mom got pregnant naturally at 40, I grew up thinking that was normal-or at least normal for my family. And, I thought if I did have a problem, IVF was supposed to be for older women……..even into their late forties. I also never got to try naturally with my partner because as soon as we committed and were ready to start, he was diagnosed w cancer. Within a couple weeks we had his sperm frozen and we set off to focus on his 6 months of chemo (completed), followed by a stem cell transplant (next month). We fit my first IVF appointment into this window. Although I asked for guidance when we had the sperm frozen, no one told me to rush based on my age. I spent the time trying to take care of him and research his cancer so we could make the best choices for his treatment. So I’m only finding out all the ins and outs of IVF now, and my initial appointment was a total shock! What I thought would be informational and the beginning of a process that was made for me has suddenly turned into a desperate race for a finish line that I may have already missed. I just finished my initial testing. I don’t think I have the official labeling for all markers like the rest of the people here, but I will try. My IVF doctor described my follicles as being good/adequate. The number I think was 3-4 in each ovary which met his minimum of what he likes to see. My AMH was .87. My FSH was described over the phone as “good” but I was told my estrogen was high at 107, therefore my FSH was unreliable. I was then told I’d be doing the Micro Flare Lupron protocol. My appointment to get all the details is tomorrow. To find out more, I got online and that is where I found you and read these articles about NOT doing the micro flare specifically for people of advanced reproductive age (even though it’s described elsewhere as something to do exactly for that). As it is now, I’m just at the cut-off for fitting in a cycle before the winter break. If I have to wait to start until January-February, I’ll have lost another 4-5 months in this race. In your opinion, is my doctor wrong? If so, how should I challenge him and still have a good relationship and have us both feel confident? If he doesn’t agree to a new plan such as what you describe, should I look for someone else, even at the expense of waiting until next year? Is there a way to approach another doctor with all my results and have this discussion to see if they can start me in this upcoming cycle on the kind of protocol you suggest? The plan is to do an all freeze cycle, then PGS, then transfer normal embryos about 6 months, after my partner has recovered from his transplant. Thank you so much!   ________________________________________________________________________ MY RESPONSE: Hi R, Your story is so very, very heart-rending and I really would like to be of assistance to you without being intrusive. It simply would not be right for me to inject myself into your treatment plan as you are being treated by another physician. However, I would like you to know that in spite of your advanced “biological clock” (age (42y) and diminished ovarian reserve (DOR) (AMH=0.87ng/ml) there is in my opinion, still a modest window of opportunity for you to have a baby using your own eggs. However, to be successful, you cannot afford to spin your wheels. You need to be proactive and strategic and engage ASAP. I cannot provide you with specific directives and would not be so presumptuous as to tell you how to approach your treating physician, however I am willing to provide you with an insight into how I deal with such cases and as to why I take such an approach. This having been said, you should know that what follows represents my personal opinion which is not shared by all in the field. So here goes: You see, the older a woman becomes, the more likely it is that her eggs will be chromosomally/genetically “incompetent” (not have the potential upon being fertilized and transferred, to result in a viable pregnancy). That is why, the likelihood of failure to conceive, miscarrying and of giving birth to a chromosomally defective child (e.g. with Down syndrome) increases with the woman’s advancing age. In addition, as women age beyond 35Y there is commonly a progressive diminution in the number of eggs left in the ovaries, i.e. diminished ovarian reserve (DOR). So it is that older women as well as those who (regardless of age) have DOR have a reduced potential for IVF success. Much of this is due to the fact that such women tend to have increased production of LH biological activity which can result in excessive LH-induced ovarian male hormone (predominantly testosterone) production which in turn can have a deleterious effect on egg/embryo “competency”. While it is presently not possible by any means, to reverse the age-related effect on the woman’s “biological clock," certain ovarian stimulation regimes, by promoting excessive LH production (e.g. short agonist/Lupron- “flare” protocols, clomiphene and Letrozole), can make matters worse. Similarly, the amount/dosage of certain fertility drugs that contain LH/hCG (e.g. Menopur) can have a negative effect on the development of the eggs of older women and those who have DOR and should be limited. I try to avoid using such protocols/regimes (especially) in older women and those with DOR, favoring instead the use of the agonist/antagonist conversion protocol (A/ACP), a modified, long pituitary down-regulation regime, augmented by adding supplementary human growth hormone (HGH). I further recommend that such women be offered access to embryo banking of PGS (next generation gene sequencing/NGS)-selected normal blastocysts, the subsequent selective transfer of which by allowing them to capitalize on whatever residual ovarian reserve and egg quality might still exist and thereby “make hay while the sun still shines” could significantly enhance the opportunity to achieve a viable pregnancy. I hope this information helps you and I wish you good fortune in your upcoming IVF journey. Sincerely, Geoff Sher


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