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Diminished Ovarian Reserve – IVF case studies (patients’ stories)

Foteini Chouliara, MD, MSc
Obstetrician & Gynaecologist at Assisting Nature, Assisting Nature – Human Reproduction & Genetics

Category:
Low Ovarian Reserve, Success Stories

low-amh-success-stories
From this video you will find out:
  • How do maternal age impact oocyte and embryo competence?
  • What is the value of Anti-Müllerian Hormone (AMH) in the prediction of pregnancy?
  • Does Preimplantation Genetic Testing for Aneuploidy (PGT-A) really improve IVF outcomes in advanced maternal age patients?
  • Does the accumulation of embryos improve the outcome of poor responders?

What treatment options/protocols are best to manage diminished ovarian reserve?

In this webinar, Dr Foteini Chouliara, Obstetrician & Gynaecologist at Assisting Nature, Thessaloniki, Greece presented a topic on Diminished Ovarian Reserve (DOR). Dr Chouliara has talked about 4 different cases, presented the diagnosis, protocols, and treatment protocol that allowed them to have a positive outcome.

What treatment options/protocols are best to manage diminished ovarian reserve? - Questions and Answers

When you find diminished ovarian reserve and fertility indication for surgery, do you advise oocyte freezing first and then go on with the surgery?

Every surgery done on the ovaries, regardless of how careful the surgeon is, is always going to end up damaging ovarian tissue. There is always going to be a follicle loss. In that case, I would advise doing some social freezing first and then performing the gynaecological surgery.

I am 42, I have a low ovarian reserve. All the tests are clear. I did 2 IVF sessions. The first one was estrogen flare, 2 eggs were retrieved but didn’t fertilize. The second IVF, of which 4 eggs, 2 fertilized, but didn’t implant. My BMI is 23, I’m a non-smoker in great health, and all tests were clear. My husband’s sperm analysis was normal. Is it worth trying one more time?

You’ve had 2 attempts so far, so I think that if you have the emotional stamina and the financial backup to maybe try one more time, I wouldn’t be against it. You can try one more time, but if that fails, I think that it wouldn’t be bad to consider egg donation.

Why is PGT-A proposed for a severe male factor if ICSI is performed and the best sperm is chosen?

ICSI is a very good option when we have a male factor. The spermatozoa are chosen on their motility, morphology, but then again, it doesn’t show that the genetic material is perfect, so it might look good, but on the inside, it’s like judging a book by its cover. PGT-A helps us determine that the result, which is the embryo, is normal.

Although the best spermatozoa are selected, it doesn’t necessarily mean that the end product, the embryo, is also going to be normal. Most of the time, a bad embryo is because of bad oocyte quality, let’s say 90% is because of bad oocyte quality. A smaller percentage is because of sperm, and it’s usually because of very bad sperm parameters on sperm analysis. In those cases where the couple has tried, and they’ve had embryo transfers, and they’ve been successful, it’s worthwhile doing a PGT-A, and if the results are not very good, maybe they could consider a sperm donation.

Have you worked with anyone with AMH as low as 0.4 pmol/mL and were able to retrieve any eggs? I am 32.

It’s a very low AMH, but 32 is not that bad because we might not have the quantity of the oocytes, but at least we’re hoping for better quality. Possibly the stimulation cycle is not going to work very well for you, but you can always try with natural cycles.

For as long as you’re having periods, you have a chance every month to monitor your cycle and to try to retrieve that oocyte, and maybe you will get lucky. I wouldn’t give up, I would try with every cycle for as long as I would have my periods. Things would have been different if you were 42 or 43, possibly, it wouldn’t be so much worthwhile, but at 32, I would try.

Why did you do intra-lipid infusion in case 4?

We’ve tried everything with this couple, we tried to do anything that we could do to help them out. The intra-lipid infusion is like a fat emulsion solution that might help with the implantation by regulating these natural killer cells in the uterine lining. It’s not proven to be 100% effective, but some studies suggest that modulating this immune response in the uterus environment could favour implantation, so we did try it out.

What is your opinion on PRP ovarian rejuvenation method?

I can understand the way of thinking behind it. Platelet-rich plasma (PRP)  is being used in different specialities such as orthopaedics and dermatology as a way of rejuvenating various tissues. I’m not very convinced that it can work, I think we still need a bit more evidence before actually applying it for most of our patients.

The theory is that it might sort of rejuvenate and increase the available follicles, but I will wait and see more data and more evidence on how effective it is before applying it to my patients. We’re not using ovarian PRP at our clinic, but we’re doing endometrial PRP for resistant thin endometrium. There is no harm done by the procedure, but I am not yet convinced, at least PRP for ovaries. When it comes to PRP for thin endometrium, we have very encouraging results so far. 

Is AMH fluctuating during the cycle?

When we’re talking about the hormonal profile, we always tell our patients to do their hormone levels between the second and the fourth day of the cycle. The AMH is fluctuating throughout the cycle, but not so much. You can check it whenever, it’s not that crucial. The most important thing is to perform it at a very reliable lab to get credible results.

Why do you do endometrial scratch every time before embryo transfer?

We’re very fond of endometrial fundal scratching in our clinic (Assisting Nature). It would be a very good idea to do a hysteroscopic evaluation every time before doing any embryo transfer, unfortunately, this is not always easy, and it’s a bit expensive as well. We only go ahead with the hysteroscopy if there is valid evidence from our ultrasonographic evaluation that there is an abnormality, like a fibroid, polyp or septum.

Even if no pathology is found, the hysteroscopy doesn’t go to waste because we do perform this procedure, which is called endometrial fundal scratching, it is like a scar that is done in the fundus of the uterus using the endoscopic micro scissors, and in a way, this injury to the endometrium seems to be activating regeneration factors, and it’s another way of sort of rejuvenating the endometrium.

We started doing this procedure, and we were very amazed by the results, and so it’s something that we regularly do, and we’re carrying out a study to be able to prove what we can say in our experience to have the statistics back us up as well. 

When would you advise women to check their AMH?

That’s so, so important, it’s so crucial.  I would say to take it at least in their 30s when they are 28-30 years old to check their AMH levels. If they are in that very small proportion of women faced with a low ovarian reserve, and premature ovarian failure, at least they will have their options open before it’s too late, and then there isn’t much that IVF can do for them.

Authors
Foteini Chouliara, MD, MSc

Foteini Chouliara, MD, MSc

Dr Foteini Chouliara is an Obstetrician and Gynaecologist with a special interest in Reproductive Gynaecology at Assisting Nature since 2018. She was awarded the Bachelor of Medicine and Bachelor of Surgery degree (M.B., Ch. B) by the University of Glasgow School of Medicine in 2005. After completing Foundation Year 1 post-graduate training she started her residency in surgery following by the residency in Obstetrics & Gynaecology at Hippokration Hospital of Aristotle University of Thessaloniki/ Greece. Since 2017 she is working as a qualified Obstetrics & Gynaecology Consultant. She received her Master of Science (M.Sc.) Degree in “Human reproduction” from the Democritus University of Thrace in 2019. She is also a Research Fellow of the Aristotle University of Thessaloniki carrying out research work on the role of particular biomarkers in the pre-surgical assessment of ovarian tumours as part of her Doctorate. Dr Foteini Chouliara is deeply committed to the supervision of the International Patient Department at Assisting Nature. Her current scientific interests include: Biomarkers of ovarian cyst and their value in Human Reproduction, PCO, Prenatal first trimester diagnosis in Reproductive Patient. She has been a part of scientific publications, presentations, papers, such as: Najdecki R, Chouliara F, Timotheou E, Tatsi P, Chartomatsidou T, Asouchidou E, Pakaki F, Bouchlariotou S, Humaidan P, Papanikolaou E. Single follicular degarelix, a new long-acting GnRH-antagonist for LH surge suppression during ovarian stimulation in oocyte donors. A randomized controlled trial. ESHRE Annual Meeting, Vienna 2019 (oral presentation) Prevalence of antenatal depression and associated factors among pregnant women hospitalized in a high-risk pregnancy unit in Greece, Social Psychiatry and Psychiatric Epidemiology, 2016 Jul. Antenatal depression among women hospitalized due to threatened preterm labour in a high-risk pregnancy unit in Greece, Journal of Maternal and Fetal Medicine, 2017 Mar 21.
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