By fertility experts from Spain.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.