During this session, Dr Elena Santiago, Gynaecologist & Fertility Specialist at Clinica Tambre, Madrid, presented a young couple’s case where the female partner had diminished ovarian reserve at 32 years of age. Dr Santiago has explained what tests were performed on the couple, what treatment protocols were suggested and how they were able to finally have a healthy baby.
Dr Santiago started her presentation by explaining that women are born with all the eggs in their ovaries. There are around 2 million eggs at birth, and then this number is decreasing throughout life. For example, we have 2 million eggs at birth, and we will have only 400 000 in puberty, that’s when our fertility is going to begin. From then on, each month we’re going to be losing lots of eggs. When we are 37 years old, we should have around 27 000 eggs.
There are lots of women with low ovarian reserve, and the egg quality decreases at the same time. In menopause, we can still have some leftover eggs, and it’s about 1000, but these are no more going to be available because the ovaries are not going to be responding to hormonal stimulation.
What are the factors that influence ovarian reserve?
How can we check your ovarian reserve? There are 2 important tests that we should be checking in a first fertility consultation. The first thing we can do is to do an ultrasound to check the antral follicle count (AFC), we can see how many antral follicles we have in each ovary. A normal ovarian reserve should be between 10 and 20 antral follicles between both ovaries. This result we have to compare to a blood hormonal testing of the Anti-Müllerian hormone (AMH), and a normal reference is between 1 or 3.5 ng/mL. A high ovarian reserve is when we have more than 3.5 ng/mL, and a low ovarian reserve is when there is less than 1 ng/mL. It’s necessary to compare ultrasound and check AFC with AMH level. Sometimes, we may not see all the follicles during an ultrasound due to birth control pills a woman is taking, but they do have a good ovarian reserve.
The case presented a couple who have been trying to conceive for 1.5 years. The woman was 32 years old with a normal BMI, no previous treatments, no diseases or current medication, and there was no familial background of early menopause. She didn’t smoke or drink alcohol every day or several days per week, only occasionally. Her partner was also 32 years old, with no diseases or current medication or no familial background.
We started with performing a sperm analysis which was normal, with a concentration of 22.1 mil/ml, in total, he had 44 million, which is quite good, the motility was normal at 58%, it should be more than 32%, and the morphology was 4% of normal sperm which is quite common. We did a karyotype test, which was normal, and the test for infectious diseases screening was negative.
A female patient had a low AMH level at 0.5 ng/ml, such low ovarian reserve begins to appear most frequently from 38-40 years onwards. She had 1 follicle in one ovary and 4 follicles in the other ovary, so in total, there were 5 follicles which are low as well. A normal ovarian reserve should be between 10 and 20 follicles. We also checked FSH, which was high LH, normally, it should be lower than 10, and the patient had 15.2. She had a normal smear test, the infections diseases test screen was negative, she had normal blood cell count and clotting, and we also checked her thyroid, and TSH was 1.01, which was normal.
Taking into account all the factors, in this case, we decided to do an antagonist protocol which is a short protocol. Normally, we go with this protocol in almost all patients nowadays. We started medication between the 2nd – 3rd days of the cycle, and we used a medication called Choripholutropine alpha, a type of gonadotropin that we like to use in low ovarian reserve. We used a higher dose of 150 micrograms, and also we put an effect of HMG, a kind of LH effect to try to have the best quality of eggs as well as the highest number of follicles. On the 8th day of stimulation, we added FSH recombinant at 225 UI, there were 10 days of stimulation which is more or less the average, and on the 11th day, we had in total 4 follicles growing. In the right ovary, we had a greater follicle of 20 millimetres, the others were small, and in the left ovary, we also had a good follicle of 19 millimetres, and other ones were. In total, we had 5, but we had only 2 that were of good size.
We did a double trigger to provoke ovulation, for this we are using 2 medications, GnRH and hCG. We tried to increase the chances of having the maximum number of mature eggs, we had only 5 follicles, and 3 of them were very small, so we wanted to try to have more mature eggs. We performed a hormonal blood taste on the day of the trigger, we had good Estradiol at 8.68 pg/ml and progesterone level was high at 3.62 ng/ml, and when progesterone is higher than 1 ng/mL on the day of the trigger it’s preferable to do a transfer in another cycle because implantation rates are going to be lower. Sometimes we can have high progesterone because of medication, this depends on the response of the patient. We finally went for the egg retrieval, we only obtained 2 mature eggs, we performed the ICSI procedure, meaning that each egg is injected with previously selected sperm, we kept embryos in the time-lapse incubator and the next day, we saw that both eggs fertilized.
Those 2 embryos developed into blastocysts of good quality, we achieved a day-5 blastocyst of 3BA and another 6-day blastocyst which was 3BB, both embryos were frozen for a deferred transfer. We did an endometrial preparation with oestrogens of 6 milligrams per day for 12 days, we did an ultrasound to see if everything was okay, we started with oestrogens, and did a second scan for 12 days after, we had a trilaminar endometrium of 9 millimetres. We started the luteal phase support by adding progesterone pessaries of 400 mg every 12 five days before the transfer. We recommended going for a single embryo transfer, and 11 days after, we did the pregnancy test, which was positive with a very good hCG level of 326 UI/ ml, a good prognosis is 100 hCG or more. There were no fetal or maternal complications during the pregnancy, and 9 months later, a healthy baby girl was born. It was 2 years already, and the couple came back to the clinic because they wanted to try for another child as they had the frozen blastocyst left, so we did a very similar endometrial preparation, but in this case, the pregnancy test turned to be negative.
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