Low ovarian reserve & IVF case studies

We count antral follicles when they are lower than 10 millimetres, but we do count all because if, for example, we’re doing an ultrasound on the 13th day of the cycle, we’re going to have a great follicle in one of the ovaries for sure, we do count with that follicle too.

It’s the other way around. We normally try to trigger when we have follicles at a minimum of 18 millimetres at least, but if we have other lower size follicles, we try maybe to wait for a little and see if we can get more follicles of good size, let’s say from 16-17 millimetres onwards. In this case (in my presentation), as you’ve seen, we had 2 follicles with good sizes, but the other ones were too small, and we couldn’t wait for them anymore. As I said, after 10 days of stimulation, on the 11th day, the trigger was off, we don’t go for the trigger before because we don’t think that this is going to help.

It seems that there’s bad quality of the eggs. It could be related to age and other factors that we don’t know the reason for bad quality. As you’ve mentioned that you had more or less the same result with a normal cycle and mild cycle, you could go ahead with another stimulation and try a natural cycle, possibly.

You have to decide whether you have the strength to go ahead with it because you’ve seen that 2 times, the results were very similar, so sometimes we can get better results, but it’s very difficult to do something medically that is going to improve that result. You have to see uh whether you want to try again, as I said, mild stimulation or even a natural cycle could be an option, or if not, the other option would normally be egg donation donated eggs. With egg donation, you will have much more chances of pregnancy for sure.

Nowadays, at our clinic, we don’t do that, it’s something that we don’t have enough evidence on yet.

It’s hard to give you the cause. It has to be related to egg quality. We normally say that the first days of division when we don’t have good results, it’s more because of the egg than the sperm, but here we would need to see more details about the male and female factor to have more information.

We do lots of PGS testing, nowadays, but in this particular case, we didn’t advise doing it because it was a 32-year-old woman. At this age, you are going to have at least 50% of healthy embryos. The idea was that we were not going to have loads of blastocyst, let’s say to select them with PGS, that’s why we decided not to go ahead with PGS, but it’s something that you can always do if you want. In this case, it wasn’t indicated.

It was the next cycle for the stimulation, we waited to have a period, and we did a scan with that period, we saw that ovaries were already resting. We did go ahead directly with a transfer. Sometimes, stimulation can cause the ovaries are not resting with a period, and we have to wait 1 month more to have a good situation and start the endometrial preparation.

We started them on the 5th day because we already had one follicle at 14 millimetres, so our idea is to start antagonists when we have at least 1 follicle of a minimum of 14 millimetres. If not, another way is doing it on the 6th day of the stimulation. We normally go for the first option with 14 millimetres, but sometimes we do have patients that have very small follicles during the first 5-7 days of stimulation, and we do have to wait a little more to add the antagonist, in this case, it was the 5th day.

Optimally, we need to have 3 layers to go for transfer and no signs of ovulation in the ultrasound, but I don’t know if they did this, but you have to check that there hasn’t been any spontaneous ovulation before doing the trigger. You check it by doing a progesterone test, so I don’t know if this was done. If you don’t have 3 layers shown on the ultrasound, you have to check if there has been any premature ovulation.

This is very important, sometimes we do have endometrium that is not trilaminar, and there hasn’t been ovulation, it happens as well. This depends on each case, sometimes you can have ultrasounds where the angle of the uterus is not perfect to see a trilaminar endometrium, so this is something to take into account as well.

It’s very difficult to put a limit, you’re still very young with a good prognosis, but it’s true that after 2 failed attempts if there are no other known factors egg donation could be an option. However, I don’t know if you had a good embryo quality or if there’s a need to do some other tests, we have to check, it depends on the case. After 2 or 3 attempts, we do always recommend egg donation if we see, for example, that the egg quality is not so good according to your age before doing anything. If you’ve done 2 cycles and we see that egg quality is not good, then we do recommend going for an egg donation.

Your FSH seems very high, I’m not sure if this was done at a good time of your cycle, but as I said, it’s normally not important. AMH, I think you’re talking possibly about picomoles, not nanograms, so 2.1 picomoles, is quite low with only 1 antral follicle. Even if you are very healthy with good immunity, good body weight, your age is not a very good prognosis because we can go ahead with the stimulation, we could achieve a follicle growing after stimulation, possibly we could retrieve an egg, and it could fertilize, and we could have a good blastocyst, but you have to take into account that getting there is quite difficult, even if we have an embryo chance of pregnancy are low because of your age.

Instead of having, for example, 50% chances of success with 1 embryo, you’re going to have around 20% chances, because as I said, egg quality is going to be lower, and they are going to be chromosomally abnormal embryos. You are in a situation where you could try with your own eggs to see what happens. My advice is to be very conscious of the situation. You need to be aware that if it doesn’t work, you should go for egg donation.

Both things. If you are using Time-lapse, you have to take into account that if you had normal divisions, you are going to have a morphological classification. However, if that embryo had abnormal divisions during, for example, the first days, that is something you have to take into account for sure. If at last, you have a very good quality blastocyst, but not very good divisions and you have other blastocysts to choose from, then you will perhaps choose the one that didn’t divide correctly, the last one.

This is something that you have to take into account in the final classification, which is normally morphological. However, if there are very bad divisions, let’s say, or abnormal divisions in the first days, it’s something that we have to take into account in the final classification for sure.

Normally, we don’t use Duphaston for the luteal phase support. We use micronized natural progesterone, these are different pharmaceutical combinations, Duphaston, we don’t use it.

At first, I would like to have more information, but at first, it seems that it’s not a bad sperm count, and for an IVF, we don’t need lots of sperm, we can do IVF as you’ve seen we are going to select only one sperm of all normally millions that we have. If you have good progressive motility and I hope that normal morphology, but don’t worry, even if you have an abnormal morphology, you have 1-2%, it’s fine for an IVF treatment and ICSI.

Yes, normally, we give 2 together 36 hours before the egg retrieval. There are cases, if unfortunately, we had, for example, spontaneous ovulation, and we don’t understand why this happened, maybe we were changing the timing and giving these drugs a little later, changing the timing, but that’s not the standard case. Normally, we give both of them 36 hours before.

This is very individualized. At our clinic, we normally add LH from the beginning. It’s true that perhaps if we have a patient who you started with FSH only for whatever reason and we see that the response is not very good, and we want to increase the dose or whatever, we can add that LH during the first ultrasound before starting with stimulation, it’s around the 5th day of the stimulation cycle. Normally, we give it from the start, but there are other options where we can add Menopur or LH later on.

We’re doing quite a lot nowadays because, for example, we have lots and lots of patients with a low ovarian reserve, unfortunately, and normally as I said, we are doing PGS from 38 years old onwards. If we think that we are going to achieve 1-2 blastocysts in each cycle, we do recommend trying Duo-stim from the start. We think it works quite well.

The results show that the response, so the final number of eggs, is the same as in the previous stimulation cycle or even a little higher. Whenever we can, we do recommend going ahead with the duo-stim. Another advantage is that you don’t have to wait 1 month and a half to go ahead for another stimulation, you start 5 days after the first egg retrieval.

Yes, we measure progesterone before the transfer when we do the trigger as you’ve seen, and we do measure it before doing the transfer, for example, after endometrium preparation for frozen embryo transfer. Before adding up the progesterone pessaries, there are also shots, we always measure progesterone even in a natural cycle.

There’s no protocol for everyone, as I said, we try to individualize it. If you mean which protocol we use comparing antagonists or agonists, as I said, normally antagonist, it depends on the person, age. The idea or the recommendation is to try to have between 12-1 5 mature eggs so we can have maximum chances of success in the future.

You can do a single trigger or a double trigger as well whatever you prefer, there is no inconvenience in, for example, putting hCG before the second stimulation. You can trigger with whatever you think is going to be best, we do lots of dual triggers in duo-stim as well as we do have a low ovarian reserve, we do it a lot. If you have a patient that has a very high response, a very high number of follicles, and there is a risk of getting hyperstimulation, then we only use the agonist of GnRH, Decapeptyl. You won’t have that added risk of hyperstimulation, but as I said, you can use both of them if you want.

We normally do lots of combined treatments. We put in FSH and HMG or LH effect because nearly all our patients are aged more than 35 years old, and we believe that we try to increase egg quality by putting both medications, so normally we go with both of them.