In this webinar, Dr María Calomarde, Fertility Specialist at IVF-Spain located in Madrid, has talked about low ovarian reserve and provided some of her patients’ stories who were struggling with a low ovarian reserve and were able to achieve pregnancy.
Dr Calomarde started by presenting a graphic where it is shown how live birth percentages decrease from 39-years-old onwards. The most important indicator of a good ovarian reserve is the mother’s age, and with the help of an ultrasound, we can study the antral follicle count. AMH test done by a blood test decreases with age, and we can see that a 25-year-old has a normal range of AMH at 5.4 ng/ml, and in women more than 40 years old, we can see that it’s lower than 1. The antral follicle count also becomes lower in women over 40. However, we can’t study the quality of the oocytes with these indicators.
The next graph represented the relationship between maternal age and the aneuploidy rate. In other words, the quality of the embryo depends on the quality of your oocytes and the sperm. It can be observed that until the age of 35, the rate of aneuploid embryos is established at 50%. After this, the percentage starts to decrease, and after 40s, it decreases more drastically. Women younger than 35 normally have a good ovarian response, the capacity of the ovary to provide egg cells, hence at this age, there is a high probability of finding a healthy embryo without any issues. However, over 35 years old, the ovarian reserve starts decreasing along with the quality. It is more common to have problems with getting pregnant, and there is a higher miscarriage risk. Finally, we can see that at the age of 43 and onwards, it is almost impossible to get pregnant naturally with a woman’s own eggs.
What do we mean by genetic issue? An aneuploid embryo has an abnormal number of chromosomes in a cell (46 is the usual number). For instance, if there is an alteration in the chromosome, i.e., 21, the diagnosis will be Down Syndrome. If it is in chromosome 18, then it will be Edward Syndrome, and when it occurs on chromosome 13, it will be Patau Syndrome. These 3 cases are known as Trisomies alterations. Other alterations also exist, and in most cases, those will end in a miscarriage or a negative pregnancy test.
In the first presented case, the woman had a low AMH level of 0.8 ng/ml, and 5 follicles were found, in total. The partner was 36-years-old and was diagnosed with teratozoospermia, they never got pregnant, and they tried to conceive for 2 years, there were no previous IVF cycles. Since she had a very low ovarian reserve we suggested an IVF cycle, we started a short protocol with 5 days of Omifin and 150 of Pergoveris for 10 days, and the result was 3 follicles in development, and finally, during the egg retrieval we found no eggs, so there was no embryo transfer.
In the second cycle, we tried again with a short protocol, we prescribed Gonal-F 225 and Menopur 75 UI. This time, we got 3 follicles in development, during egg retrieval we got 1 mature and 1 not mature egg. We got 1 embryo that didn’t reach the blastocyst stage, therefore, no embryos were transferred. Then we tried with a third cycle because the patient was young and wanted to do everything as soon as possible, so we tried with another cycle. A similar protocol was used with lower doses, 1 follicle was in development, and then we got 1 mature oocyte and no fertilization, so again nothing to transfer.
By that moment, as we had no embryos, no blastocysts, we discussed what to do, whether to change to egg donation or whether the couple wanted to continue trying. That always depends on the psychological situation of the couple and the economic situation. The couple decided to try again.
We suggested proceeding with a mild-stimulation protocol, which means very low doses of medications. We started with Omifin 50 mg daily and Menopur 225 UI on the 4th day of stimulation. The result was the same, 3 follicles in development, we got 3 mature eggs, 2 fertilized, and finally, we got 1 blastocyst of medium quality. We performed a fresh transfer and the pregnancy occurred, and the patient delivered a healthy baby girl.
In the second case, the woman’s AMH was also low, it was 0.7 ng/ml, and there were 6 antral follicles in total. The partner was 41 and had 2 children from a previous relationship with normal sperm count. The female partner had an ectopic pregnancy with left salpingectomy before, then they tried to conceive for 1.5 years. They had no previous IVF cycles. The couple wanted to try IVF with their own eggs.
We suggested doing PGT-A because of the age. We started a short protocol with Pergoveris 225 UI, 6 follicles in development were found, we got 5 mature oocytes, 4 fertilized, and we obtained 2 embryos. We performed a biopsy of both of the embryos and then froze them. After 3 weeks, we got the results, 1 of them was euploid, normal, and the other was abnormal. As we had only 1 embryo, we tried to know more about the window of implantation, and we performed an ERMap test to check the receptivity, and it was P+6, which means 6 days of progesterone. After that, we did the frozen embryo transfer, and we had a positive pregnancy test and a healthy baby boy.
Low Ovarian Reserve and Age – IVF Patients’ Case Study