In this webinar, Dr Halyna Strelko, the Co-founder & Leading Reproduction Specialist at IVMED Fertility Center, Kyiv, Ukraine, presented a real-life patient story who suffered from a poor ovarian reserve. Dr Strelko explained in detail what tests were performed, what protocols have been undertaken, and how, in the end, she managed to get pregnant.
The patient came to the clinic (IVMED) with 5 frozen eggs (3 mature) preserved before her chemotherapy. When she came to the clinic, her AMH was 0.2, and on the ultrasound, only 1 antral follicle and 1 corpus luteum was found.
All the investigations were done, infections were negative, coagulation tests found increased fibrinogen, but it may happen in such conditions, the general blood test was also normal as well as hormonal levels. The patient’s husband had a bit decreased sperm quality, only 3% of normal morphology and a decreased motility, a bit low count of sperm cells probably due to varicocele, which is the enlargement of the testis.
We discussed what is the best approach in this case and concluded that the stimulation is probably useless because of only 1 antral follicle, which means that stimulation will not increase the number of oocytes. Therefore, we decided on the natural IVF cycle and thawing these frozen oocytes, fertilising them, and performing a fresh transfer.
We received 1 egg, we are thawing 3 eggs MII and 2 MI. The embryologists tried to make the MI mature, and they were successful, they became MII. The ICSI procedure was done, but unfortunately, only 1 4AB blastocyst was obtained and transferred, however, the result was negative.
The couple came back after a few months on day five of the cycle so that we could try to receive 1 more egg. On day 5, a dominant follicle of 23 millimetres was seen, and it was ready to ovulate, which is very early, but this is the problem of a woman with very poor ovarian reserve where the follicles start to grow even in the previous cycle before menstruation. At the beginning of this cycle, we can see that they have 2-3 follicles, but one of them is big, another one is average, and one of them is little, so in the end, we cannot receive more than one.
We decided not to take this follicle and wait for the ovulation. We prescribed estrogens because we wanted to decrease the FSH level. After ovulation, progesterone was added, and in 2 weeks, we have seen 4 antral follicles. We started a new stimulation with Clomid + FSH and triggering with hCG, we received 4 mature oocytes and 2 blastocysts. The results were very good, with 2 blastocysts of very good quality 5AA and 4AA. One of them was transferred, and one frozen. We received a positive result, and the couple got pregnant with twins. It was monozygotic twins, and she had delivered two healthy boys.
There is an official recommended criteria called Bologna criteria, established in 2011. During an ESHRE meeting, a guideline has been created to define poor ovarian reserve.
It is necessary to have at least 2 of those 3 points to say that this patient has a poor ovarian reserve. Why is ovarian reserve testing so important? It’s because each egg at any age has a probability of live birth of around 4-6%, the more eggs we will retrieve, the higher chance of pregnancy. The ovarian reserve permits us a prognosis, for example, the number of follicles, probability of pregnancy, what should be the starting and total dose of medication we use, and success rate. In some cases, when we see that the probability of pregnancy is very low, less than 1%, we can discuss it with the couple and suggest egg donation or just the opposite if there is still a good probability of achieving pregnancy with our own eggs.
There are a lot of markers of ovarian reserve and lots of possibilities to measure the number of follicles and oocytes. The first is age, then some hormonal tests like FSH, estradiol, Inhibin, and AMH. There are some dynamic tests, which means that we give something to the female and then measure what happens, like The Clomiphene Citrate Challenge Test (CCCT), and the GnRH agonist stimulation test (GAST). We can use ultrasound, we count the number of antral follicles, ultrasound machines are quite sensitive, and if we have follicles of more than 2 millimetres in diameter, we can see them on an ultrasound.
Another important marker is genetic tests because, in some cases, women can have a good number of antral follicles, but her receptors are not correct, they don’t see an FSH or LH molecule. In this case, the response to stimulation will be much lower than expected. The most precise method is histological, where it is necessary to take some part of the ovary and then see the number of follicles however, normally, we don’t do that.
Why is age the first predictor of ovarian reserve? It’s because we know that age of women correlates with the probability of pregnancy. It is always individual, but in most cases, the number of follicles decreases with advancing age. Age is the most reliable predictor of pregnancy and live birth rate, not the number of follicles. Taking age into account, along with other markers, gives a better prognosis. In most cases, the limit of receiving a live birth with own eggs is 40 to 43 years old. This is mostly due to the genetic problem of eggs.
If women have an average response, so 7 -10 eggs before turning 39 years old, almost 100% of these women will have at least 1 genetically normal embryo. However, if we have poor responders, 1-3 eggs at 42-43, only 17% of embryos will be genetically normal, and only 37% of women will have a minimum of 1 genetically normal embryo.
Another marker of ovarian reserve is the Antral Follicle Count, which is the number of antral follicles, which we can find on the ultrasound. This is a very important marker and has a low variability between cycles. Between antral follicle count measurement and a number of eggs in poor response and ovarian hyperstimulation syndrome, we can see a very high sensitivity, therefore, it is a very good method.
Why is AMH the best marker of ovarian reserve? If we compare, for example, AMH with FSH at 30 and 40, we can see FSH is normal. Then, when the age is near 50, we have mostly 0 ovarian reserve, it quickly goes up. One day it is okay, but it may be absolutely out of normal range the next day. It’s difficult to understand the moment we start to lose our eggs with FSH. The same is with estradiol and progesterone, the range is normal and then when we are going into menopause, it drops. When we look at the AMH level, the curve decreases progressively, and it permits us to measure it in the current situation.
If we compare the prediction of live birth rates in a fresh cycle, antral follicle count, AMH and age, we can mostly see the same result. The AMH level correlates with the number of follicles which we can receive. When we’re measuring AMH, it is always necessary to think about the laboratory variability of this measurement. It may be due to pre-laboratory preparation of blood, some temperature conditions, tests used in the laboratory, and in some cases, the results may be different from what you have in your plasma, so it is always important to have 2-3 different methods of measuring the ovarian reserve to be more exact.
What is the normal AMH level? The level depends on the goal and why we are measuring AMH level. It is better to talk about the possibility to receive some amount of eggs according to the AMH level. If we have less than 1 ng/ml, it is considered a reduced ovarian reserve, if we have less than 0.5 ng/ml, it is a very reduced ovarian reserve, from 1 till 2.5 ng/ml, it is more or less okay, it means that we expect to receive 10-15 eggs if it is more than 3 ng/ml, we expect to have a high response, and more than 3.5 ng/ml, suggests a risk of ovarian hyperstimulation. However, it is only concerning further stimulation.
There is also a new theory of follicular waves. In the past, doctors were thinking that follicles are constantly growing, but it was discovered that follicles are growing by waves. In some cases, during one cycle, we can have 2 waves, in some other cases, we can have 3 waves. According to this, there is a time that will be good to adopt our stimulation protocol and find the moment when the wave of the growing follicle will be the most important, and it may permit us to receive more eggs.
On the slide shown, there is a change in FSH level during this cycle, and we can see the growing follicle. That’s why we have used these estrogens in our clinical case after ovulation, it decreased FSH level and the difference in the size of follicles a bit. Sometimes, we can 2 waves, sometimes 3 waves in the cycle, but the lower the ovarian reserve we have, the more difference in the size of follicles we can see at the beginning of the cycle. This is one of the biggest problems in patients with poor ovarian reserve. They come first on the second day of the cycle, and we cannot start the stimulation although we can see follicles, those follicles have different sizes, and sometimes we can start stimulation in the second phase of the cycle, sometimes just after ovulation. Therefore, it is important to look for these waves and find the best moment to start the stimulation.
Nowadays, the cryopreservation of embryos and oocytes works extremely well, at our clinic (IVMED), we’re doing around 85% to 90% of cryotransfers. The survival rate is around 99%, so there is no risk of the embryo not surviving the freezing, and it permits to start of stimulation any day of the cycle. Then we can freeze the embryos, wait for the optimal moment to thaw and then do the transfer.
The next slide presented the comparison of stimulations with estrogen priming, which means giving estrogens after ovulation. It can decrease FSH levels a bit, and antral follicles grow in a more homogenous way. The number of follicles received is better, the maturation rate is higher, and the clinical pregnancy rate is mostly two times higher as well as the live birth rate. It may be a good method to receive more follicles and more eggs.
How to improve the result of simulation for poor responders? There are a lot of methods available, and we try to use them all. However, there are some that we use more often:
The poor ovarian response is a very typical situation in the reproductive clinic, and ovarian reserve testing is one of the most important parts of infertility evaluation because it permits us to understand what to do and how quickly we should start and which protocol, and which medication we should use. The essential markers of ovarian reserve are age, Anti-Müllerian Hormone (AMH) and Antral Follicle Count (AFC). AMH indicates an only number of antral follicles and is not related to quality. Age is the most important predictor of the quality of eggs, and in difficult cases, we should use an individual approach for each patient because it is essential for successful treatment.
It is not very common to have 12 follicles and only 1 mature egg with AMH over 8. In this case, the problem is mostly with maturation because 12 follicles is a good number. The problem with maturation may be due to different reasons. One of the reasons is a low dose of stimulation, so follicles were not big enough at the moment of triggering. There is no information in this question, but there probably was only 1 follicle 18 millimetres, and others were like 14-15. The second reason could be not good triggering. Some patients don’t react well to agonist triggering, it is around 5% of patients. Sometimes patients don’t react well to hCG triggering, it is mostly less than 3% of patients, but it may occur. It also may be the issue between the triggering and egg retrieval. Normally, it should be 35-36 hours, but it may be a bit more individual maturation, and it may take more than this standard 35 hours. There is also a possibility of some defects inside the oocytes, and it is not related to medication, it is like an internal issue.
For the next stimulation, it is necessary to change triggering, possibly waiting a bit more between triggering and egg retrieval will be beneficial. Stimulation should be probably used with growth hormone. Sometimes in such cases, I’m using growth hormone, and we receive a little more eggs and more mature eggs, however, it may be some issue inside of follicle and oocyte, some biochemical problem, and in this case, medication will not be able to resolve this problem.
IUI is not better nor worse, it is a different method. IUI is the method where we are using sperm after special preparation, and we put it inside the uterus the moment we expect to have ovulation. The probability to have a pregnancy with IUI even at 30-35 years old mostly do not exceed 10%. Theoretically, it may work, but the problem with IUI is difficult to analyse because we don’t see the egg, we don’t see the embryo, we don’t understand if this embryo reached the blastocyst stage or not. That’s why it is difficult to say why pregnancy does not occur after failed IUI.
One IVF attempt mostly gives the same probability of pregnancy as one year of another kind of treatment. When we are talking about a 42-year-old, it’s probably better to move to IVF because there is no time to waste.
Regarding protocols, it’s necessary to see the antral follicular count at the beginning of the cycle, and if we have 3-4, we can try the stimulation with Clomid or Letrozole with FSH. Sometimes it helps to stimulate more follicles than with standard FSH. Sometimes we can use a high dosage of FSH, but if we can see only 1 or 2 follicles, it’s probably better to follow them with a natural cycle or probably give some oestrogens and check it after ovulation in this cycle or the next cycle. Sometimes we can see more antral follicles, and at this moment, we can start stimulation immediately.
We can use Letrozole, which is the medication that also decreases oestrogens and increases FSH. Normally we are using such medication for stimulation as well.
Every follicle has fluid inside. We call follicular cysts in case we don’t receive eggs. Normally all developing follicles have oocytes, so for me, triggering day 7 is a bit early, but it is necessary to see all protocols, all sizes of follicles and probably estradiol level day of triggering.
8.4 pmol/mL is a decreased ovarian reserve, but 12 follicles is a good number, so as I have mentioned, sometimes we can have an AMH level that does not correspond to the plasmatic level due to some laboratory condition. In your case, it is probably necessary to change the medication. You can use, for example, Pergoveris, and this is the medication where you not only have FSH but also LH. Urinary Gonadotrophin is also useful because they contain HMG, which has the same activity as LH. The stimulation should last a bit more than 7 days, however, I would need to see the whole protocol in detail.
It was around 10 or maybe 12 years ago, and it was very popular to prescribe DHEA, there were some publications in The United States about 1 gynaecologist who following a woman who started the stimulation for fertility preservation and receiving DHEA and a couple of months later he received a lot of follicles, a lot of eggs and it was very popular. Nowadays’s scientific works do not show there is a big influence of DHEA on follicle number, and now it is mostly transdermal testosterone proposed for that, and it seems that it is working better than this molecule.
This situation is more or less typical with patients over 40-42 years old. There may be several problems in this situation. First, with a low blastocyst formation rate, 7 MII, all fertilized by ICSI and only 1 morphologically good blastocyst means that the embryo is not developing. This may be due to some genetic issue inside the oocyte, so abnormal nucleus, but also it may be due to abnormal cytoplasm of oocytes. We know that over 38, the number of mitochondria inside an oocyte decreased dramatically, at least double when we compare it with a 30-year-old. In this case, the oocytes don’t have enough energy to develop till blastocyst.
A second issue may be a lack of ions of calcium inside the oocyte, it happens a lot more often in advancing age and with decreased ovarian reserve. All intracellular processes are related to the increasing of ions of calcium. In your case, I think will be more promising to change embryological strategy rather than stimulation. With stimulation, we can improve your response a bit with growth hormone, with a higher dosage of recombinant LH, we could probably do a double trigger hCG plus agonists, but in this case, you described the main problem it is the low blastulation rate.
Continuing with your own eggs would depend on you and your doctors. You can try to modify the strategy, for example, try Piezoelectric activation, calcium ion or spindle transfer. In this case, it is about seeing the blastocyst formation rate. It might be also good to see if your blastocyst is genetically normal and then take further decisions or start talking about egg donation.
When your FSH level is more or less normal, priming will not be very helpful, but in this case, you can try to start the stimulation just after ovulation to 3 days after. When the second wave of follicle growing starts, and probably in your case, it may be helpful.
These luteal phase stimulation protocols have the same results as follicular phase protocols in a number of eggs, quality of eggs and lengths of stimulation, the general number of FSH total dose. It has started when doctors proposed to do fertility preservation for cancer patients. Cancer patients have a very short time for stimulation, 2-3 weeks, and it is necessary to start immediately because there is no time to wait. For this category of patients, different kinds of protocols were used. E.g., luteal phase protocol, mid follicular phase protocol. Finally, it has been shown that most of the time, all give the same result.
Now luteal phase protocol is more or less a standard protocol for women with a decreased ovarian reserve, and we are doing what we call DuoStim. First stimulation from the first day of the cycle, then ovulation, egg retrieval and in 2-3, we start second stimulation. We are using twice the number of eggs, so the answer is yes, it is mostly the same.
Normally, for 5 days and then stop because these molecules decrease the level of own estradiol, and as we know, the level of FSH is regulated with estradiol, so the less estradiol we have, the higher FSH we will receive. We will use FSH, which will increase and add in FSH with injections, and we’ll receive a higher amount in circulation and more effect of stimulation.
At 41 years old, the probability that the egg will have normal genetics is quite good, but if you will try to do the same at 43-44 years old, this probability will decrease dramatically. If you can freeze extra 2-3 embryos, it will be a good idea. With AMH 2.3 pmol, you will probably have only 1 follicle during the cycle. During 3-4 cycles, you will be able to receive 2-3 three eggs and extra 2 embryos. If you have this possibility, I think it will be good to do that.
The idea of using estradiol is first to decrease the FSH level a bit. In the second phase, it regulates these waves of follicle growth. Sometimes a little amount of oestrogens can give anti-apoptotic effects, which means that follicles, even when menopause is established, they continue to grow, but they stop at some point in their development. When we add a little amount of oestrogens, androgens or some medicine that improves ovarian blood circulation, it may decrease these apoptotic reactions, and in a couple of months, we can sometimes see an increased number of antral follicles.
Even when a patient comes to see me and is in established menopause, after 2-3 of replacement hormonal therapy, which consists of 2 milligrams of oestrogens and 10 milligrams of progesterone, we can receive 1-2 follicles and 1-2 eggs. This effect does not last for years, it is probably 1-2 years after the beginning of menopause, after this serious decrease of the ovarian reserve, but sometimes it may be helpful.
With this AMH, it should be around 5-7 eggs, but sometimes the level of FSH does not relate to the ovarian reserve. Sometimes we can have a better situation than we expect to have with FSH level, and sometimes worse. It’s always necessary to check the antral follicular count (AFC), but it should be something like 5-6 eggs.
If it is FSH 54, it is quite high, which means that the estradiol level is low and probably the cycle is very irregular, and some cycles are without follicles, 2-3 months without menstruation. In this case, we can try PRP, but I would prefer to prescribe replacement hormonal therapy first. I would recommend coenzyme q10, something like molecules that improve blood circulation, and we can also do PRP. However, it will not be very successful because of your low level of ovarian reserve.
According to hormonal level, of course, it is possible to receive eggs. The main question is the quality of your eggs, as we have mentioned, it depends on age rather than on AMH level etc. If you have done 5-6 stimulation and never had a normal embryo, good quality blastocyst, in this case, it would probably be better to move on to egg donation. If it is your first simulation, you can try it with your eggs. There is no possibility to predict the quality of eggs and embryos with hormonal level or whatever analysis, we can only see the quality after egg retrieval. Until 43, rarely 44 years old, we can receive a live birth with our own eggs, after it, it’s almost impossible.
Sometimes it is 2 mg, sometimes it depends more on how many antral follicles we can see and the patient’s weight. If you are not overweight, we can give a lower dose of oestrogens, if the weight is higher, the dose needs to be higher, it may be from 2 to 6 mg.
Yes, sometimes it may be helpful, and we have quite a lot of cases where we have mostly day-3 development arrest, and after Piezoelectric activation, we have a good number and good quality of blastocysts. Sometimes it may be helpful but not in all cases, it depends on which kind of problem we are dealing with. It’s impossible to say whether, in your specific case, it will work or not. If we take 100 cases like this, probably one-half of those cases will have a better result with Piezoelectric activation and Calcium(2+).
Estrogen priming is done to make follicles more homogeneous. The problem with starting a stimulation in patients with a poor ovarian reserve that comes on their 2nd or 3rd day of the cycle is that there are follicles, but follicles have different sizes. When we start normal stimulation, in 5 days one of them is already formed, and the other 3 or 4 start to grow. This is the main question when to do the egg collection? When we are waiting, these big follicles will be post-matured or ovulated. The estrogen priming may be helpful to make this cohort of follicles more homogeneous.
Clomid and Letrozole is another story. To make follicles grow in poor or normal responders, we should increase the basic FSH level by 10%, 20% or 30%, 30% is better, but as a minimum 10% on the basic level. Each medicine contains 75 units of FSH increase basic FSH level less than 0.8 to 1, so not very high. If basic FSH level, for example, 12 or 10, 11, 30% is 3-4, so we should give 5-6 samples of FSH so a very big dosage, and sometimes it doesn’t work. Clomid and Letrozole help us increase our own FSH, we decrease for a short time own estradiol, and your body produces much more FSH at this moment, and we add extra FSH from the outside, and we receive this increase of 30-40% easily and not with 6-8 samples per day, this is the main idea.