By fertility experts from Spain.
The ovarian reserve is the quantity and quality of eggs a patient’s ovaries can produce. Diminished, or low reserves occur naturally with age as the ovaries lose their reproductive potential leading to reduced fertility. Although this process is completely natural it can also affect younger women in some cases.
We invited Professor Evangelos Papanikolaou, the co-founder of the Assisting Nature IVF clinic in Greece and world-renowned infertility expert to explain what fertility specialists do to combat this issue and what options are available for patients with such a diagnosis. He does so by using the examples of four real-life cases he encountered in his professional experience.
The first case Professor Papanikolaou describes is that of a 44 year old woman, recently married, who experienced two miscarriages from natural conception. Her first IVF cycle failed during the implantation stage – despite being able to produce two blastocysts, the implantation did not result in a pregnancy. As the patient didn’t accept hormones for further stimulation, professor Papanikolaou decided on a natural IVF cycle – that is to say, a cycle without hormonal stimulation – in order to create as many embryos as possible, which were then put through PGS testing. Following nine natural cycles, the embryologists were left with seven day three embryos, which then were tested.
The results of the test, however, revealed the cause of the repeated failure – all seven embryos were aneuploid, or chromosomal abnormal. Faced with such results, the patient decided to undergo a fresh egg donation cycle, resulting in a successful pregnancy concluding with the live birth of a healthy child. Two years later, the patient underwent another egg donation cycle, this time using frozen cells, which also resulted in a child.
The second case concerned a 30 year old patient with a very low AMH – 0,1 ng/ml. Following two failed IVF cycles in a different clinic, she decided on a third attempt under the care of prof. Papanikolaou. Following another stimulation cycle, no eggs were able to be retrieved.
Following the result, a decision was made to undergo natural cycles in order to accumulate embryos; four such cycles resulted in a single egg being retrieved during one of the cycles. After it was fertilised and implanted, the pregnancy did not take hold. It was obvious that pregnancy using the patient’s own eggs wasn’t an option; therefore, she agreed to an egg donation cycle, which resulted in a successful pregnancy on the first attempt. At age 31, she gave birth to twins.
Patient number three was also young – diagnosed with infertility at 27 years of age, she begun attempting to conceive using IVF two years later. Her AMH was similarly low to patient #2 – below 0.3 ng/ml. Her first cycle, using ovarian stimulation, resulted in one healthy blastocyst, which unfortunately did not result in a pregnancy.
The second attempt, then, was made with the goal of freezing every embryo that could be generated; it turned out only one embryo was generated, which was then vitrified. Before it could be tested and implanted, however, the patient became spontaneously pregnant! The pregnancy resulted in a successful delivery of a healthy child. As you can imagine, this is the best possible scenario for an infertile patient.
The fourth case Professor Papanikolaou described was that of a 42 year old woman suffering from polycystic ovary syndrome (PCOS). She did, however, have regular cycles. After being diagnosed with infertility half a year prior, she underwent her first IVF cycle with ovarian stimulation and PGS testing. Five blastocysts were generated and biopsied, with two being determined as genetically normal. Following a frozen embryo transfer, the patient became pregnant following just one cycle.
The conclusion then, can be drawn: low AMH does not differ much from other causes of infertility. There are successful strategies that result in pregnancy. Women with low ovarian reserve and women in an advanced reproductive age face the same difficulties. There are four ways a patient like that can end their reproductive journey: they may undergo egg donation, continue with repeated IVF attempts while utilising techniques such as PGS, getting pregnant spontaneously or giving up altogether. As you can see, then, the choice is really whether to continue trying with the patient’s own eggs, or whether to use a donor.
Both methods are valid choices, although it really depends on the individual patient and whether or not they are able to produce eggs in sufficient amounts to generate healthy embryos. Some, like patient number two, are not; for them, egg donation would be the only option. It is worth noting that egg donation cycles have around a much higher than own egg IVF cycles, even in the best of circumstances. Oocyte quality plays that much of a role in successful embryo development.
Patients deciding to undergo egg donation often express concerns – what will the child’s character be? Will it resemble me and my partner? What about inheritable diseases? Do I tell my child?
Fortunately, egg donation is very well regulated by law. In most countries the donation process, while anonymous, requires clinic to match donors and patients using phenotype characteristics (that is, hair and eye colour, race, height, weight etc.), while in some countries additional information may be disclosed, such as education and character traits. Because of that, the child is guaranteed to resemble the parents as much as possible. Donors are also screened for any genetic predisposition towards or carrier markers of genetic diseases; if they are found to be the carrier of any illness which could endanger either the mother or the child, they are disqualified from the donation process. Egg donation patients are also often offered psychological counselling which helps them fully understand the implications of the process.
The screening process deserves to be touched upon in more detail. As Professor Papanikolaous argues, the current tests according to egg donation guidelines aren’t adequate, as family histories of donors are often inaccurate. Genetic carrier screening is the first step in addressing that issue, allowing clinics to determine if the donor is a carrier of congenital deafness, heart defects and other diseases. However, it needs to be stressed that everyone is a carrier of at least five genetic mutations – in the future, as full genetic mapping and screening becomes the norm, it will be readily apparent that “perfect donors” don’t actually exist.
When considering egg donation, choosing a reputable clinic should be the priority. Professor Papanikolaous points out several aspects which patients need to make special notice of when choosing a clinic. First of all, the clinic should only recruit donors with a proven fertility record; that does not only mean the donor has already had children or donated eggs which resulted in children, but also that they are psychologically stable and that they can deal with the responsibility.
Second of all, the clinic should focus on quality, rather than quantity, in their stimulation treatments – although they should aim to receive a reasonable amount of oocytes, they can’t drive their donors into ovarian hyper-stimulation syndrome (OHSS), as it can severely impact the quality of received oocytes. The use of OHSS-free protocols is a must in modern reproductive medicine.
The clinic should also only transfer day five embryos; that is, only those which have reached the blastocyst stage. The use of time-lapse incubators and the availability of PGS testing also indicate modern quality of service.
Thirdly, the clinic should place a heavy emphasis on investigating the patient’s condition. Hysteroscopies provide a wealth of information to fertility specialists, which makes it puzzling as to why some clinics shy away from them. Professor Papanikolaou’s Assisting Nature clinic recommends a hysteroscopy as part of the initial examinations into the patient’s reproductive health. It also allows doctors to perform a uterine scratch in order to boost endometrial receptivity.
The pharmaceutical protocol used on patients should also include doses of aspirin or heparin in order to combat potential thrombophilic effects. Professor Papanikolaou also believes in augmenting the treatment with low doses of corticosteroids to induce more favourable immunologic conditions.
We also got to learn a few insider secrets – here are some things to ask the clinic in order to gauge the quality of their services. First of all, ask them who performs the embryo transfer – some centres train new, inexperienced doctors. As noble as that is, there is a documented difference in pregnancy rates between clinics who only allow experienced staff to perform the transfer, and those who don’t.
The quality of the work performed at the embryological laboratory is also worth asking about – is anyone auditing the lab? What are the quality control measures in place? Does the lab submit their results for review to some sort of authority?
And speaking about the lab – what about the vitrification or freezing of cells? It is, after all, an operator-dependant procedure; that means that the results can be wildly different depending on who actually does the deed. Only experienced embryologists should perform the procedure. If you’re interested in a clinic, ask about their survival rates and who performs their vitrifications.
Professor Papanikolaou also tackled a common concern among patients – namely, the quality of the eggs received from donors. According to a study performed in the United States, 65% of eggs received from donors are aneuploid. Some patients who decide on egg donation think it’s going to be a magic bullet that will make them pregnant outright. The data shows that won’t be the case in the majority of cases, however.
IVF is still a game of odds – doctors generate as many embryos as possible with the expectation that at least a third of them will be euploid. Commonly, in egg donation scenarios, oocytes retrieved from a single donor are split between two recipients. With an average of fifteen eggs retrieved per cycle, seven eggs are assigned to a patient, a third of which will result in euploid embryos. This means only one or two viable embryos per cycle! Fortunately, we can skew the odds in our favour using modern testing procedures, such as PGT-A. Unfortunately, genetic testing is not a standard part of embryo selection yet; for now, embryos are still selected using morphological parameters. The falling costs and rising availability of PGT-A, however, may change that in the coming years.
The best way to game the odds, however, is to offer exclusive donors. In order to save time and costs, many clinics offer “1 to 2” donation – that is, a donation is split between two recipients. According to data presented by Prof Papanikolaou, however, simply switching to exclusive donation increases delivery rates from 50% up to even 70%, simply because the embryologists have more materials to work with.
If you think that egg donation treatment is something you are willing to consider, your next step is to choose between fresh or frozen donor eggs. Before you make a decision, you may want to watch another webinars “Fresh donor eggs or frozen eggs for IVF – what’s better?” We also recommend another webinar on ‘Donor eggs – it’s all about quality, no. of eggs & qualification process‘.
I think that, as I showed you in real case scenario no. 4, at 42 and having a PCOS genetic condition, actually could be positive for becoming a mother after 40. So, taking metformin is the right thing to do. You should stop taking Clomid. You should try again with IVF—I would suggest with your own eggs. If the PGS result is positive, [inaudible] there is a 50% chance of becoming pregnant with your own embryo. If you would like to go for a 4th attempt—if you’ve already done the 3rd one—the maximum you can do is 4 cycles. You’ve already done 2 IVFs. I would totally suggest that you should do it with a pre-implantation genetic diagnosis and if you still believe that you’re capable of having a baby with your own eggs, a 4th IVF trial should be the final attempt. Then you might opt for oocyte donation.
What is the age? Ok, 37. Although we used to say that endometriosis does not affect the quality of the eggs, there are studies on donors who were diagnosed with endometriosis after donation and tend to have fewer pregnancy outcomes when compared with eggs from normal healthy ladies. Probably there is only a tiny effect on the quality of the eggs in cases of endometriosis. Only 1 unsuccessful IVF with 4 ET does not really mean anything. Definitely, metyloprednizolon does not influence the success or failure of a cycle. Before you undergo a new IVF trial, you should have your endometrial cavity screened and you and your husband should have a karyotype analysis and check thrombophilia. If you try next time, only do it in the freeze-all strategy and only with blastocysts.
At the age of 40, the success rate is not 8% but around 20% with your own eggs. So, an AMH of 1.4—if this means nanograms—is normal for the age of 40. If it’s nanomoles—i.e. 0.3—then it’s a bit low, meaning that you have a low ovarian reserve but if it’s nanograms, then you’re completely normal. Definitely try two more cycles with your own eggs and only if this fails should you try egg donation. That is the easy choice, of course.
The research was performed with polar body biopsies, which is an expensive technique first of all, and all the chromosomes were tested, not only a group of them. Also, studies have been performed on real eggs but they couldn’t be used afterward. You can test the egg but, unfortunately, the egg dies after the test and you cannot use it. This is the problem. We hope that this will be the next big evolution in IVF—how to test the eggs non-invasively and know straight away how many of the eggs are euploid, which means with 23 chromosomes. So, this will be the future and one day it will definitely come.
So, to answer the first question, low ovarian reserve is not connected with the thickness of the endometrium. Actually, what we see in virtually the majority of patients is that if they have a low ovarian reserve, they have an excellent endometrium, which means more than 7 mm. So, 7 is the limit, not 8 or 9 as it used to be in the past. So, if it’s 7, this is perfect and I would like to answer here that if it’s not 7 but above 6 and trilaminar—you can see 3 lines in the endometrium—this is also a very positive indicator for the quality of the endometrium. So, the answer to the first question is definitely no.
As for the second, estrogen and progesterone supplementation is not affected by the ovarian reserve.
In answer to the third question, if the estrogen [55:47 inaudible] endometrium of 7 mm, then we can try other routes. For example, in our clinic we use 8 mg—4 in the morning and 4 in the evening—and 2 mg vaginally. So, we give 5 tablets of estrogen—4 tablets of perox and 1 vaginally—and this helps sometimes. We have also developed a very good protocol that was published in the Journal of Assisted Reproduction and Genetics, where for 7 days at the beginning of estrogen supplementation, in the second week of it, we also supplement with a minimal dose of acid Z that sometimes helps the endometrium to reach 7 mm, but this is a protocol that we follow in our clinic and it seems that it works.
The fourth question: what are the chances of getting a healthy child with a blastocyst on day 6? Definitely, becoming a blastocyst on day 6 means less chance of getting pregnant. So, if you’re below 35 and have an excellent blastocyst on day 5, the chances of getting pregnant are 33%. If you have 1 blastocyst on day 6, the chances of becoming pregnant are less than 20%.
Answering the fifth question, about the side-effects of taking estrogen and progesterone during several IVF treatments, actually, progesterone is protective against cancer, so don’t worry. Taking estrogen, the only possible side-effect is that you might develop thrombosis in the lower extremities. This is mainly superficial thrombosis, not deep vein thrombosis which is very rare unless you have a thrombophilic predisposition. If you’ve taken estrogen and progesterone over 3–4 trials and you’re not pregnant but will continue with future IVF treatment, then it will be wise to check for thrombophilia. Also take aspirin treatment together with estrogen.
Most of the time it’s not that it shrinks, but that it was measured incorrectly on one of the two occasions. Even if the same doctor did the measurement, sometimes a doctor can make a mistake so maybe the first time was 6 or the second time was 7 but it was measured as 6. As I said before, 7 mm is perfect. Sometimes there are cycle variabilities. During some cycles, the endometrium may never reach 7, either with medication or with a natural cycle. You took the right decision to try again and if it’s 7 mm, that’s perfect for performing the embryo transfer. As for whether aspirin might assist the endometrium thickness, the answer is no. Aspirin has nothing to do with endometrium thickness. It’s just a coincidence.
In our on-site donation program, if that’s what the question refers to, we start with 4 mg of estrogen and we go up to 8 mg, i.e. 4 tablets. Then, if the endometrium does not reach 7 mm, we prescribe a fifth tablet to be taken vaginally [inaudible] we use up to 600 mg of micronised progesterone like Utrogestan or 3 tablets of micronised progesterone like Lutinus or 2 vaginal creams Crinone or a maximum of 2 subcutaneous injections of Prolutex. We don’t go for high doses because if you know physiology, you know that the progesterone and estrogen receptors have thresholds beyond which whatever you give, the receptor gives the same response. So, there is a ceiling effect and once this is reached, it doesn’t matter how large the dose is; the result is the same.
If we measure natural killers in the blood rather than on the endometrium, this is a mistake. I guess that this CD56 marker refers to endometrial cells, although I’m not 100% sure. The natural killer cell marker CD56 normally decreases during the implantation window, but these results of 19 and 29 are so weak that clinically it means nothing since we never test the maximum percentage of CD56 for naturally conceived babies at the moment the woman got pregnant because this would be unrealistic. So, actually, we don’t have normal values and the normal values that this test provides are completely arbitrary and, in my opinion, of no meaning. I can’t really answer this question, but we should not focus on 5 embryo transfers without pre-implantation genetic diagnosis. It would be a pity to blame the endometrium if we don’t know which of the embryos of the 5 embryo transfers—I don’t know if there were 10 embryos, for example—were normal or not. So, how can we blame our endometrium receptivity when we have no clue whether we transferred normal blastocysts?
None of the tests are reliable. They can only assist 1 in 1000 patients with repeated implantation failures of a maximum of 10 blastocysts or biopsied euploid blastocysts. Then you can test the endometrium receptivity with any of the tests available on the market and try to find an answer, but for the time being, they are less informative than we would like.
As I mentioned before, the concept of uterine scratching started by reading many years ago published literature on monkeys and baboons. They did endometrium biopsies and after 1 month removed the uterus of the monkey. We found out that they were pregnant when they were sacrificed and the uterus was tested. Some of the baboons were pregnant and the implantation site was on the incision of the endometrium because of the biopsy. This led to the notion to start thinking that maybe scratching induced an aseptic inflammation that with the chemokines, not really with downregulating the natural killer cells, actually more of a chemotactic effect, so the chemokines or interleukins may attract the blastocysts to invade the place where the upper layer of the endometrium has been set off .
I think the best person to reply to this question is the embryologist who treated your eggs So, really, if the impression is that your eggs were of bad quality during all of those 4 egg retrievals at the beginning—from day 0, I mean, from the day of fertilisation—maybe there is an oocyte quality problem. As I mentioned, there is no way to look into the quality of the eggs. However, if the third or final attempted ended up with 2 blastocysts, that’s not a bad result. Maybe the first 2 IVF trials were not performed under optimal conditions. If you have blastocysts with your next try, I would suggest that you have them biopsied and do preimplantation genetic diagnosis (PGD) to find out if there is a problem with the genetic quality of the embryos. Still, it won’t be possible to blame the eggs for the genetic quality of the embryos. However, we know that 80% of abnormal embryos is due to egg quality and 20% is down to sperm quality. So, I think before you jump into egg donation, you should definitely do pre-implantation genetic diagnosis.
Definitely. The only caveat that you should be aware of is that when we have really premature menopause, we should use estrogen replacement therapy. The reason is that if you don’t take any pills in a cyclic way, the uterus becomes atrophic, as does the endometrium. So, if you, or anyone else, are not on cyclic HRT (hormone replacement therapy), I advise you to start the hormones for 3 months to make the uterine environment start rolling up and then there will be no problem at all trying egg donation.
My worst moment is when I have a lady who has the same scenario as yours—with several of your own IVF cycles and having made the difficult decision to move into oocyte donation, you then experience another failure. My answer is that 95% of women will have a baby either with the first, second or third egg donation. Some patients really do need a third egg donation—by that I mean a third donor trial and not a third embryo transfer. This does happen. I would definitely check the genetic quality of your partner’s sperm and perform PGS the next time.