Seang Lin Tan, MBBS, FRCOG, FRCSC, FACOG, MMed(O&G), MBA
Professor in Obstetrics and Gynecology, McGill University; James Edmund Dodds, Chair in ObGyn; Medical Director, OriginElle Fertility Clinic and Women’s Health Centre; Founding Director, McGill Reproductive Centre, OriginElle Fertility Clinic & Women’s Health Centre
In this session, Dr. Seang Lin Tan, MBBS, FRCOG, FRCSC, FACOG, MMed(O&G), MBA, Professor in Obstetrics and Gynecology, Medical Director, OriginElle Fertility Clinic and Women’s Health Centre; Founding Director, McGill Reproductive Centre has been talking about IVM as an option for poor responders and how can it improve their chances to achieve pregnancy.
I don’t think this is something you should be very worried about. This can happen to some patients, we are talking here about preparing the surrogate for embryo transfer. Sometimes, some women especially, if they’re young do produce functional cysts, and this functional cyst may stay there for a month or two months or three months, but they invariably go with themselves. I think here is where patience is of the virtue because the surrogate is obviously young, I would just wait for the surrogate to have the cyst disappear before starting the cycle. In the meantime, freeze the embryos for the transfer in preparation for the surrogate, that’s all.
We’re talking here about a potential poor responder with a low AMH level. I would say that in most cases, we would try IVF in the first instance. Here, in Montreal and Ottawa, we have had healthy babies born with IVF even if the AMH level is lower than that level. Having said that, if we get a poor response to IVF, then in the case we would use IVM, and we’ve had healthy babies born with IVM. These patients are the ones who are likely to b poor responders.
I would need to know a bit more details about that previous cycle. In principle, as I said, an FSH of 32 and an AMH at 0.2 obviously says that there is an ovarian failure. The irregular periods are probably because of ovarian failure. Now, if the doctor wishes to do IVF, you can try IVF first. However, if you try IVF and you’ll find that there are virtually no eggs, you are the type of patient that is the topic of today’s lecture, we could try IVM. If you live in North America, we would have you come to Montreal for about two weeks and do everything here. If you live in Europe, we could work together with the center in Europe, do a telephone consultation, you would give them our protocol, they could do all the blood work and the essential, tests in Europe, have the first one or two ultrasound scans are done there, and we might give them a small dose of Puregon or Gonal-F f on day-4, day-6, then day-8, as I showed you on the slide. After that, as soon as the biggest follicle is 8-10 millimeters, you would need to come to Montreal or Ottawa, and then after that, as soon as the biggest follicle is 12 to 14 mm, we trigger and collect the eggs. The length of time you’ll need to spend in Canada will be about a week to 10 days if you’re doing a fresh transfer. We can also freeze the embryo, you fly back to Europe, and then you come back as a subsequent time to do the transfer. Nowadays, flying from Europe to Canada is pretty easy except for the pandemic obviously, which changed our lives but normally there are daily flights from London, Paris, Rome, Spain, all the major capitals in Europe, so coming to Montreal or Toronto is very easy. From Montreal, for example, it’s a 1.5 hour or 2-hour drive to Ottawa. We can fly directly to Ottawa as well, then have a stopover in Montreal.
If you exclude the cost of drugs an IVM cycle, we’re talking about 4 to 5 thousand dollars. The cost of drugs depends on where you buy them, you need a bit of a drug. I would suggest buying drugs in Europe because the cost of drugs, in Europe, is a fraction of the cost of drugs in North America. Drugs in North America for IVM might add an extra 1 or 2 thousand dollars, but in Europe, it might cost a couple of hundred dollars.
IVM would be an option. Whether it would be the best option for the next cycle, I can’t really know. In these cases, I would say it’s probably best if you contact us directly. You can send us a copy of your medical file, we could examine it in detail first before giving some advice. The information you’ve provided is just too general. Obviously, 11 fertilized eggs and then to get poor quality embryos in one cycle itself is not an absolute indication for IVM, but it would be an option. It will depend on your age, other factors, the partner’s DNA fragmentation, whether any other factors are important to consider first, whether PGT-A is considered or can be done in your country, and so on.
There are many different ancillary treatments, which can so-called improve egg quality. DHEA, CoQ10 is widely known, there’s Myo-inositol that you can try, there’s MACA from South America that you can try, some people have taken baby aspirin, and so on, but none of these methods are guaranteed to work. We ourselves do give, in some cases, growth hormone to improve egg quality as well. Regarding this method, you should probably discuss it with your own doctor because I would never like to give patients advice that is overruling the patient’s own doctor.
The age limit for IVM is the same as it is for IVF. Some doctors will stop doing IVF for women who are 41-43. They will not do IVM as well in such a case. The law here in Quebec says that it’s not possible to treat a woman with her own eggs if she’s more than 46 years old. Obviously, for IVM, it’s the same, we have to stop it if a woman is 46, but in Ontario, there’s no age limit, so long as the patient has a chance and she understands the chances are small, the treatment can be done.
It’s not the same. Duo-stim is a method of stimulation for IVF. In Duo-stim, what they do is that they will stimulate ovaries by the antagonist protocol, collect all the eggs above about 10 or 12 diameters, and about two days later, after the egg collection, start stimulation again and then do a second egg collection. In our center, we even did the triple stim, and you do get some successes. However, medication cost is expensive because we’re talking about 2 or 3 rounds of egg collections in one cycle. The cost of distribution methods is quite different from IVM, where we are trying to give little medications and collecting eggs when they are immature to be collected. So, no, Duo-Stimulations is not similar to IVM.