During this webinar session, Dr Halyna Strelko, the Co-founder & Leading Reproduction Specialist at IVMED Fertility Center, Kyiv, Ukraine, talked about advanced maternal age (AMA) patients & presented 2 IVF cases where all the steps were thoroughly discussed.
The first case described by Dr Strelko presented a couple where a woman was of advanced age. In most cases of advanced maternal age, it is quite difficult to receive oocytes that will produce normal embryos. The patient had 1 previous attempt where 8 eggs in total were obtained, however, they only got 1 poor quality embryo which after PGT-A testing turned out to be abnormal.
Due to the patient’s age and previous attempt, which revealed an abnormal embryo, the egg donation program was suggested, but the couple wanted to proceed with own eggs. Therefore, considering that the patient had a good ovarian reserve and they got 1 blastocyst even though it was of poor quality, we decided to try the stimulation.
The patient had normal hormonal levels, she had quite a good AMH level for her age, it was 1.1 ng/ml, infections, coagulation, karyotype as well as other tests were normal. Her husband had a normal sperm count and a normal DNA fragmentation rate. The patient was a bit overweight, her BMI was 31.3, but otherwise, all was fine.
We decided to do a natural cycle because of a low number of blastocysts, so we wanted to try with less stimulation, and we were hoping to receive better quality eggs. We also wanted to perform PGT-A, if we received at least 1 blastocyst and then the cryotransfer in a natural cycle.
We received 1 mature egg, it was fertilized, but after 72 hours of development, the embryo arrested. With 1 embryo, it may sometimes happen, even at a young reproductive age. Therefore, we decided to move to another strategy and try a new stimulation with the use of a high dosage of FSH and LH because we know that in late reproductive age, there is a lack of LH receptors, and the LH activity is necessary for the final egg maturation. We decided to add growth hormone and use special sperm selection methods. If we received good-quality embryos, we would perform genetic testing and cryotransfer in a natural cycle.
We started the stimulation, but we saw that only 1 follicle was growing, we obtained 1 mature egg that was fertilized, unfortunately, 72 hours later, the embryo arrested again. In such a situation, on the egg collection day, 3 follicles were seen in the right ovary and 3 in the left ovary, and we decided to do the second stimulation in the same cycle, it’s called double stimulation, which means that one day after the egg retrieval, we restart the second stimulation with the same medication. In the end, we got better quality.
The stimulation was performed with a high dose of gonadotrophin 3000 IU of urinary FSH, we obtained 8 follicles, and then we got 7 eggs, 6 were mature, 5 were fertilized, we got 6 embryos, and only 1 reached the morula stage, but this one arrested on the 6th day of stimulation as well.
All our interventions with changing the protocol, the medication, the fertilization method, and using the stimulation in the second phase of the cycle improved the response, but we still didn’t receive viable embryos. This is the main problem in the late reproductive age, where we can change a lot of things, but we cannot influence the crucial problem, which is producing a good quality embryo.
The patient was 46 years old, her main clinical diagnosis was advanced reproductive age, and she had a second marriage and 1 healthy baby from her first marriage. Her AMH level was not so bad (0.9 ng/ml) for her age. She was a bit overweight, she never had any fertility treatment before, and her husband had normal sperm parameters.
We suggested starting the egg donation process, the couple agreed, and we have chosen a donor from the database, we fertilized the eggs and receive good results, 5 excellent blastocysts, 4AB and 5AA, we also did a genetic test, and only 1 embryo was abnormal, other embryos were normal. We decided to do the cryotransfer, and prescribed replacement hormonal therapy protocol, a standard protocol of 8 milligrams of estradiol and 800 milligrams of progesterone. However, the endometrium was always 6-7 millimetres, and in the 2 consecutive attempts, HCG was negative. We decided to do the natural cycle protocol, and when we saw the ovulation, we waited for 120 hours, and we performed the transfer. During the natural cycle, there are different types of oestrogens circulating in the blood, and sometimes it improves the endometrium quality and thickness. It worked in this case as well, the endometrium was 8.5 millimetres, and we received a positive HCG result.
We know that follicles grow in groups, and in waves. In some patients, we can have 2 waves during the cycle, for example, 1 in the follicular phase and another 1 in the luteal phase. In some others, we can have 3 waves, and we should follow these waves as it permits us to receive a much better response when we choose the right wave.
The study presented they compared starting the ovarian stimulation on day 2 versus day 15 of the menstrual cycle in the same oocyte donor. It showed mostly the same results in the quality of eggs. We can use that and stimulate in the most convenient period of the cycle, and thanks to that, we can achieve a good response.
Why do we have such a problem? Some studies showed all these mechanisms that can end in the arrest of the embryo. These factors and mechanisms are due to the male and female partner as well, because as we know, in late reproductive age, in most cases, the male partner also is of advanced age, these factors together give us the result that the embryo may arrest. There is also a genetic mechanism involved, which means that there is an abnormal number and quality of chromosomes in the nucleus. When we compare the embryos that arrested and developing embryos, we can see that in developing embryos, the probability of genetic abnormality is lower than in arrested embryos. In arrested embryos, we can detect a mostly complex abnormality, which means that not only one chromosome is wrong but different, so all these mechanisms do not work. If it is only one chromosome problem, sometimes it may correct itself, but if it is a complex abnormality, it means that oocytes and embryos cannot correct all these disorders.
The statistics on IVF outcome and age show that in all eggs after 42 years old, the probability of live birth in the first cycle is quite low, and at 43 and over, it is less than 2-3%. After 40 to 43 years old, the success rate is very low and only 0.2% of women theoretically have a more or less good chance to become pregnant and have a live birth after 42-43 years old with their eggs.
I have seen recently an article about AMH level variability, and at first, AMH level was thought to be stable, but in fact, it may change during the cycle by 20-30% in a different phase of the cycle. It is increased when the LH level is higher and decreases when the LH level is lower. It can also vary between 20-30% from cycle to cycle. Another important thing about AMH level is that the level in blood circulation and the level you receive in your analysis may be different. It may be influenced by the lab that does the analysis.
Sometimes if your blood was frozen or heated or not put 3 hours and waiting to store for a couple of days or something else before it was put in the machine, it may affect the result. You can check AMH level even 3 times per cycle, but as for me, it’s better to do an ultrasound and check the antral follicular count (AFC) to check how many antral follicles you have in your ovary and take blood for AMH and see if both results are more or less the same. I think it’s enough to understand your real ovarian reserve. If, for example, you have a higher antral follicular count and lower AMH level, it’s probably necessary to take into consideration the antral follicular count. There is also very interesting work where they compared people with high AMH level and low antral follicular count and the opposite and showed that if there is a discordance, it’s better to consider antral follicle count.
It’s a difficult situation because you already had 10 IVF attempts. To understand this situation better, it is necessary to see how many eggs were produced during all these attempts, the percentage of fertilization, the percentage of blastulation if you have done the genetic test of embryos, if you have done, for example, the specific test of endometrium receptivity because if in most of these attempts, you had excellent, genetically normal embryos, and for example, but you never tested your endometrium, it would be probably better to do such test and check your receptivity.
About egg donation, it is also necessary to see how many eggs were used, how many blastocysts, the quality of these blastocysts, protocol of preparation, so that is difficult to answer without more details.
Personally, no, I don’t work with a male partner. Our urologist works with them, but he does not use growth hormone. We are using the stimulation with FSH and hCG mostly in case of azoospermia, and sometimes we receive a couple of sperm cells after this stimulation but grows hormone, unfortunately, no, I have no experience with male partners.
There are also different publications on that. Some of them say that it is maybe 5-6 days, if we start progesterone on Monday, we should do the transfer on Saturday, but another publication says that it’s better to follow 120 hours and a recent publication, for example, if you are using natural cycle IVF, 2 hours after hCG triggering your progesterone is rising. It means that if you would like to do a natural cycle and you would like to do your transfer on Saturday, your trigger should be done in the evening on the previous Sunday, not 1 day before like for ovulation, but a bit later because progesterone rises more quickly. For egg retrieval, we are doing it 36 hours before egg retrieval, but for cryo embryo transfer, we are doing it just a couple of hours before you start your progesterone. That’s why it should be 120 hours of progesterone in a normal case, but if you have done the endometrium receptivity with the ERA test, it is sometimes necessary to do it 140 hours or less like 72 hours, it depends on the result of your test.
It is indeed described as FSH receptor mutation, and they are not receptive to standard FSH therapy. Sometimes we can use hCG for stimulation, and sometimes we can use LH, unfortunately, it is impossible to treat it because it is a congenital condition, but we can try to use it if, for example, your own ovary is working and sometimes you have your own ovulation, it means that your body detects your own FSH. For stimulation, you can use protocols like anti-estrogens which will produce the rise of your own FSH, and after adding something like low dose hCG or LH, sometimes it may be helpful.
Some genetic laboratories specialize in performing these tests, and they can detect the mutation of FSH and LH receptors. Our laboratory, unfortunately, does not do this test, but I know a couple of laboratories where you can do that for sure.
It is true that in advanced maternal age the main risk is obstetric complications like high blood pressure, diabetes, thrombosis, placenta previa, etc. If a woman is overweight, it will be good to decrease her weight. The second point is to see insulin resistance before the treatment because insulin resistance provokes the concentration of a deposit in the belly, and these increase the probability of insulin resistance and high blood pressure. It is like a circle, and during the pregnancy, progesterone increases insulin resistance, so if you’re in late reproductive age with abnormal weight, it will be good to try to decrease it.
Also, the less medication a woman will receive, the better it will be for her health. Finally, in this case, try to do a natural cycle, and also there are scientific works that say that the natural corpus luteum produces some specific substances and growth factors which improve the probability to go with the full-term pregnancy and artificial cycle sometimes may increase the probability of high blood pressure. All methods which improve the placental blood circulation also will decrease the probability of high blood pressure.
In Ukraine, we do not have very strict legislation, so as a clinic (IVMED), we have no right to give personal information about our egg donors, but we have an agency that is not a clinic, and they can provide this information and give you a full profile of the egg donor.
The fibroid is estrogen-dependent, and progesterone also depends on the benign tumour, so if you take during them for a long time and with a big dosage probably per se, it will not provoke, but if you have a little fibroid, it will cause this fibroid to increase the size.
However, the preparation protocol normally lasts for about 2-3 weeks, but pregnancy lasts for 9 months. During the pregnancy, fibroids are growing much faster than during the preparation of whatever dosage you’re using. The main problem is not if you have a fibroid, not the preparation, but pregnancy which will produce the growth of this fibroid.
We can think about that. We don’t use this method at our clinic (IVMED), so I have no personal experience, so it is necessary to talk with your doctor about it.
There are different options, different approaches, some doctors propose to do a surgical intervention, some doctors propose to use medication to shrink the fibroid a bit before they do further preparation. There is a very interesting method called High-Intensity Focused Ultrasound (HIFU). During this method, a specific Doppler ultrasound increases the temperature inside this fibroid, and after that, the fibroid shrinks. Different approaches exist, and it is necessary to see the exact situation, the location of your fibroid, the blood circulation, and if this fibroid is close to the endometrium and if there is a big risk to harm endometrium during the treatment, so a lot of things should be taken in consideration.
There are a couple of things that would be good to clarify, for example, 13 follicles and only 6 eggs, and I would need to know the reason for it. Whether it was because the follicles were not of the appropriate size or because the trigger was done earlier, or you have some problems with the egg maturation. When eggs are not mature enough, we receive fewer eggs. For the stimulation, it would probably be a good option in the second stimulation to postpone it one today and probably give a bigger dosage like a double trigger and increase the egg maturation. There is a nuclear maturation that can be detected with a microscope, and there is a cytoplasmic egg maturation that we cannot, unfortunately, detect. These produce less fertilization, if your cytoplasm is not mature enough, you will not have very good fertilization, you will have slow embryo development and probably not very good blastocyst quality.
As for me, if it is your first IVF attempt, I would prefer to try another stimulation, it is necessary to see your first protocol, but it would be good to modify it and probably increase the dosage and the duration, doing something like double triggering and trying to receive more eggs to see if you will have better blastocyst formation rate. We could use Calcium iodide after fertilization to improve fertilization and embryo development.
Day-6 embryo, the probability of implantation it’s true is a bit less likely because they have a bit more percentage of genetical abnormality, but it is not a rule because it depends on the culture medium. The embryo is growing much faster, in some medium, blastocysts arrive rising on day-6. It is necessary to check it with your embryologist, and also if, for example, your egg collection is at 2 PM, it means that fertilization will be at 4 or 5 PM, it means that your day-6 is not 6 days but more the end of the 5th day, so this it is necessary to check it with laboratory. All these things are necessary to discuss with the team to understand better what happened, but as for me, I would try with a second stimulation in your case.
I receive such questions almost every day from my patients. PGT-A is a method that does not improve blastocyst, it is the method that permits selection and transfers the best embryo in the first attempt, for the second attempt a bit worse embryo, etc. In case you have only 1 blastocyst, as for me, you should be very careful because PGT-A may give some false positive and false negative errors as any method of testing.
The second point is that the cells which were taken from the embryo may not be representative of all embryos, it means that the cells that are taken from an embryo, from the trophectoderm, so future placenta has normally higher percentage of genetic abnormality than cells staying inside the embryo. If you receive a mosaic embryo or even an abnormal result, sometimes, in some cases, it may not represent the real situation. You will not use this embryo, but it may have a chance to implant and give a healthy baby. If you have only one embryo and have no very serious reason to do PGT-A, I would prefer not to do it because it may decrease your chance to receive pregnancy. However, if you have 5 previous attempts and in each attempt, you have a baby with trisomy, then it is necessary to do the testing. We need to see the exact reason for this test, but in your case, it might be better not to do PGT-A. Also, when you are doing a biopsy and if the embryo is not 5AA, it may be harmful to this embryo, there are different methods of biopsy, different influences, but finally, it may decrease the viability of this embryo.
It’s true that at 43 years old, the probability of pregnancy with own eggs is not so good. Regarding your husband’s sperm parameters, if for example, he has very bad sperm parameters, but you have excellent eggs, it can restore some problems and some DNA breaks in sperm, but if we have a problem inside of sperm and inside the eggs, as I have shown, in my slide, it increases the probability of embryo arrest and adds the additional problem of the development of the embryo.
As for me, at 43 years old, it would be probably better to try with egg donation, or if you have tried only once, for example, it may be possible to try with another stimulation to receive more eggs and probably one more try with your own eggs. However, the probability of success is not so high, and it is necessary to understand that whatever intervention we will do, we can only increase the quantity of eggs, but in most cases, we cannot influence the quality.