Ksenia Khazhylenko, MD
Obstetrician-gynecologist, Fertility specialist & Geneticist, IVMED
Low Ovarian Reserve, Success Stories
I want to emphasize that we usually start from a very low estradiol level, and if a patient feels good, there is no need to increase this dosage because we are talking about quite a long time for replacement hormone therapy. Regarding the thyroid dysfunction, we added Levothyroxine 25mcg and advised to come to me after 6 months, but 4 months later, she came with a positive pregnancy test, and it was a normal pregnancy, it was a normal birth and healthy baby. She breastfed for a long time, but it wasn’t a miracle, it was great news, but we know that the patient with Premature Ovarian Insufficiency can become pregnant, and we always need to keep that in mind.Even if women have any menstrual disturbance or amenorrhoea, they still can become pregnant, almost 5% of them have this chance. The same patient came back to the clinic (IVMED) 2 years later, she was 36 at a time, she has been breastfeeding for more than 1 year, she just stopped it, her BMI was normal (20), and she had regular menstrual cycles for the last year. It was very surprising, we checked her gonadotropins levels, and FSH and LH levels were normal, TSH was also in the normal range, what’s even more surprising is that her AMH level has increased to 2.4 ng/mL. During an ultrasound examination, there was a normal number of antral follicles. The reason for this change wasn’t known, but it is possible. It could have been the stress, we know that almost half of all patients with Premature Ovarian Insufficiency have a history of anxiety, depression and negative emotions, so it can trigger this condition. The patient came back to the clinic after 5 years, and she still has normal menstrual bleeding, she has normal gonadotropin levels, normal ovarian function, and she is a healthy woman.
I think the problem was very low BMI. Gonadotropin levels were very high, and also I didn’t see any antral follicles on the ultrasound. When women don’t eat enough, and they lose weight, it can be dangerous. The regulation of menstrual function comes from our cortex, from the brain, and during a stressful time can be the reason for amenorrhoea. After you deal with stress, the menstrual function can recover.
It’s a very difficult question to answer, how many eggs is enough for the process. Unfortunately, in patients of older age, we need more and more eggs, however, ovaries cannot produce more. If we are talking just about 7 eggs at 40 years old, generally it’s a good result, but it may be not enough for our aim, we don’t only want to get just the eggs but take-home baby. This number may not be enough, but it’s not a sign of stopping ovarian function. Seven eggs mean that, at least for some years, you will have a normal ovarian function. When we are talking about IVF, it’s different, and even in the case of premature ovarian insufficiency, sometimes there is this situation when the patient has more chance of natural conception than in IVF result. In IVF, we require more eggs than for natural conception, it’s a paradox of reproductive medicine because, in natural conception, we need just 1, and in IVF, sometimes we need much more to get the result. Some patients have good euploid embryos and live birth with just 1-3 eggs at 40 years.
Regarding laparoscopy, in Ukraine, we don’t use laparoscopy just for checking the tubes and trying to unblock them. The success of this procedure is quite low. We use laparoscopy just when we need to do something else, for example, when we need to remove some myomas or when endometriosis is very big in the ovary, it’s not a routine precision.
If we are talking about just this case, I think this was just that she worked with her stress. Generally, it’s a very common question of what to do to decrease FSH and increase AMH, unfortunately, I don’t have any recipes for this treatment. We cannot increase AMH by 100%, we can use vitamins, androsterone and testosterone, but they are not very effective. For some patients, we can improve folliculogenesis a bit, and when we get more eggs than we previously thought, it may be due to this therapy or it’s just due to some lifestyle changes.
About FSH, we cannot decrease a very high level of FSH when it is more than 20 units per millilitre. However, sometimes if this level increases a bit and we start the stimulation, if we have some 3 or 4 antral follicles and a bit higher level of FSH, there are some options like using Estradiol before starting the stimulation. In some cases, we need to use agonist gonadotropin-releasing hormones Diphereline or Decepeptyl, but we need to be very careful with this second option. Taking estradiol is less dangerous, but is also less effective.
It’s not a good idea to lose weight during stimulation. We need to decrease BMI if it is high before starting the stimulation. Losing weight is stressful for the ovaries, and the ovary can be sensitive to a high cortisol level. In the case when a woman is 40 years old with a very low AMH level, having just 1 oocyte can happen despite this diet situation. We don’t know if it would be the same or a different outcome.