Fertility assessment in POI (Primary Ovarian Insufficiency)

We rely on this statistical data, however, I like those patients that are out of statistics. Those patients who are getting naturally pregnant after their 40s. I just saw one of such patients today, and I was really happy. I need to mention that everything is possible, and it all depends on the patient, beliefs, strategies, etc. There are AMH and AFC, we need to talk about both, so I would like to see the number of antral follicles over 5 for a patient over 40. I would say 15 is the best, however, we need to be realistic, and also, I would consider AMH as we know the AMH  is a hormone that will show us the potential of how many we are going to receive if we will do some additional activities, for example, dual stimulation or if we would decide to have some pre-treatment strategies for the next treatment cycle or if we would increase the gonadotropin levels. I want to see both antral follicle count over 5 at the age of 40 and to see a reasonable number of the AMH, which in this case would be over 0.5, and if it is more, the better.

If it were 5 follicles in one ovary and five in another ovary, it would be 10 in total, so it would be even better. However, we need to understand that we can see PCOS patients who were diagnosed when they were young, and those patients probably will have 5 and 5 at 40. However, there is an issue with the ovarian age, the female age and the quality. We need to make sure that we received euploid oocytes, so we can get euploid blastocyst, and this will be the winning situation.

Ovaries have their volume, and they are round, and also they have cortex in the cortex there is a maximum number of the follicles. It depends on the volume of the organ, but there could also be adenomyosis, endometriosis, perhaps you had some surgeries on one of the ovaries before or not even on the ovary, for example, we can have an appendectomy, and through laparoscopic treatment, the ovary can be somehow affected. Such ovary starts to respond slower. Many factors can affect the number of follicles, but this is not a crucial thing. For IVF doctor, the most crucial thing is the total number of follicles in both ovaries. We never divide them into right and left, we only can do this in case we are thinking about IUI to be done for young women for the male factor of infertility and in case one tube is blocked. We would consider the ovary, in which the tube is okay, but if we are talking about IVF treatment, there is no question about this.

Yes, if you’ve seen my previous webinars where I’m talking a lot about options of the biological materials that can be transferred. This is my practical experience which I started back in 2008, once I was coordinating the first international program in Ukraine on the export of biological materials, we imported sperm from the country where outside the nation is legal uh we did fertilization we did a full cycle of the donor fertilization of the oocytes with the male sperm which was imported, and we sent the embryos back into the country where they were implanted.  Nobody needed to travel,  just the medical couriers.  The doctors were checking the whole processes in both clinics.

Therefore, there is a possibility not to travel to Ukraine but to receive the biological material into your home country. The only rule is that this country should officially allow oocytes donation, such countries as Ireland, UK, Austria, Poland, Latin America, Canada, U.S., all can receive materials from other countries from outside banking, and this is all doable. In these specific times, I am always up for it because while seeing the patients in our clinic, I always like to communicate with all patients and to treat them however I understand if I will treat 30, 50, 100 patients per month or if we will establish the cooperation with the centre, we would help more patients by doing this transportation of the materials, and we have countries where many children were born already using Ukrainian oocyte donors so if you need to get more information on this you can contact me later, and we can discuss it.

It’s a great question. We already passed through these many years of discussion related to the fact whether we should do the NGS testing of the blastocyst, should we do PGD/PGD, what to do with the mosaic embryos, does it mean if this is mosaic we should not use it or if we would take the biopsy from another piece of the zona pellucida if that would be different etc., and also one laboratory would give one result, and if you would compare this, it will give another result, and this all depends on the quality, methodology, people, the machines, etc.

However, the scientific conclusion and the recommendations given are that if we have a medical indication, for example,  age is a medical indication for genetic testing of the embryo, of the blastocyst. When we recommend this to the patient, this is a patient decision or a patient’s and doctor’s decision. For sure, we have a significant statistical difference in results once transferring genetically tested embryos and those not tested. In terms of the proper implantation, early miscarriages, potential genetic mutations to be found in the second trimester of the pregnancy, etc.

I believe, as always, methods can be improved, but we worked with the proven laboratory which is selected, and we worked with that laboratory for years for our blastocyst biopsy and the NGS testing which we do for blastocyst, we have no concerns regarding the quality of this, and we do the same and just testing of the oocytes there as well. It’s not mandatory, we may recommend using 10 oocytes, which are not tested, and we would expect to have 70% blastulation or 60% blastulation if this is a proven donor. If we used NGS tested oocytes, this figure will be even higher.

I would need to get more information. As I’ve mentioned, I saw that wonderful, positive pregnant woman at the age of 42 who conceived naturally, she was prepared for the IVF starting the next cycle, so still, this is out of the statistic, but it’s possible. Let’s say you are less than 38, you have a proper ovarian reserve, great sperm quality of your husband, your tubes are normal, you have no endometriosis, there are no issues with the immune response, etc., you may consider improving oocyte recruitment by adding supplements like vitamin D, CoQ10, folic acid, some additional supplements.

But again, if we are talking about science, it is not that easy for you to conceive naturally and how soon. There is also a question on how long have you been trying, there are some other factors that are not working and are not letting you get pregnant. Frankly speaking, I do recommend some additional supplements, but I consider them as a psychological addition done by the woman so that she feels that she’s doing something to improve her recruitment and the growth of the follicles. However, I can’t tell you that something specific will work because there is no proof.

This is a very discussable question, and this is the question of fertility preservation which is a technique that gives us a potential or possibility to freeze the tissue or the cell, and there is a recommendation again based on the statistical data that we should preserve any materials either the ovarian tissue or the oocytes or the embryos until the age of 38 for the patient. However, with the NGS testing of the oocyte and because every patient has the right to try. This is more of an ethical question like should we recommend patients to go ahead with the treatment to spend money for the medication, pay for the procedures if we know that the probability of getting good quality material is very low.

However, this is a final patient’s decision and again going out of the statistics even if we would preserve 1-2 oocytes in one cycle for the patient who is over 40. Then we will have another cycle, and we will preserve an oocyte or 2, we will still have the probability to work with that material. There is no possibility to freeze it inside the body. In every cycle, we are given a specific number of follicles, and if we are not using them, we just lose them.

That’s why we can think about preserving the materials, but we need to do some actions like stimulation and then freezing the oocytes or embryo. I would not recommend ovarian tissue in this specific case, of course, but I would consider having stimulation or better to go ahead with the fertilization and embryo transfer because having a baby between 40-50 is a good time to do so to have a baby between 40 and 50.