I have very low AMH and high FSH, should I use my own eggs or donor eggs?

I come across this question very frequently.  I would really wonder how to answer this because the person who asks this question is trying to make a very important, life-changing decision, which will determine their fate. I will not have any idea about their personal circumstances too (their financial strength, family and social pressures so on).  Recently I received one such query and I answered it in the following way. Hope it helps some of you to decide.

I have very low AMH and high FSH (poor ovarian reserve) should I use my own eggs or donor eggs?

Let me explain using an analogy. You have a basket (ovary) with balls (eggs) which are of two different colors, green and red. Assume that green balls are good eggs and red balls equate to genetically defective eggs. You are going to play a probability game (IVF cycle) in which you are going to blind-fold your eyes (no way of selecting only genetically normal eggs) and pick balls from the basket. You win if you pick more green balls. A young woman with a normal AMH and FSH will have more balls in her basket (more eggs in ovaries) and you will have less balls (number of eggs in your ovaries will be less because of poor ovarIan reserve). The probability of getting green balls from your basket becomes less if you have poor ovarian reserve as a result of advanced maternal age (older women will have more genetically abnormal eggs when compared to young women). If you are of young maternal age, suffering with poor ovarian reserve, the number of balls you can pick from the basket becomes limited as the total number of balls available for selection is less too.The game gets too complicated if you have to pick up green balls with your eyes closed (there is no fool-proof technology to select only genetically normal eggs) and transfer the balls safely into a narrow mouthed container situated nearby you (this equates to picking up good eggs, fertilize it, grow it safely into embryos in the lab and transferring it to your uterus). Even if you are successful in picking up the few green balls (very few good eggs available) there are so many other variables which determines IVF success like:  the sperm should fertilize the egg; there must not be any inadvertent lab errors;transfer to the uterus should be perfect; and your uterus must be receptive enough; hence your chance of IVF success decrease drastically. But a young woman with a normal AMH and FSH will have a high probability of picking up more green balls from her basket (presence of more eggs and more genetically normal eggs too) and hence her chance of success is high (in IVF).  If you are extremely lucky you might pick up the green ball (good egg) in your first IVF attempt and if all goes well the embryo created out of it might implant and may develop into a healthy baby. Such miracles do happen but very, very rarely (because the probability of getting a genetically normal embryo is less in your case !) If you have money, patience and determination you can play the IVF game for 'n' number of times with the hope that it will click one day. You might find success in the next attempt with your own eggs or after 10 attempts or never ! Now you have to decide whether you will go by luck or by scientific evidence and knowledge!

Good luck for whatever you decide. If I were you I will put my knowledge first and try to have a baby with donor eggs. Any baby you love will be yours and by doing this you give your husband a very good chance for propagating his genes. There is a technology available to select genetically normal embryos but again you need more eggs and eventually more embryos so that it will be easier to find couple of good embryos from the cohort.

NB: If the woman who ask this question is of younger reproductive age (less than 35 years), her chance of success is better (only slightly) than a woman of advanced maternal age (35 and above aged woman). Her chance of success is slightly better because her egg quality might equal to that of women of her age.  But her success rate cannot equal to that of women of her age since she is running out of eggs and the chance of success is better in IVF if there are more eggs to work with ! What if, if the woman is of advanced maternal age but with normal ovarian reserve (good AMH and FSH value)? Unfortunately her chance of success is not any better than a woman of her age. This is because eventhough she has good ovarian reserve, with age, her egg quality declines irrespective of the quantity. So her chance of success will not be equal to that of a younger woman with normal AM H and FSH value.

Basic Infertility Workup Which Every Couple Struggling to Get Pregnant Must Do !

Please do a complete workup before starting treatment haphazardly!

You need to do ALL  the following simple medical tests:

Semen analysis for your husband ( to check his sperm count and motility). Read more at www.drmalpani.com/sperm.htm

Blood tests for you for the following reproductive hormones – FSH ( follicle-stimulating hormone),LH ( luteinizing hormone),PRL ( prolactin) , AMH ( antiMullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs). Do this from a reliable lab such as SRL ( http://www.srl.in/). Day 1 = Day the period starts.

HSG ( hysterosalpingogram, X-ray of the uterus and tubes, www.drmalpani.com/hsg.htm)  on Day 8 of your cycle ( to confirmYour fallopian tubes are open);

The vaginal ultrasound scan on Day 10-11 should check for the following. A. ovarian volume b. antral follicle count c. uterus morphology d. endometrial thickness and texture

Courtesy : Dr. Aniruddha Malpani, Malpani Infertility Clinic, Mumbai, India

What can I do differently after a failed IVF cycle to increase my chances of success ?

This post is for you Anu (thanks for the kind suggestion!) and for all my blog readers! I will be very happy if you could ask me more questions. Remember, every of your questions and doubts will help others who are in a similar situation too !

"Manju, what did you do differently this cycle ? You have undergone 7 embryo transfers without success, so what helped you to succeed this time ?" This is the question I am asked most frequently now-a-days.  I wonder how people came to the conclusion that doing something different helps in achieving success ! Here are my answers.

1. Can you tell us something about your medical history ?

My reason for doing IVF is tubal factor infertility. At the age of 29 I was diagnosed with a hydrosalpinx in the left tube and I had to remove it. My right tube is present but non-functional due to adhesions. I started my IVF journey at the age of 29. I learned that women with tubal factor infertility have very good chance of IVF success and now I am 35 years old and pregnant with embryos that were created from eggs extracted from my ovaries when I was 33 years old ! I expected my IVF journey to be short but I it took almost 6 years to get pregnant and carry it past the first trimester !

2. Is there any problem with you other than non-functional fallopian tube ?

I was diagnosed with PCOD and I am insulin resistant (this tendency run’s in my dad’s family!). I have been on metformin 1500mg from the age of 25. While on metformin , I had regular periods. Many different tests were done on me during my IVF attempts and after my miscarriage. The following “abnormalities” were found :

• Compound heterozygous MTFHR mutation – I started taking 5 mg folic acid because of this diagnosis.

• I was tested for HLA compatibility with my DH. They found 2 or more HLA loci compatible with my husband. This test was done immediately after my m/c. I didn’t have much knowledge then. I thought let them do whatever is needed so that I will have my baby. My RE in Germany asked me to undergo paternal lymphocyte immunotherapy to help my embryos implant and prevent further m/c. I didn’t even understand the principle behind the therapy then. I asked my RE but he had no clue either ! The therapy was performed like this : they isolated lymphocytes from my husband’s blood, injected them under my skin and monitored my blood after 1 month to see whether I had developed antibodies against his HLA ! They said “you have to get pregnant within a year, otherwise the antibody titer falls and you have to repeat this therapy again”. This therapy was done in 2009. I never conceived in my further attempts. I really started to panic whether this therapy did any irreversible harm to me and then I started to explore what this therapy really means. Then Dr. Malpani asked me whether I could write about it. During that time I learned a lot about HLA matching and about the “mindless” therapy I underwent for no good reason. My current pregnancy shows that HLA matching between husband and wife has nothing to do with successful embryo implantation or early pregnancy loss ! Please read : http://myselfishgenes.blogspot.de/search?q=HLA

•  I have PAI 4g/4g mutation. The literature says PAI 4g/4g mutation predisposes me to insulin resistance. Another information I now know about this is, this mutation carriers may have increased risk for HELLP syndrome.

3. What kind of therapies were suggested by your REs ?

As mentioned already , I underwent paternal lymphocyte immunotherapy in Germany 4 years ago without it helping at all! My RE in Germany firmly believed that giving me heparin will help. I asked Dr. Malpani about it once and he said it was unproven and not necessary. I was so comfortable with Dr. Malpani’s conservative approach. He never wanted to experiment on me with any therapy which had no evidence to back it. His confidence made me very confident too. He believes firmly that embryo quality matters the most and that is what is my current pregnancy shows. I never again thought about using heparin – after all , I don’t have any problems with blood clotting. I did not even use baby aspirin this successful cycle.

4. How many IVF cycles have you done and where ?

I have done 6 IVFs and 3 FETs (9 embryo transfers altogether). The last FET was a success and I am currently 11 weeks pregnant with twins. I have done 5 IVFs and one FET in Germany without success (although I conceived in my 2nd IVF , that pregnancy was short lived !). I did my 6th IVF with Dr. Malpani of Malpani infertility clinic. You can see all my IVF cycle details (dosage of medicines, how many eggs retrieved, how many embryos were obtained and how many were transferred to the uterus ) in this post : http://myselfishgenes.blogspot.in/2012/05/my-ivf-journey-timeline.html. You can also read about a more detailed description of how I ended up with more eggs in my 6th IVF in this post : http://myselfishgenes.blogspot.in/2012/08/from-3-eggs-at-age-of-29-to-24-eggs-at.html

In my 6th IVF cycle with Dr. Malpani, I got more eggs than all my other 5 IVF cycles combined. Dr. Malpani allowed me to tweak the protocol in the beginning a bit , but I do not think that could be the sole reason for a high egg yield. I took 75 mg DHEA for 8 months (as per Dr. Malpani’s recommendation) before my 6th IVF and I also stopped metformin which I was taking for years. I also didn’t use Gonal F (a recombinant form of FSH which is a highly purified form) during my 6th IVF. I used a much cheaper version of FSH called Menopur ( a crude form of FSH preparation which is isolated from the urine of menopausal women). Might be a combination of everything or just the increased dosage of FSH which Dr. Malpani started me on from day 1 of cycle worked its magic and I got 24 eggs in that cycle. I am sure Dr. Anjali’s egg retrieval skills played a major role too.

5. What kind of transfer was your successful cycle – was it a fresh embryo transfer or frozen embryo transfer ?

I got 24 eggs in my 6th IVF. 3 good embryos were transferred during that cycle (fresh transfer) and 7 embryos which were of good quality were frozen. Out of 7, 2 were blastocysts and 5 were 8-celled day 3 embryos.

My fresh transfer was not successful. I had a great endometrial lining during that cycle. It was around 10mm, trilaminar. The next was a FET where we transferred 2 frozen blastocyst stage embryos. Again no pregnancy was established- the embryos failed to implant. We thought my poor endometrial lining (only 6.5 mm) was to be blamed for this failure (I used G-CSF for this cycle as uterine infusion to help my endometrium grow but it was of no use, my endometrium didn't respond well to G-CSF as expected).

I got a BFP with my recent FET during which my endometrial linig was only 6.7 mm. We transferred 3 8-celled embryos which were graded excellent. The remaining two 8-cell embryos ( out of the 5 frozen ) were grown to blastocyst and were refrozen again. Out of the three transferred two implanted and I have completed 11 weeks as of 28.8.2013 - and so far so good !

Remember, FETs are much more successful than fresh transfers now-a-days ! So find a clinic which uses vitrification for embryo freezing ! Please read this post for more info : http://myselfishgenes.blogspot.de/2012/12/in-past-standard-was-transfer-best.html

6. So what did you do differently this time ?

To be very honest, I didn’t do anything differently.

Many things went wrong this cycle. I had a poor endometrial lining again. It was only 6.7mm at the time of transfer ! I took 4 progynova (estrogen, 2 mg each) from day 1 of my menstrual cycle until day 21. Usually I ovulate at around day 21 so I thought why not give my lining a bit more time to grow. Since my endometrium was thin I just continued taking 4 progynovas until day 21. But the lining didn’t increase its thickness beyond 6.7 mm. I didn’t use lupron this cycle to suppress my pituitary. We actually thought lupron use might have caused poor endometrial growth but later we found that lupron was not the culprit (omitting lupron didn’t make any difference in my endometrial response to progynova). Since I didn’t use lupron this successful FET, at around day 7 of taking progynova I had an early LH surge (which indicates ovulation !), my LH at that point was 22 IU/l. But my progesterone was within pre-ovulatory range at that point and I didn’t have any follicles in my ovaries ripe enough for ovulation. Hence there was no chance for ovulation. So we continued with the cycle. Just 5 days before transfer I ended up with severe pain in my stomach (perhaps amoebiasis due to eating in restaurants in Mumbai !), so I ended up taking metrogyl 400 mg twice a day and I stopped it just the day before embryo transfer !

So with a lining of 6.7 mm, a premature LH surge and taking massive doses of metrogyl (actually this wouldn’t have had any ill effects anyway !) we carried on with embryo transfer. Dr. Malpani was not so happy that I decided to transfer my precious embryos to my poor lining but he was happy to let me decide. I always told him “Dr, I have the best lining in the whole world”.

7. What went right this cycle ?

Lot of things :)

• I believed in what I did. My poor endometrium (as per so many scientific publications !) did not deter my spirit. I didn’t waste my time thinking that something is wrong with my endometrial lining and I didn’t do anything to improve it. I didn’t take massive amounts of estrogen nor did I take baby aspirin or any other blood thinners. No Viagra too :) After thinking a lot, I came to the following conclusion - My endometrium grew very well during all my fresh IVF cycles (10-12mm). This clearly showed that I had no underlying problem (fibroids, adhesion, infection etc) with my uterus. I confirmed it with a hysteroscopy which took just 5 minutes. The doctor who did hysteroscopy concluded that I had a small uterus but there was nothing to worry about – after all there will be lots of biological variations in the size and shape of uterus ! Since my endometrium grew well in fresh cycles (where enormous estrogen is present in the body) any end-organ damage is ruled out. During FET my estrogen levels (on progynova) rose to about 200pg/ml and this is in the normal range for an ovulatory cycle (200-300 pg/ml). With that amount of estrogen in my body, my endometrium could only grow upto 6.7 mm. I thought well and good, that might be my body’s natural response. I see so many women in infertility forums worrying about their lining thickness and trying so many different therapies to increase the thickness. From my experience I would say, If you do not have any underlying problem in your uterus , then do not worry about the lining thickness. The receptivity of the lining is what matters the most, and a thin lining can be receptive. What matters most is your embryo quality. If endometrial lining is that important for embryo implantation how come ectopic and extra-uterine pregnancies occur ?

• I had wonderful people around me who made me so comfortable during embryo transfer. Dr. Sai’s gift to me did magic to my confidence level ! I suggest every IVF clinic give their patients some cute gifts before ET to boost their morale (how much does a gift cost when compared to the huge amount they charge :)

•  I was so relaxed and was ready to face whatever comes my way. I always have plan B, C, D etc

•  I believed in the competency of embryologist and my Dr - I trusted them !

• My embryos looked so beautiful-thanks to the embryo creating skills of Dr. Sai !

• My loved one’s prayed for me. My mom sent me to the ET room like a warrior, she applied some holy ash on my forehead ( and my DHs’ as well for extra god luck) . I did feel like going to a war front :) The love I felt in her gesture and HER prayers, the sacrifices she made (removed her hair, gave up eating sweets and pickles – the things which she likes most !) did play a major role in achieving this BFP.

8. Manju, did you take any supplement ?

I personally don’t believe in taking supplements to improve endometrial lining or its receptivity. So I didn’t take anything at all. All I took was 5 mg folic acid, 500 mg metformin (I am insulin resistant !), 4 progynovas and uterogestan ( progesterone) as instructed by my Dr and that is it. Please read : http://myselfishgenes.blogspot.de/2013/01/does-taking-supplements-help-ivf.html

9. How about bed rest ? Did you restrict your activities ?

I was on my feet 5 minutes after ET . I went back to hotel room, had my dinner and slept. From the next day onwards I took it easy, meaning, I didn’t engage in any strenuous activity. I went out for shopping, walked to a nearby restaurant to have my lunch, roamed with my mom and husband in the evenings. No bed rest at all ! Please do not torture yourself by lying down in bed for 3 or 4 days-it doesn’t help. It can harm your physical and mental well-being. Please read : http://myselfishgenes.blogspot.de/2013/02/will-embryos-fall-out-after-embryo.html

10. Can I fly immediately after ET ?

Yes, you can. But I stayed in Mumbai for 5 days after ET. The sole reason was to spend time with my mom. I get a chance to see her only when I come to India . She lives with my old granddad , and takes care of him, so it is not possible for her to visit me in Germany. I was not able to take holidays because I needed holidays for my treatment. I was so happy to be with her and my DH those 5 days. They both treated me like a queen :) (few joys of being infertile !)

11. What was your thyroid level pre-pregnancy ?

I was diagnosed with sub-clinical hypothyroidism (TSH 5.5) few years back. So I am on thyroxine. I do not have TPO antibodies. I tried hard in the beginning to keep my TSH around 1, as it was said that a TSH of close to 1 is ideal for achieving a pregnancy. I took 75 mcg of eltroxin and my TSH was around 1.3 or so but I felt like crap. I felt too hot, got frequent cramps in my leg and lost weight. After sometime I gave up worrying about the numbers on the papers and tried to concentrate on my body. I took 50 mcg and my TSH was around 3.5. I felt good. I had no symptoms of hypo or hyperthyroidism. So I maintained my dosage of 50 mcg. Last week during my visit to gynecologist (at around 10 weeks of pregnancy) they checked my TSH again and it was 0.88 to my surprise. As hCG hormone increases TSH levels tend to fall. Such increase in thyroid function is normal during pregnancy I learned. If you have thyroid autoantibodies it is wise to regulate your levels before getting pregnant but please listen to your body rather than obsess about the values on the lab report. Maintain a dosage which is comfortable for you and do not try to bring your TSH too low if you are not comfortable with this . A large scale study didn’t show any association between sub-clinical hypothyroidism, chance of conception or miscarriage. Women with TPO antibodies are prone to increase in their TSH (due to declining thyroid function) during pregnancy. So please check your TSH during pregnancy and adjust your dosage accordingly. Remember, severe hypothyroidism has to be treated as it can lead to abortions and premature deliveries.

12. Is there any advice you can offer me to increase our chance of IVF success ?

Yes, for sure !

• Select a competent clinic. Go to the best IVF clinic available nearby. It does make a lot of difference.

• Learn a lot about the IVF procedure. Opt for information therapy before IVF therapy.

• Ask your clinic to show you your embryos. Educate yourself about how your embryos should look according to their age. Do not say I trust my doctor so I do not have to look at my embryos. There is a old saying “ Believe in God but lock your car”. Be wise and protect yourself from fraudulent activities which exist in the field of IVF. If someone cheats us once, they are fools . If they cheat us twice, we are. Please read : http://myselfishgenes.blogspot.de/2012/10/what-can-i-do-if-my-ivf-doctor-does-not.html

• Demand a copy of your medical records.

• Do not think IVF is a single attempt process. The younger you are and the more the eggs you produce , the more likely you are to succeed. So have patience and be persistent in your attempts. Be flexible and open to different treatment options (like donor eggs, donor sperms etc)

• Do not doubt your uterus, in most cases the culprit is the egg quality ! Please read : http://myselfishgenes.blogspot.de/2012/12/why-did-my-ivf-cycle-fail.html

• Trust the doctor you selected, appreciate them for the work they do for you, be friendly with the hospital staff. If you treat them only as workers you will fail to get their warmth and compassion when you need it the most !

• Please do not undergo any unproven therapies like IVIG, LYMPHOCYTE IMMUNOTHERAPY, USE OF STEROIDS, BLOOD THINNERS (if you are not diagnosed with clotting problems) which are not scientific established when undergoing IVF. IVF is a game of probability. If you are young and lucky enough you will find success soon. Otherwise it might take a few more attempts. I recently received a mail from an infertility specialist who conceived in her 17th attempt. An IVF failure doesn’t mean something is wrong with your body and you need to “correct” something. Human reproduction is a remarkably inefficient process. A normal, fertile couple needs on an average 12 months to conceive. If they don’t conceive in their bedroom in 4 months, they do not go to the doctor and ask him to “correct” something in their body- you don’t have to either!

Please read : http://myselfishgenes.blogspot.de/2012/07/my-advise-for-someone-starting-their.html

13. Can you provide me with an IVF checklist – what kind of tests are a must before an IVF cycle ?

• Check your anti-muellerian harmone (AMH) and antral follicle count (AFC) to test your ovarian reserve.

• Check your Thyroid stimulating hormone (TSH). If it is not within the normal range please see an endocrinologist to further asses the reason for thyroid dysfunction.

• If you are diagnosed with PCOD and have high BMI, check your fasting insulin. If the fasting insulin is high, life-style changes along with metformin use will give you a better chance for IVF success. Metformin use during the first 12 weeks of pregnancy was shown to reduce miscarriage rate in PCOD women.

• Check your blood sugar to make sure you don’t have diabetes. This test becomes very important if diabetes runs in your family.

•  Hysteroscopy to check your uterus if any abnormality was detected using ultrasound images.

14. What did your infertility experience teach you ?

I will never consider my infertility experience as ill-fate. Infertility taught me many good things, introduced many wonderful people in my life, and made me knowledgeable. I have an infertility blog (thanks to Dr. Malpani !) now which helps many people and all the writing I did and the knowledge I gained because of that made me very confident. The confidence thus obtained and emotional protection it gave me is also one of the reasons for my success.

The lessons I learned :

• Never believe in unproven therapies that exist in the field of IVF and waste your time, energy and money.

• IVF is a game of probability, you may need few attempts before finding success. If you do not find success soon, It doesn’t mean your body is defective.

• There are only three main components important for IVF success : good embryo, efficient embryo transfer and a uterus without any defects. Your embryo quality is decided by two factors : your age and your clinic’s competency in producing good embryos and to some extent the quality of sperm (perhaps a 10%). Embryo transfer (please read : http://myselfishgenes.blogspot.de/2013/02/embryo-transfer.html) depends on two factors again : the ease with which your uterus can be accessed and your doctor’s skill. Your uterine cavity must be free from adhesions, scar tissues and certain type of fibroids which might interfere with embryo implantation.

• The competency of your IVF clinic matters a lot ! Always asses your clinic’s competency by how your embryo looks. Please, please do see your embryos before transfer and demand pictures of your embryos.

• Patience and persistence during times of infertility provides rich dividends. 

• Helping others is the best way of helping yourself.

• Find good emotional support.

• Have healthy hopes and weed out unhealthy expectations.

• Infertility struggle doesn’t end when you get a positive BFP. The real struggle starts then and doesn’t end until you have your baby. Even if you get a positive BFP be cautiously optimistic. I was totally heart-broken with my m/c after my 2nd IVF attempt – I wish someone could have warned be about the possibility of m/c. 1 in 4 pregnancies end too early and the risk of m/c increases as your age increases.

• Enjoy the journey !

15. I do not have enough money to do IVF, IVF is too costly for me – what should I do ?

This is a tough question and a question which breaks my heart all the time. I will try to suggest some possibilities :

• If you are ready to donate half of your eggs to women who are in need of egg donation , then you are entitled for free IVF in some clinic. Please do find out if this is feasible. But for egg donation you must be within 30 years of age.

• Some clinics offer a money-back guarantee programme. You have to pay for 3-4 cycles and if your IVF is not successful, they then repay 100% of your treatment costs . This gives you some financial security . You can check out an example of such a program at http://www.drmalpani.com/guaranteedpregnancy.htm. Not everyone qualifies for this programme, and age matters , so enquire about this option in your clinic.

•  Bargain – there is nothing wrong in bargaining with your IVF doctor. Doctors are humans too and if you could give a valid reason and show proof that your income is low , many doctors might help you. I know in Dr. Malpani’s clinic they do free cycles for people who couldn’t afford IVF. But again if you are healthy and young the chances are more that your doctor is willing to help you.

• The most important solution is to fight for the rights of infertile couples. We need to pressure the government to pass rules which ensure that IVF treatment is covered by medical insurance. It will take a lot of effort and lots of people to achieve this.

Poor Ovarian Reserve

(A) Follicular dynamics and illustration of the folliculogenesis process in physiology. (B) The possible mechanisms generating POI may affect different stages of folliculogene © 2011 Society for Endocrinology
POI - Primary Ovarian Insufficiency or premature ovarian failure

What is poor ovarian reserve ?

Poor ovarian reserve or diminished ovarian reserve ( DOR) is a condition where the amount of eggs which have the potential to give rise to a healthy baby decline.  Most women develop poor ovarian reserve 6 to 8 years before reaching menopause. As women age, their ovarian reserve declines too. But there are some women who develop diminished ovarian reserve much earlier in their reproductive period and their ovarian age does not match their calendar age . In 90% of cases there is no explanation (idiopathic) why such premature ovarian aging happens.  But there are a few explanations for premature ovarian aging . These include :

• Mutation in genes which codes for proteins that are involved in reproductive function
• Autoimmune disorders
• Certain viral infections
• Chemotherapy or radiation exposure during cancer treatment
• Surgery on the ovaries to remove cyst , or to remove endometriosis implants

Read more at : http://blog.drmalpani.com/2010/04/poor-ovarian-reserve-as-cause-of.html

http://www.drmalpani.com/ovarianreserve.htm

How will I know whether I have poor ovarian reserve ?

There are three important tests which are routinely used in the field of ART for predicting a woman’s ovarian reserve :

1)      Measuring Anti-Müllerian Hormone levels (AMH) in blood

2)      Measuring FSH levels in blood

3)      Counting antral follicles (AFC count) present in your ovaries using vaginal ultrasound

Read more at : http://www.drmalpani.com/ovarianreserve.htm

These are very simple tests to perform and the information they provide is pretty accurate.  

How does poor ovarian reserve compromise IVF success ?

• Women with poor ovarian reserve have fewer antral follicles in their ovaries. Antral follicles are the ones which grow in response to ovarian stimulation. This is why they produce fewer eggs when their ovaries are stimulated with gonodotropins (FSH and LH), which reduces their chances of IVF success .
• Older women with poor ovarian reserve have poorer egg quality too. Older eggs are more prone to genetic errors , like aneuploidy. Embryos formed from these eggs either fail to implant or fail to achieve a healthy pregnancy.

I am diagnosed with poor ovarian reserve , will I be able to have my genetic child ?

Women with poor ovarian reserve have a poor prognosis with IVF treatment. However, younger women who are diagnosed with poor ovarian reserve have a better chance of success than their older counterparts. This is because these younger women still produce some eggs which are of good genetic quality. This means they produce fewer eggs , but the quality of their eggs is comparable to women of their age. This improves their chances of achieving a pregnancy and carrying a baby to term is high too. 

If you are diagnosed with poor ovarian reserve, it is wise to try one IVF cycle by stimulating your own ovaries , before deciding what to do. Remember, the final proof of your ovarian reserve status depends on how well you respond to ovarian stimulation during IVF. There are women who have very good AMH levels, and yet they respond poorly to ovarian stimulation - and vice versa. Theoretically, as long as you produce eggs, you have a chance of achieving a pregnancy.  During your IVF cycle, if your doctor finds that even with maximal stimulation, you are unable to produce a decent amount of eggs ; and  if those eggs give rise to very poor quality embryos, you may want to consider the option of using donor eggs. This is a decision only you can make !

How will I know whether I have a decent chance of success when pursuing IVF ?

When a clinic advertises that they have a  40-50% success rate per IVF cycle, it doesn’t mean this applies for every woman who undergoes IVF in that particular clinic. Even though it is hard to predict whether a woman will conceive in a particular IVF cycle or not, it is possible to calculate her chances of success , using certain parameters. The chance of achieving success depends on:

• Age of the woman – younger you are greater are your chance of success !
• Your ovarian reserve- If you have decent number of usable eggs left in your ovary, you are more likely to find success. Your ovarian reserve depends mostly on your age , but there are women who suffer from poor ovarian reserve at a young age as well .  How do you test your reserve ?
1. Anti-müllerian hormone levels (AMH) in blood, measured on any day of your menstrual cycle. AMH is produced by the antral follicles which are present in your ovary.
2. FSH and e2 levels in blood, measured on day 3 of your menstrual cycle
3. Antral Follicle Count (AFC) –  scanning your ovaries using a vaginal ultrasound probe on day 1-5 of your menstrual cycle will allow your doctor to count the follicles which are between 2-7 mm is size. These follicles are called as antral follicles. The higher your antral follicle count, the better your ovarian reserve, because these are follicles which will grow when you are superovulated.

•      A healthy uterus which is able to develop good endometrial lining  !