ASRM Update #2: High FSH and Zombies

Yesterday at the Post Graduate Course that I attended there was a great deal of discussion about ovarian reserve testing (ORT) and what it really means. As I have indicated in several past blogs ORT predicts response to fertility drugs and age predicts egg quality. So ORT does not indicate if a woman has any good eggs left...the only proof of a good egg is of course the delivery of a healthy baby. The overall consensus was that ultrasound and antimullerian hormone (amh) were the best indicators of ovarian reserve and response to fertility drugs. Unfortunately we will probably never have a true test of egg health except repeated treatment failure which is a pretty expensive way to test for healthy eggs!

The following case was presented: 38 year old with no previous pregnancies and an FSH of 18. The question raised was what additional testing should be performed and what treatments offered. First of all the question we asked whether the patient was infertile. Many ObGyns check FSH levels on older patients even before they have tried to conceive. This leaves the patient with a seemingly bad prognosis but she hasn't even tried to conceive yet! So remember that patients with high FSH levels can conceive without assistance but if she tries IVF her response may be suboptimal with a high rate of cancellation.

I presented the following perspective....The data shows that patients with diminished ovarian reserve have a high rate of failing to make it to retrieval in spite of spending thousands of dollars on medications. On the other hand, if these patients do make it to transfer then pregnancy rates are acceptable. In a patient like the one presented it seemed likely that her response to medications will be suboptimal. If she is a one egg a month person, either with or without drugs, then I believe her options are to 1) try on her own if tubes and sperm are ok, 2) try IUI with no drugs or 3) try Natural Cycle IVF. The fact that NC-IVF is even an option has given these patients hope even if many other clinics have refused to attempt stimulated IVF. Last month I had a patient just like the one presented above and we had success on the first cycle.
There is nothing wrong with attempting stimulation in such a patient but the chance of success is clearly much reduced because of the high rate of cycle cancellation. NC IVF could still be looked at if the stimulation was really poor.

OK so what about the zombies.....well as I was leaving the convention center there were thousands of people in the streets around the 16th. St Mall dressed up as zombies. The screaming and moaning was really disturbing. There was a zombie Santa and a zombie Elvis and a zombie spiderman just to name a few. Occcasionally, a human (designated with an x on his/her back) would be chased down and "eaten." Yup, it was quite a sight to say the least.

Apparently the Denver Zombie Crawl broke all previous records and just think I was here to see it,

http://www.examiner.com/zombie-in-denver/2010-denver-zombie-crawl-breaks-world-record