Question of the Day: Diminished Ovarian Reserve

Yesterday I gave Grand Rounds at Inova Fairfax Hospital in Falls Church, VA. Fairfax is a very large hospital routinely performing over 10,000 deliveries annually. There are over 100 Ob/Gyn physicians on staff and I have the title of Division Director of Reproductive Endocrinology and Infertility. As Division Director, I am responsible for ensuring educational content at the weekly departmental meetings that have an educational purpose. These meetings are called "Grand Rounds" in order to distinguish them (I guess) from "Not-so-grand Rounds."

As a child growing up in a medical household I often heard my Dad and Brother speak of "Grand Rounds." But I though they were saying "Ground Round" which was this great chain of burger restaurants in New England that was famous for providing bowls of popcorn and peanuts to all diners as they sat down. Of course, we kids would stuff our faces full of popcorn leaving no room for the overpriced burgers which may explain why we rarely went to the Ground Round for meals!

So given that the topic of ovarian reserve has been on my mind, here is today's Question of the Day:

I have high FSH so my RE says I'm not a good candidate for regular IVF but I've done 3 rounds of meds and IUI with NO success. Would Natural Cycle IVF (NCIVF) be better?


DrG answers:

The short answer is "yes." The long answer is "yes, probably."

First of all, a high FSH suggests diminished ovarian reserve and a probably poor response to fertility medications. BUT a high FSH does not mean that there is not a good egg left in the ovary. The odds of having a good egg is very dependent upon age. The older the patient, the lower the odds of success. This patient didn't tell me her age. Younger is better. Less than 40 is better than over 40. Less than 44 is better than over 44 (although we had had a delivery in a 48 year old patient following NC IVF).

Secondly, I usually encourage patients with borderline elevated FSH levels to consider stimulated IVF as a first choice. If the patient fails to respond then you can do an IUI and then re-evaluate. I have seen many patients demonstrate decreasing responsiveness to FSH shots - 7 follicles then 4 follicles then 2 follicles. If at that point the patient switches to IVF she will likely get canceled prior to retrieval.

So what about the proven low responder to medications. Is NC IVF an option? Yes, we have had some amazing success with these patients. Are donor egg/embryo/adoption more likely to work? Yes, but those options may not be acceptable to all patients. That leaves NC IVF and I think that one can consider this a viable option for patients with diminished ovarian reserve.

I have a 41 year old patient who had FSH levels in the 18-26 IU/L range on several occasions. Her AMH was <0.16 and her antral follicle count was 2. Her husband had male factor (previous vasectomy and reversal). Her insurance company denied her IVF coverage because of the high FSH. She attempted NC IVF and her FSH level was 40 IU/L on day 3 of that cycle. Yet she conceived and is currently in her 3rd trimester with normal genetic testing and a healthy baby. Go figure.