Managing DOR at Dominion Fertility

Here in Washington DC we love acronyms. The entire government is one big acronym....DHS, HHS, DOJ, IRS, etc, etc.

In medicine we are similarly guilty of using incomprehensible terminology. We say "ick-see" (ICSI) but spell out IVF. We throw around terms like IUI, DI, AI without a second thought.

Last week during a consult a patient confided in me that she had "door." I didn't want to sound like a dolt so I just rolled with it until she asked me again if I had a lot of patients with "door." Hmmm. Now this past week I was under the weather from some unknown cause and needless to say I was a bit slow on the uptake. Finally, the synapses clicked and I got it..."door" = "DOR"= diminished ovarian reserve.

Diminished ovarian reserve refers to the clinical situation of a patient who has a limited number of follicles (usually for unexplained reasons) and therefore whose response to fertility drugs is usually very disappointing. Many patients with DOR fail to get egg collection in a stimulated IVF cycle and end up getting canceled after spending thousands of dollars on fertility medications that were ultimately of no benefit.

There have been numerous suggestions as to what drug protocol is best to use to stimulate such patients: microdose lupron flare, stop lupron, no lupron, clomid/gonadotropin combo, low dose stim, high dose stim, snake oil and pixie dust.... In addition, many adjuvant drugs have been used: DHEAS, growth hormone, thyroid hormone, MiracleGrow, etc.

There is no real harm in trying these protocols (except to one's bank account and also the emotional exhaustion that sets in when repeated cycles have failed to get off the ground). 

So at the end of the day patients who have repeatedly failed to get to egg collection are usually told that their only options are egg donor or adoption or quit trying. However, one benefit of having a well-established Natural Cycle IVF program is the profound satisfaction I get from receiving birth announcements (sometimes with yummy cookies attached) from patients who were previously told that their situation was hopeless. So although I totally agree that donor egg IVF or adoption are higher yield options in terms of success, these are not always viable choices for all patients. In addition, just the act of trying NC IVF represents an important bridge for some patients.

So I guess the take home lesson is that in our office is that if you have DOR that doesn't mean I am going to show you the DOOR. (ugh, terrible pun but couldn't resist).