From High Responder to Low Responder: Natural Cycle IVF Success

Infertility can certainly be a wild ride. Here is an extreme example of how patients can ride that roller coaster of emotions...

DK is a 38 year old who came to see me in September 2008. She and her husband had undergone fertility treatment 3 years earlier at another center and conceived with CC/FSH/IUI but had a quintuplet pregnancy that ultimately ended up as twins. They were very worried about having another multiple pregnancy and wished to discuss options.

However, as part of the evaluation her FSH was found to be 14 with a normal E2 but an AMH of<0.1 and an antral follicle count of 2-3. Although they had originally considered stimulated IVF with single embryo transfer that option seemed unlikely given her diminished ovarian reserve. After failing a few natural cycle IUIs they decided to try Natural Cycle IVF in 2009. Their first Natural Cycle IVF was a biochemical pregnancy. They tried Natural Cycle IVF again in June 2009 and were successful. She was sent off to her Ob Gyn with a normal looking pregnancy.

But the roller coaster was just getting cranked up....

She underwent a CVS given her age and the results showed that some of the cells were normal but some were trisomy 9 (not compatible with life). Her Ob Gyn was suggesting a D&C so she called me just to let me know what was going on. I fired off an email to Dr Mark Hughes (the world's smartest geneticist). Since we know that the 8 cell human embryo can contain both normal and abnormal cells (limiting the usefulness of PGS) I was thinking that maybe the CVS results represented a case of placental mosaicism where the baby is normal but the placenta has both normal and abnormal cells. Dr. Hughes confirmed that was indeed possible.

The couple elected to continue the pregnancy and undergo amniocentesis. The amnio was totally normal and all sonograms were normal. She went full term and just went home from the hospital today after delivering a healthy 9 pound baby!

So this case demonstrates many interesting points. First of all, is Natural Cycle IVF appropriate in a couple with normal tubes, normal sperm and previous pregnancy? The answer was a resounding "yes" in this case. Secondly, can ovarian reserve drop dramatically in just a few years? The answer is "yes" and although this case is a bit unusual in that the patient went from quints to diminished ovarian reserve in just 3 years. Thirdly, this case does demonstrate again the limitations of PGD/PGS and even CVS in cases of mosaicism. Finally, this case shows how important it is to consider all options especially when confronted with an unexpected result (like mosaicism on CVS).

I am so happy for this family and considering that I am not a big lover of roller coasters, all I can say is a few more wild rides like that one and I probably wont have any hair left at all!

DrG