“Poor Ovarian Reserve in Young Infertile Patients May be Best Treated First Using Natural Cycle IVF”

So says Dr. Isaac Kudoch in the November, 2011 journal Fertility and Sterility.  Hello everyone.  Dr. D here to discuss this article and of course, add some personal experience performing Natural Cycle IVF (NCIVF) in young patients with poor ovarian reserve.

Let me illustrate how NCIVF helped C.M., a 32 year old lady with a 3 year history of primary infertility and poor ovarian reserve.  She came to see me for consultation in December, 2010.  In 2009, she underwent a diagnostic laparoscopy which revealed stage 4 severe endometriosis and an ovarian endometrioma was removed.  Her serum AMH level was 1.0 with a poor antral follicle count.  We decided to first try stimulated IVF.  I stimulated her ovaries using high doses of gonadotropins in a “Lupron – flare stimulation” which, in my experience, produces the best follicular responses in patients who have diminished ovarian reserve.   Unfortunately, her ovaries responded poorly to her stimulation drugs making only 2 eggs and her estrogen level fell, so her cycle was cancelled.  It was clear that stimulated IVF was not going to work for her.  She then decided to just try natural cycle artificial insemination, which not surprising to me, also failed after 2 attempts.  Since, her menstrual cycles were regular, I again recommended NCIVF.

In August, 2011, we transferred a single blastocyst embryo in her first treatment with NCIVF but this was unsuccessful.  She immediately tried NCIVF the following month and this time it worked.  In fact, it worked only too well.  On October 11, 2011, we diagnosed a twin pregnancy (monozygotic twins)!!!  Everyone, including me, was in shock!  However, a subsequent sonogram showed only one viable fetus.  Nonetheless, the couple were ecstatic and off to their Obstetrician. 

So, perhaps Dr. Kadoch is right.  Maybe we should first perform NCIVF in young patients who have poor or diminished ovarian reserve rather than proceeding directly with stimulated IVF since we know that such patients often poorly respond to ovarian stimulation drugs even when using high doses of gonadotropins as it was in this patient’s case.  

In Dr. Kadoch’s article in Fertility and Sterility (2011;96:1066-08), he notes, “The biological advantages of NCIVF may provide a single oocyte of better quality and thus allow the transfer of a healthier embryo into a more receptive endometrial environment.” In my experience, the quality of an egg or embryo is much more important than quantity.  Thus, all IVF centers are now transferring fewer but much higher quality embryos than we formerly transferred even a couple of years ago.  I will conclude by saying that all of this is terrific news offers much hope for patients with poor ovarian reserve who otherwise were facing egg donor IVF or adoption as their only options.  Dr D