Premature Ovarian Decline

Recently, a 24 year old woman and her husband came to consult with me. I was the third Reproductive Endocrinologist she had seen in the last few months in her quest for assistance in her desire to conceive a child.

After her first year of attempting to conceive, she sought out the opinion of her Ob/Gyn who assured her that based on her youth, her menstrual regularity, and her strong family history of fertility, she had nothing to worry about and she should continue to try every month.

After another year of such efforts with no success, she went to a Reproductive Endocrinologist who determined that she had a day 3 FSH value of 63 mIU/mL and an undetectable AMH level. The devastating diagnosis of premature ovarian decline had been made. The doctor’s recommendation was to proceed to egg donor IVF, as all other assisted reproductive technology would likely prove futile. As it turns out, this young woman – for both personal as well as strong religious convictions – cannot turn to the option of egg donation IVF, as effective an option as it may be.

Her first Reproductive Endocrinologist outright refused to treat her using any other modality, as did her second. This is the part where I came in. And to end the agonizing conjectures, yes, I will treat her using methods involving her own eggs.

My preference would be to do natural or “EZ-IVF”, stockpile embryos over the course of a few months, and then transfer a few embryos en masse. Why this way? Because natural or low stimulation IVF is relatively inexpensive, easy on the system, and often requires no post-retrieval down-time. Because, like it or not, IVF is still the most effective treatment we have, even if your egg reserve is poor. When you are running out of eggs, the best thing one can do is acquire the eggs while you still have them.

Transferring the embryos right away is great if you achieve a successful pregnancy right away. But what if you get a chemical pregnancy? An ectopic pregnancy? A miscarriage at 10 weeks? One could therefore lose anywhere from 2 weeks to 6 months waiting for this sad scenario to play itself out before attempting to try again. And in that time, egg reserve falls lower still.

I do not fault infertility specialists who choose to not treat such patients outside the context of egg donation IVF. It is ethically justifiable and appropriate to avoid a treatment that can hurt and likely won’t help. But with the advent of inexpensive, gentle techniques requiring little to no medication or anesthesia, I think it’s time we give such patients an opportunity to work with what they have. Granted, not all women with FSH values in the sixties are equivalent. My particular patient is 24 years old. With youth often comes many unexpected “breaks in the storm clouds”. There may be a more serendipitous month for my patient when her antral follicle count is higher than her current one or two. Time will tell. But one thing is certain: donor egg IVF success rates will be extremely high today for my patient and will still be extremely high for her in 10 years time if she ever opts to go that route. But today may be her only chance to conceive with her own eggs, and it saddens me to think that this window of opportunity for her could have been summarily closed without due consideration of all the variables involved.

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