Low Ovarian Reserve


 

Low Ovarian Reserve: What to Do?

So you’ve just found out that your egg reserve is low. You may be filled with a mixture of shock, disbelief, sadness, and panic. It’s OK to feel that way, give yourself some time to cry and let your emotions to settle. But once you regain your spirit, be a fighter.

Look at the situation at hand and be proactive to find the best solution to the problem. Don’t despair. We have seen women with seemingly impossible odds who became pregnant by themselves after they’ve exhausted all medical assistance.

Remember that you need only one good egg to have a successful pregnancy. In the natural setting, only one egg is allowed to mature and released at ovulation. Nature only needs one, so why should it not be possible to conceive if you have only a few eggs a cycle?

The questions we must ask are how low is the egg reserve and what can be done about it?

This is when things get a bit tricky. It’s typically not as straight forward once you start to measure the costs and risks against the potential benefits of treatment. Ideally, IVF provides the shortest route to pregnancy, but not everyone can afford this pricey treatment nor do they have enough eggs to make the treatment worthwhile.

How do I know how many eggs I have?

While there are several methods to check ovarian reserve, we have found that the baseline antral follicle count (AFC) and the serum level of Antimullerian hormone (AMH) are the most helpful indicators of egg reserve.

Antral Follicle Count (AFC)

The baseline AFC is the number of follicles visible on the ovaries by sonogram during the first 3 days of menses. At the start of each cycle, Mother Nature will decide how many eggs will be available for that month after assessing the remaining egg reserve and act accordingly.

If the ovarian reserve is high, more follicles will be visible on the ovaries by ultrasound. Conversely, if the egg reserve is low, only a few follicles will be visible during menses.


 

A total count of 12 follicles or more is consistent with normal ovarian reserve, whereas a count of 10 or lower would indicate a low ovarian reserve and increase the cost of IVF treatment.

Antimullerian hormone (AMH)

AMH is produced by the very young follicles of future cycles and is another excellent indicator of egg reserve.  An AMH level of at least 1.5 ng/ml indicates normal egg reserve whereas a level of

For practical purpose, low ovarian reserve can be further categorized as borderline, low, and very low.

Borderline Reserve is when we see AMH between 1.0 to 1.4 ng/ml or 8-11 antral follicles at baseline sonogram. Low Reserve is for AMH between 0.6-1.0 ng/ml or 5-7 antral follicles at baseline, and Very Low Reserve for AMH less than 0.5 ng/ml and AFC of fewer than 5.

Interestingly, we have observed that in many cases of low egg reserve (AMH less than 1.0 ng/ml), the first number following the decimal point of an AMH level can give an estimation of the number of eggs available for each cycle (plus or minus 1 egg).

For example, an AMH level of 0.6 ng/ml would suggest an availability of 5-7 eggs and a level of 0.2 ng/ml would indicate a potential for 1-3 eggs a cycle.

While this correlation is purely clinical (not scientific), we have found it to be a useful tool in planning treatment for our patients with low ovarian reserve.

What is the best treatment for low ovarian reserve?

Once we have an idea about your egg reserve, we can formulate a plan of treatment. Treatment will depend on how low the egg reserve is.

If you are on the low to borderline (AFC of 6-10 and AMH between 0.5-1.4 ng/ml) aggressive IVF protocols can be considered as the most advanced treatment option.

However, in cases of very low reserve (AFC of ≤5 or AMH of ≤0.5 ng/ml) standard IVF protocols would incur high cost of medications without much added benefits. IVF medications would allow the current pool of eggs to become mature but not much else and no additional eggs can be recruited by use of higher doses of medications.

But, don’t despair! For patients with very low ovarian reserve, the Mini IVF protocol can offer a chance to undergo IVF treatment without the excessive medication cost. Many patients with very low egg reserve have had successful pregnancies using the Mini IVF cycle.

Nevertheless, if your ovaries can only provide 1-2 eggs a cycle, you might consider limiting your treatment to ovulation induction with intrauterine insemination. In this scenario, even with Mini IVF, the financial and emotional costs would be too high to make IVF cost effective. 

Remember that you only need one good egg to become pregnant and with proper intervention you could be hearing the pitter patter of little feet in the not so distant future.

After you have given it all using your own eggs but still without pregnancy, hopefully you will find closure and move on to donor egg IVF or other options whenever you’re ready.

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