Date: May 6, 2020
Hello and welcome to this discussion on IVF treatment in Elderly women. As you know there is an age related depletion of ovarian capacity in women. Therefore, AGE is the most important parameter of fertility in woman besides other factors. Much more than MALE PARTNER AGE.
Erosion or reduction of egg reserve in ovaries starts by the age of 35 years and after 40 years there is rapid decline such that by 42/43 years the ovarian reserve may be totally gone.
Then there is the condition called premature ovarian insufficiency or failure wherein the Ovarian function ceases earlier than usual. This might be coincident to premature menopause or the menses might continue even though ovarian function is very low.
A: There are certain grades or degrees of ovarian reserve. Poor – Low – Moderate – Good – Very Good. All these are the grades of ovarian structure and function. Different women have different ovarian reserves depending upon the number of follicles (eggs) their ovaries have at puberty. Then, during their lifetime, there is a gradual depletion of this reserve which accelerates at different stages in different women.
When we say poor ovarian reserve or low ovarian reserve it means that those women in whom there was depletion of ovarian follicles so that she can possible recruit much lesser number than another woman with normoovarian reserve.
What is the trend you are seeing in your clinical practice as far as these aspects of ovarian reserve are concerned?
A: Nowadays we see many women who are relatively young, maybe in their early 30s or even late 20s come with low to poor ovarian function when investigated. Most of these are in process of undergoing premature ovarian failure or menopause as we know. Yes, it’s very surprising but true. However, poor or low ovarian function is not the same as poor or low ovarian reserve. The latter occurs as aging occurs resulting in urgent need to do something before it’s too late.
How would you know that a particular woman has poor ovarian function or reserve?
A: So, we have clinical history, examination and tests that we do for these women who actually present in clinic as infertility cases.
Clinically – Hypomenorrhea/amenorrhea – irregular/absent menses.
Hormonal profile – FSH, LH and E2 on Day 2 of cycle or if she’s not menstruating then any given day.
Antimullerian hormone (AMH) which assesses ovarian reserve directly.
Day 2 of menses TVS – Antral follicle count in ovaries.
Other conditions like Galactosemia or Karyotyping to rule out chromosomal abnormality also has to be done.
Good ovarian reserve is when ovaries have 15/more follicles.
5-10 is low ovarian reserve.
<5 is poor ovarian reserve.
Sometimes there is a high ovarian reserve 20/more in case of Polycystic ovarian disease.
Similarly AMH levels are very good predictors of ovarian reserve and response. AMH of 1.5-4ng/ml is considered good ovarian reserve.
Once you know the lady has low ovarian reserve or low/poor ovarian function then how do you counsel and manage them?
A: If this lady is borderline low ovarian reserve as assessed by the hormonal profile, then we can boost her ovaries by giving her supplements. These have to be given for a period of 90-120 days to show effect. These supplements will activate the primordial follicles.
Once they have completed the regime then we need to do IVF for them immediately so that we can extract as many eggs as possible from the lady which then can give good success rate for clinical pregnancy. However, here I would like to remark that all ladies are not the same, in the sense some women will have good response after premedication and some will still have a very low response. So what we do in our clinic is to style our protocol depending upon ovarian response.
Supplements that we give to boost ovaries improve number, quality of eggs and therefore of the fertilized embryos, thereby increasing the clinical pregnancy rates.
You always mention the clinical pregnancy rate, so what exactly does this mean?
A: Whenever we talk about success rates of an IVF center or for that matter in a couple, we need to give them this data. Clinical pregnancy rate is the percentage of women conceiving through IVF procedures and showing a live fetus on ultrasound per the embryo transfers done. Mediheal we have clinical pregnancy rate of 50-55% which means that many women get pregnant out of 100 women who have had Embryo transferred.
There is also another term which is more significant and it’s called Live birth rate which is the number of women which deliver a live, full term, healthy baby at term. Our live birth rates in Mediheal centers are 45-47% which are comparable to those of developed countries.
How do these elderly women with depleted ovarian reserve stand a chance to conceive?
A: We have several options for these women. Those having lesser number of follicles who have still functioning ovaries – we give them boosters and do IVF as soon as possible to get the best possible outcome. However, I always counsel these women to undergo multiple ovarian stimulations, 2 or 3, in short span of time. Sometimes in the same month we can even do duo stimulation and retrieve eggs twice. The aim is to get a higher number of good quality eggs from their ovaries so that we can get best possible outcome and as I always tell my patients
NUMBER and LUCK play a very important role in the successful outcome.
In case she is above 40 years would you recommend same options or some other?
A: As a women ages not only does the ovary get depleted of its wealth of eggs but also there is depletion in quality of these same eggs, and increase in genetic abnormalities. So you might be dealing with a poor ovarian reserve and function as well as premenopausal status.
For them, my suggestion would be not to waste more time but go for
Oocyte/Egg Donation or Embryo Donation.
How does this actually happen, these terms you mention? Are they quite common? Do couples accept these treatments?
A: Yes, recently, since last 4-5 years; third party assisted reproduction has become more common and even patients are familiar with these. However, let me explain to you what these entail.
Egg donation or Oocyte donation is when we extract eggs from a young, health woman who has volunteered to be an egg donor, and we fertilize the eggs of this donor with the sperms of husband to the lady who is infertile, and place the resultant fertilized embryos into the uterus of infertile lady.
When such a lady desires to have donor sperms in addition to donor eggs then we call it Embryo donation.
Anonymity of egg donor is maintained unless there are some couples who bring their own egg donor from their family stream in which case donor is known to them.
However, the clinic does a thorough profiling of egg donor, blood tests, ultrasound and also certain infective diseases tests. Once the egg donor is considered eligible to donate then we match profiles with the recipient woman and do the procedure. Also their menstrual cycles have to be synchronized. We also give supplements to our egg donors to enhance egg numbers and quality.
In fertility treatments we hear of banks, what are those?
A: These are storage banks which have a commodity more precious than money. That means we can store eggs, sperms, embryos etc. in liquid nitrogen at below freezing temperatures, and maintain their cellular integrity for years. Mediheal has an egg, embryo and sperm bank where we have carefully labelled the names of donors or of patients to whom they belong.
Many women who have conceived and delivered a baby/babies may come in for a second pregnancy few years later if she had frozen her surplus embryos.
We charge 30-40 Kenyan Shillings depending upon storage annually.
So then is fertility preservation also the same as banking?
A: Yes, it’s like you put money in the bank to keep it safe and to be useful in the future. Similarly, there are women in our society who are profession and work driven and who do not have time for pregnancy or baby. These women could hop into our clinic and we could bank their eggs whilst they are still young and have good ovarian reserves. So that, when they are ready to begin a family they can always fall back on these reserved or cryopreserved eggs for getting pregnant, obviously through IVF.
Similarly men can do the same for their sperms.
This is called Elective fertility preservation.
However, there is a procedure called Emergency fertility preservation, especially for Oncofertility preservations.
We do egg freezing or banking for those women who are unfortunate to have been diagnosed with some cancer and have to undergo chemo or radiotherapy or even surgery. These eggs can be utilized later after she has been completely cured of cancer.
Same for men – orchidectomy, cancer therapies can bank their sperms before going onto treatment and preserve their fertility.
Posted by Mediheal Group of Hospitals on Tuesday, May 5, 2020
Q: Lastly, what would you like to tell our audience as far as take-home message?
A: In concluding I can’t stress more the issue of premature ovarian insufficiency or ovarian failure in women of 30 -35 years and also poor ovarian reserve or function leading to infertility. Also for older women who are 40 years and above, there are very slim chances for conception unless they do IVF. And these women and couples need to redress issues immediately.
Egg donations and Embryo donations have to be considered as options too and those who need to preserve their fertility for future could come and bank their eggs/sperms for future IVF treatments.
By: Dr. Shaunak Khandwala (Infertility and IVF Specialist | Clinical Director for IVF at Mediheal Group of Hospitals and Fertility Center).