Archive for May, 2010

I’ve got high FSH/low AMH … what does it mean?

Saturday, May 22nd, 2010

Ohhhh boy, I know this topic better than just about any other, as you may have seen from my story. I remember finally plucking up the courage to see a fertility specialist, being sent for blood tests, immediately getting online and googling what all the tests were and how to interpret the results … and fast coming to the conclusion that the absolute worst case scenario was an FSH over 10. “The cruelest number of all” was how one site described it.

If you’ve clocked in with elevated FSH (usually defined as any reading >10) or OK FSH but elevated E2 (>150 in NZ units, or >40 in U.S. units) or low AMH (<14 pmol/l in NZ units, or 2ng/ml in US units), then you have probably been visiting Dr. Google and have come up with a very depressing view of your chances. Your specialist may also have told you this is not good news. And no, it’s not, but here are a few snippets of information I’ve been able to glean in my travels.

First, let’s blow a few myths out of the water …

  • Your age is far more important than your FSH – if you are 33 years old with an FSH of 20, then you do NOT have the eggs of a 43-year-old. You have the eggs of a 33-year-old, just fewer of them than your average 33-year-old.
  • If your FSH fluctuates and is sometimes high and sometimes normal (with normal E2 as well), then your prognosis is about the same as if your FSH was consistently slightly elevated (say, low teens).
  • Even if your FSH reading is quite high (say, 30 or 40 or more), this alone does NOT mean you are in menopause. Menopause is defined as not ovulating and no periods for 12 months. If you still get AF – and particularly if you are still ovulating! – you are definitely NOT in menopause!
  • If you do get pregnant, your chances of miscarriage are just the same as anyone else your age – high FSH does not increase the chances of aneuploidy or miscarriage (yes, this has been studied!).

What does high FSH/low AMH mean?

  • You have diminished ovarian reserve (DOR). This means you are running low on eggs and are likely to hit menopause sooner than average (the average is age 51). How much sooner is very hard to say – it could be 10 years away or more; it could be much sooner.
  • You are likely to be a “poor responder” to IVF stimulation drugs. In other words, if you try IVF, you are likely to produce fewer eggs than most women and your chances of pregnancy will be lower because of the smaller numbers.

How can I reduce my FSH?

The short answer to this is that it’s a wild goose chase. Nothing much works to get the number down consistently, but the more important point is that even if you did, it doesn’t change the fact that you are low on eggs. Don’t waste your energy chasing a lower number because that isn’t going to get you pregnant. What you do know for sure is that you are short on time, so put your energies into finding the golden egg(s) from those that are left.

Having said that, it is possible to artificially suppress FSH using either Buserelin (an agonist), birth control pills or some form of estrogen (such as estradiol valerate). This is usually done prior to starting an IVF cycle and is known as ‘pre-cycle suppression’. More on that in another post …

Should I believe just one reading?

It’s never a good idea to make major decisions based on one blood test result, or even on two or three tests that confirm a similar result. There are some other tests of ovarian reserve, and it’s a good idea to ask for them:

  • FSH – Follicle Stimulating Hormone – should always be done with a test for estrogen as well (otherwise it’s uninterpretable); should be done on CD2-3 of cycle, although some drs will do it CD1-4.
  • AMH – Anti-Mullarian Hormone – may be done at any time during the cycle
  • AFC – antral follicle count – this is a vaginal ultrasound,  usually done early in your cycle, where the dr counts the number of ‘resting’ or ‘antral’ follicles that are candidates for selection at the beginning of a cycle. This gives you a  very rough ballpark of the maximum number of eggs you might get on the right IVF stimulation protocol.

Is there any hope for women with high FSH not using donor eggs?

High FSH does present some difficult challenges. However, there have been success cases, lots of them, especially among those with just mildly elevated FSH (in the teens). At higher levels (FSH in the 20s, 30s and 40s), we still see successes, but just in lower numbers, and the success cases show a definite drop-off in older women. There have been some rare cases of success in extremely high FSH cases – two I know of personally were a 28-year-old with FSH 164 (yes, that’s a hundred and sixty-four) and another with FSH clocking up to 110 who had three children over several years (including the last one at 41).

Those interested in poring over some unscientifically documented success cases should check out the following links:

I’ll follow this up soon with some more information on treatment options for high FSHers, including natural approaches and alternative medicine as well as different IVF protocols that seem to work best for high FSHers.

In the meantime, a great resource to check out is my friend PJ’s site: http://highfshinfo.com

What is assisted hatching?

Saturday, May 1st, 2010

Assisted hatching is an optional extra procedure used in IVF where a small hole is made in the shell (or ‘zona’) of a Day 3 embryo. This is supposed to help (in some cases) the embryo ‘hatch’ out of its shell and transform itself into a blastocyst (usually on Day 5).

Probably the best site to get a clear understanding of assisted hatching is the one from the Advanced Fertility Center of Chicago, which shows in great detail how the hatching process works, including a pic of an embryo actually in the process of hatching to become a fully hatched blastocyst. Cool!

In New Zealand assisted hatching is not part of the default IVF protocol, so you would need to ask your specialist about it.

My understanding is that public funding won’t cover assisted hatching (I could be wrong about this – please chime in if you know of criteria for eligibility). But, if you were doing a publicly funded cycle and your specialist agreed it might be a good idea, you could presumably pay for it out of pocket (it’s a few hundred dollars).

If you are a self-pay patient, obviously the choice is with you and your specialist, so ask. However (and someone please update me if this is no longer the case), if you have the OK to transfer more than 2 embies, apparently the clinics are not allowed to do AH on more than two. I can’t fathom the reasoning on that (especially for women over 42), but there you go … Minor trivia, but worth knowing in advance (if you’re like me, you hate surprises cropping up during the cycle).

Just to give a broader perspective, in the States, where patients are either paid for by insurance or out of pocket, assisted hatching (AH) seems to be used more widely. The Advanced Fertility Center of Chicago says they do it on all embryos, but they also offer the following useful list of criteria:

Who should be treated with assisted hatching?

The most commonly used indications for assisted hatching with an in vitro fertilization case are:

  • Age factor – Couples having IVF with the female partner’s age over 37
  • Egg quantity and quality factor – Couples in which the female’s day 3 follicle stimulating hormone (FSH) level is elevated
  • Embryo quality factor – Couples having IVF with poor quality embryos (excessive fragmentation or slow rates of cell division)
  • Zona factor – Couples having IVF with embryos that have a thick outer shell (zona pellucida)
  • Previous failures – Couples having IVF that have had one or more previous IVF cycles that failed

In our IVF clinic, we use assisted hatching on just about all cases – because we think it increases the pregnancy and delivery rates.

For the original page, see http://www.advancedfertility.com/hatching.htm

I’m pretty sure that assisted hatching can be used whether you are doing a 3-day or a 5-day transfer, but generally not for 2-day transfers (the embryologists say the embryo is usually too small then and there’s a risk it could break up if the zona is punctured). With a 3-day transfer, they will do this immediately before they put your embies back. With  a blast (5-day) transfer they would presumably do the AH on day 3 before putting the embryos back for their last two days of development. Anyway, these are just a few things to discuss with your specialist.

As for risks, my understanding there is a very very small increased likelihood of conjoined twins if assisted hatching is used. My own specialist told me that, although this was statistically true, the reality was that the increased chances are so miniscule that they don’t really have practical significance.

Who should be treated with assisted hatching?

The most commonly used indications for assisted hatching with an in vitro fertilization case are:

  • Age factor – Couples having IVF with the female partner’s age over 37
  • Egg quantity and quality factor – Couples in which the female’s day 3 follicle stimulating hormone (FSH) level is elevated
  • Embryo quality factor – Couples having IVF with poor quality embryos (excessive fragmentation or slow rates of cell division)
  • Zona factor – Couples having IVF with embryos that have a thick outer shell (zona pellucida)
  • Previous failures – Couples having IVF that have had one or more previous IVF cycles that failed

In our IVF clinic, we use assisted hatching on just about all cases – because we think it increases the pregnancy and delivery rates.