Posts Tagged ‘antral follicle counts (AFC)’

What seems to work best for which poor responders and women over 40?

Thursday, June 3rd, 2010

This is one of those areas where we’d hope the empirical literature would be able to tell us what works for whom and under what conditions. But unfortunately poor responders and women over 40 – and particularly poor responders over 40 – are a relatively small group and rather neglected in the research (JMHO). So, what can we draw on instead?

This isn’t particularly scientific, but if you look at some of the research that’s been conducted over the years and combine this with informal sources such as the Over 40 High FSH Board‘s Timeline post (click here or search for “timeline” to find the latest) and also the high FSH google stats page, and also based on what I observed (IVF successes and failures) over many years on those high FSH boards, here’s what I concluded:

  1. There didn’t seem to be any pattern about whether the flare protocol, the antagonist protocol, or Mini IVF worked best – it’s basically a crap shoot. You just have to try them and see.
  2. The high stim success cases (live births) were generally women under 40 with a lot of antral follicles. The few over 40 exceptions tended to have higher AFCs (>5).
  3. The VAST majority of over 40 IVF success cases were low stim. [Lots of natural conceptions too, but of course there are many more people ttc naturally than with IVF, so it’s hard to infer whether, say, low stim IVF is more or less effective per cycle than ttc naturally – High FSH specialist Dr. Jerome Check thinks IVF gives high FSHers 2.5 times better odds for that cycle cf ttc naturally in your late 30s and early 40s.]
  4. Often on high stims you can get more follicles and sometimes more eggs retrieved, but the number of embryos generally seemed to be the same from either high or low stim (I’m excluding natural and boost protocols from low stim here). In other words, on high stims you often get more empty follies and/or lower fert rates.
  5. Those of us over 40 gals who’ve tried both high and low stim have quite often seen a difference in eyeballable embryo quality – just one example, but check out my high and low stim embie pics and see for yourself

So … based on what I’ve seen, my conclusions for poor responders/high FSHers/low AMHers were:

  • Under 40 and with OK AFC –> give medium-high stims a try first (say, 450-600IU)
  • Over 40 but a pretty decent AFC (say, consistently >5) OR under 40 with a low AFC –> try medium stims first (225-375IU)
  • Over 40 with a low AFC and FSH not through the roof –> try low stim (75-150IU)
  • Really excessively high FSH or a system that goes wacky with drugs –> go natural (BD or IVF) or try a ‘boost’ cycle (start natural, add tiny 75IU boost IF needed based on monitoring)

Not very scientific, but FWIW, that’s what I concluded in the end (after starting medium/high stim at age 40 and eventually listening to my wise board buddies and Jerome Check – and trying low stim).

Please note that this post is directed at couples and women who do NOT at this point want to consider donor eggs, but want to try and get a handle on what might be the best approach to try with their own eggs.

Other posts of potential interest:

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:

Can acupuncture help?

Wednesday, September 23rd, 2009

There’s a very interesting difference between Western and Chinese medicine on how fertility is viewed. Western doctors tend to focus on the cycle in which your eggs are produced (e.g. the cycle in which you do IVF), whereas Chinese medicine takes a much more long-term view.

To help understand the difference in thinking, here’s a quick (and hopefully not too inaccurate) summary of where eggs come from.

The process starts about a year before you actually ovulate, when a bunch of ‘primordial follicles’ are recruited within the ovary. These are developed very very slowly over the course of several months.

At about three months before ovulation, these primordial follicles start a different phase in their development and are now known as ‘antral follicles’. At the very start of any given cycle, an ultrasound will show several small antral follicles that are ready to go. In fact, this antral follicle count (AFC) is a good rough indicator of your ovarian reserve – check out this guide to how AFC helps predict a patient’s response to IVF stims.

During a natural cycle, just one or two of these antral follicles are recruited and will mature, leading to ovulation of an egg or sometimes two. The remaining antral follicles just fizzle out and undergo ‘atresia’ (basically, they bow out of the race). Here’s a link to a really excellent animation showing what happens in an ovulation induction (e.g. Clomiphene) cycle, which is not that different to what happens in a natural cycle (in a natural cycle you usually only ovulate one egg).

During an IVF cycle, the goal is to try and get more of those antral follicles to mature and fewer of them to undergo atresia.

So, how do the Western and Chinese perspectives on this process differ?

Your Western specialist tends to focus on a particular treatment cycle (i.e. that one month), which is the journey from antral follicles to ovulated eggs, fertilisation and beyond.

A Chinese medicine doctor, in contrast, takes a much more long-term view of the process. The intent is to create the optimal and best balanced environment for the development of your primordial follicles and then their further development once they become antral follicles, and then finally (the last and very short conclusion of the journey), the recruitment of antral follicles to produce an egg, get it fertilised, etc.

This is why the Western view is that there’s nothing you can do to influence egg quality – you are dealt the hand you’ve got; you just have to harvest as many eggs as possible, play the numbers game and hope that one of them is good.

The Chinese medicine perspective is that, although age and heredity are huge determinants of egg quality, eggs and their chromosomes can also be damaged during their development if they are subjected to toxins or have to grow in a sub-optimal environment. So, if you maximise the quality of the ‘soil’ in which they develop, then you will be able to get the best possible eggs that the woman can produce at her age.

This is why acupuncturists (and naturopaths, for that matter, who subscribe to a similar view) will tell you that you should do acupuncture for at least three months before expecting to see real benefits. Here they are talking about optimising the development of your antral follicles prior to a particular cycle. And if you do acupuncture for a year, you are not only helping this part of follicle development, but also the development of the primordial follicles as well.

Is there any actual research that shows acupuncture works?

Yes!! OK, acupuncture is hard to evaluate because treatment is very individualised (you can’t just standardise and expect the same treatment to work on different people). Also, it’s highly dependent on the competence of the practitioner. But there have been some very good studies done that show the benefits of acupuncture on fertility. Dr. Vitalis in Auckland has posted a really excellent summary of the effectiveness research on acupuncture – check it out.

I hope all this makes sense! Please post comments or questions below if not, or if you have something to contribute. Thanks!