Yesterday I gave Grand Rounds at Inova Fairfax Hospital in Falls Church, VA. Fairfax is a very large hospital routinely performing over 10,000 deliveries annually. There are over 100 Ob/Gyn physicians on staff and I have the title of Division Director of Reproductive Endocrinology and Infertility. As Division Director, I am responsible for ensuring educational content at the weekly departmental meetings that have an educational purpose. These meetings are called "Grand Rounds" in order to distinguish them (I guess) from "Not-so-grand Rounds."
As a child growing up in a medical household I often heard my Dad and Brother speak of "Grand Rounds." But I though they were saying "Ground Round" which was this great chain of burger restaurants in New England that was famous for providing bowls of popcorn and peanuts to all diners as they sat down. Of course, we kids would stuff our faces full of popcorn leaving no room for the overpriced burgers which may explain why we rarely went to the Ground Round for meals!
So given that the topic of ovarian reserve has been on my mind, here is today's Question of the Day:
I have high FSH so my RE says I'm not a good candidate for regular IVF but I've done 3 rounds of meds and IUI with NO success. Would Natural Cycle IVF (NCIVF) be better?
The short answer is "yes." The long answer is "yes, probably."
First of all, a high FSH suggests diminished ovarian reserve and a probably poor response to fertility medications. BUT a high FSH does not mean that there is not a good egg left in the ovary. The odds of having a good egg is very dependent upon age. The older the patient, the lower the odds of success. This patient didn't tell me her age. Younger is better. Less than 40 is better than over 40. Less than 44 is better than over 44 (although we had had a delivery in a 48 year old patient following NC IVF).
Secondly, I usually encourage patients with borderline elevated FSH levels to consider stimulated IVF as a first choice. If the patient fails to respond then you can do an IUI and then re-evaluate. I have seen many patients demonstrate decreasing responsiveness to FSH shots - 7 follicles then 4 follicles then 2 follicles. If at that point the patient switches to IVF she will likely get canceled prior to retrieval.
So what about the proven low responder to medications. Is NC IVF an option? Yes, we have had some amazing success with these patients. Are donor egg/embryo/adoption more likely to work? Yes, but those options may not be acceptable to all patients. That leaves NC IVF and I think that one can consider this a viable option for patients with diminished ovarian reserve.
I have a 41 year old patient who had FSH levels in the 18-26 IU/L range on several occasions. Her AMH was <0.16 and her antral follicle count was 2. Her husband had male factor (previous vasectomy and reversal). Her insurance company denied her IVF coverage because of the high FSH. She attempted NC IVF and her FSH level was 40 IU/L on day 3 of that cycle. Yet she conceived and is currently in her 3rd trimester with normal genetic testing and a healthy baby. Go figure.
THIS AGREEMENT CONTAINS WARRANTY DISCLAIMERS AND OTHER PROVISIONS THAT LIMIT THE AUTHOR’S LIABILITY TO YOU. PLEASE READ THESE TERMS AND CONDITIONS CAREFULLY AND IN THEIR ENTIRETY, AS USING, ACCESSING AND/OR BROWSING THE SITE CONSTITUTES ACCEPTANCE OF THESE TERMS AND CONDITIONS. IF YOU DO NOT AGREE TO BE BOUND TO EACH AND EVERY TERM AND CONDITION SET FORTH HEREIN, PLEASE EXIT THE SITE IMMEDIATELY AND DO NOT USE, ACCESS AND/OR BROWSE THE SITE.
BY ENTERING THE SITE, YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE READ AND UNDERSTAND THESE TERMS AND CONDITIONS, THAT THE PROVISIONS, DISCLOSURES AND DISCLAIMERS SET FORTH HEREIN ARE FAIR AND REASONABLE, AND THAT YOUR AGREEMENT TO FOLLOW AND BE BOUND BY THESE TERMS AND CONDITIONS IS VOLUNTARY AND IS NOT THE RESULT OF FRAUD, DURESS OR UNDUE INFLUENCE EXERCISED UPON YOU BY ANY PERSON OR ENTITY.
MEDICAL ADVICE DISCLAIMER
The Author provides the Site and the services, information, content and/or data (collectively, “Information”) contained therein for informational purposes only. Using, accessing and/or browsing the Site and/or providing personal or medical information to the Author does not create a physician-patient relationship between you and the Author. Nothing contained in the Site is intended to create a physician-patient relationship, to replace the services of a licensed, trained physician or health professional or to be a substitute for medical advice of a physician or trained health professional licensed in your state. You should not rely on anything contained in the Site, and you should consult a physician licensed in your state in all matters relating to your health. You hereby agree that you shall not make any health or medical related decision based in whole or in part on anything contained in the Site.
FINANCIAL, LEGAL AND OTHER ADVICE DISCLAIMER
You hereby acknowledge that nothing contained in the Site shall constitute financial, investment, legal and/or other professional advice and that no professional relationship of any kind is created between you and the Author. You hereby agree that you shall not make any financial, investment, legal and/or other decision based in whole or in part on anything contained in the Site.
The opinions expressed in the Site are the opinions of the Author and do not necessarily reflect the opinion of his employer(s). The Site is created by the Author in the Author’s individual capacity, is the Author’s personal web site, is not edited by the Author’s employer(s) and, as a result, may not be attributed to the Author’s employer.
Any opinions of the Author on the Site are or have been rendered based on specific facts, under certain conditions, and subject to certain assumptions, and may not and should not be used or relied upon for any other purpose, including, but not limited to, for use in or in connection with any legal proceeding.
The Information may be changed without notice and is not guaranteed to be complete, correct, timely, current or up-to-date. Similar to any printed materials, the Information may become out-of-date. The Author undertakes no obligation to update any Information on the Site; provided, however, that the Author may update the Information at any time without notice in the Author’s sole and absolute discretion. The Author reserves the right to make alterations or deletions to the Information at any time without notice.
The Site is open to the public. Therefore, consider your comments carefully and do not include anything in a comment that you would like to keep private. By uploading or otherwise making available any information to the Author in the form of user generated comments or otherwise, you grant the Author the unlimited, perpetual right to distribute, display, publish, reproduce, reuse and copy the information contained therein.
You are responsible for the content you post. You may not impersonate any other person through the Site. You may not post content that is obscene, defamatory, threatening, fraudulent, invasive of another person’s privacy rights, or is otherwise unlawful. You may not post content that infringes the intellectual property rights of any other person or entity. You may not post any content that contains any computer viruses or any other code designed to disrupt, damage, or limit the functioning of any computer software or hardware.
By submitting or posting content on the Site, you grant the Author and any company substantially under the control of the Author, the right to remove any content or comment that, in Author’s sole judgment, does not comply with the terms and conditions of this Agreement or is otherwise objectionable. You also grant the Author and any company substantially under the control of Author the right to modify, adapt, and edit any content.
THIRD PARTY LINKS AND ADVERTISEMENTS DISCLAIMER
THE INCLUSION OF THIRD PARTY ADVERTISEMENTS DOES NOT CONSTITUTE AN ENDORSEMENT, GUARANTEE, WARRANTY, OR RECOMMENDATION OF, AND THE AUTHOR MAKES NO REPRESENTATIONS AND/OR WARRANTIES ABOUT, ANY PRODUCT OR SERVICE CONTAINED THEREIN.
DISCLAIMER OF ALL WARRANTIES
The Information made available at the Site is provided on an “AS IS” and “AS AVAILABLE” basis without warranties of any kind, either express or implied, including, without limitation, warranties of title, noninfringement, and implied warranties of merchantability or fitness for a particular purpose. Without limiting the generality of the foregoing, the Author makes no warranty, representation or guaranty as to the content, sequence, accuracy, timeliness or completeness of the Information, that the Information may be relied upon for any reason or that the Information will be uninterrupted or error free or that any defects can or will be corrected.
Without limiting the generality of the foregoing, the Author makes no representations or warranties with respect to any Information offered or provided within or through the Site regarding treatment of medical conditions, action, or application of medication.
Under no circumstances, as a result of your use of the Site, will the Author be liable to you or to any other person for any direct, indirect, special, incidental, exemplary, consequential or other damages under any legal theory, including, without limitation, tort, contract, strict liability or otherwise, even if advised of the possibility of such damages. Without limiting the generality of the foregoing, the Author shall have absolutely no liability in connection with the Site for:
1. damages as a result of lost profits, loss of good will, work stoppage, failure of performance, delays in operation or transmission, nondelivery of information, deletions of files, mistakes, defects, errors, interruptions or computer failure or malfunction;
2. any loss or injury caused, in whole or in part, by the Author’s actions, omissions, or negligence, or for contingencies beyond the Author’s control, in procuring, compiling, or delivering the Information;
3. any errors, omissions, or inaccuracies in the Information regardless of how caused, or delays or interruptions in delivery of the Information; or
4. any decision made or action taken or not taken in reliance upon the Information.
RESERVATION OF INTELLECTUAL PROPERTY RIGHTS
The Site is protected by United States copyright laws. The Author hereby reserves any and all intellectual property rights in the Site.
The Site is intended for persons eighteen (18) years or older. Persons under the age of eighteen (18) should not access, use and/or browse the Site.
You agree to indemnify and hold the Author harmless from any claim or demand, including attorneys’ fees, made by any third party as a result of (1) any content posted or made available by you on this Site, (2) any violation of law that occurs by you through the Site, and/or (3) anything you do using the Site and/or the Information contained therein.
If any provision of this Agreement is held to be invalid or unenforceable in whole or in part in any jurisdiction, then that provision shall be deemed ineffective in such jurisdiction but shall have no effect on the enforceability of the remaining provisions.
GOVERNING LAW, CONSENT TO JURISDICTION AND LIMITATION ON CLAIMS
This Agreement and your use of the Site, along with the Information contained therein, shall be governed by and construed in accordance with the laws of the State of Virginia without regard to conflict of laws principles, and you agree to submit to the jurisdiction of courts in the State of Virginia. You further agree that any claims or causes of action arising out of or related to this Agreement and the Site, along with the Information contained therein, shall be filed within one (1) year after such claim or cause of action arose, or such claim or cause of action shall be forever barred.
You hereby acknowledge that this Agreement represents the entire understanding between you and the Author concerning your use of the Site and the Information contained therein.
The Author may, in the Author’s sole and absolute discretion, modify the terms and conditions of this Agreement in whole or in party at any time for any reason without any notice to you, whether prior or otherwise. Such modified terms and conditions shall supersede these terms and conditions and shall become binding when published online on the Site.
The Author’s failure to exercise or enforce any right or provision of this Agreement shall not be deemed to be a waiver of such right or provision.
THE SITE AND THE INFORMATION CONTAINED THEREIN IS MADE AVAILABLE BY THE AUTHOR FOR EDUCATIONAL PURPOSES ONLY AND IS NOT INTENDED TO PROVIDE MEDICAL ADVICE. BY ACCESSING THE SITE, YOU UNDERSTAND AND ACKNOWLEDGE THAT THERE IS NO PHYSICIAN-PATIENT RELATIONSHIP BETWEEN YOU AND THE AUTHOR. YOU FURTHER ACKNOWLEDGE YOUR UNDERSTANDING THAT THE SITE SHOULD NOT BE USED AS A SUBSTITUTE FOR COMPETENT MEDICAL ADVICE FROM A LICENSED PHYSICIAN IN YOUR STATE.