Poor ovarian reserve is usually found in women with advanced age > 35 years. But now a days for some unknown reasons (probably lifestyle, stress, environmental toxins) there are many cases of premature ovarian ageing in women < 35 years of age as well. The diagnosis is based on hormone test such as Anti Mullerian Hormone AMH (<1.5 ng/ml; FSH > 10 miu/ml) and ultrasound Antral Follicular Count AFC < 7. In majority of patients there is no cause for poor ovarian reserve, other than age. However, patients with ovarian endometriosis, genital tuberculosis, autoimmune disease like thyroiditis, chromosomal disorders such as turners mosaic syndrome, genetic disorders like fragile x syndrome can present as poor ovarian reserve. One should do tests such as x ray chest, sputum AFB, Mantoux test, blood IgG & Ig M and TB PCR of the endometrium to look for tuberculosis. One can do thyroid profile, thyroid antibodies and karyotyping to rule out Turner’s syndrome. One should rule out fragile x syndrome by doing FMR1 DNA test.
It’s very important to counsel young unmarried patients with poor ovarian reserve to preserve their fertility using the technique of oocyte retrieval and egg freezing.
In infertile patients with poor ovarian reserve, ovarian reserve should be improved using adjuvants such as micronized DHEAS, pre-treatment with testosterone gel, arginine, coenzyme Q, whey proteins yoga. Following this one can try a few attempts of ovarian stimulation along with intrauterine insemination (IUI). If that fails one can go in for IVF. During ovarian stimulation, we commonly use Growth hormone in combination with heavy standard ovarian stimulation (450 IU gonadotrophins/day starting from day 2) or mild ovarian stimulation Younger patients with poor ovarian reserve (< 35 years of age), who undergo IVF have a better yield of eggs and embryos. They have a better chance of achieving pregnancy. In older patients with poor ovarian reserve, there is a problem of getting few or no eggs during egg retrieval. Sometime the eggs fail to fertilise or in other patients the egg fertilisation rate is also very low, resulting in fewer no of embryos. In such patients, if the embryo quality is good, instead of transferring the embryos in the same cycle, we freeze the embryos. We perform three to four multiple cycles and then pool (collect & store) these frozen embryos together. Once we have adequate number of embryos, we can thaw them and either do a blastocyst transfer or a sequential transfer. This results in a good chance of pregnancy. We have been successfully treating cases with poor ovarian reserve after pooling embryos over 2 to 6 IVF attempts/cycles. In case the patients fail to achieve pregnancy and are not willing to opt for egg donation, we can offer them newer techniques of ovarian rejuvenation such as ovarian tissue activation or Mitochondrial spindle transfer. Newer techniques of ovarian rejuvenation such 5 days of daily GCSF subcutaneously, followed by laparoscopic or ultrasound directed intraovarian injection of bone marrow stem cells or platelet activated plasma derived from patients’ peripheral blood may be offered after proper informed consent and explanation that these are experimental techniques with very poor outcome. Ultimately if patients fail to achieve pregnancy, they can opt for egg donation. Egg donation has very high success rate with nearly 90 % patients achieving pregnancy during treatment cycles.
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