Feedback Friday: Should I hang up my ovaries and call it a day?

Dear Eggsperts—LOVE your “eggspert” name! What would you tell a 38-yr-old female that got pregnant easily 3 times (but miscarriage less than a year ago, and irregular periods since D&C) who went for thyroid check, basic evaluation and ultrasound, and found out AMH <0.015!?!  2 boys (age 7 & 4) wanted to try 1 more time for a girl…..not a candidate for IVF should I hang up my ovaries and call it a day?—Rattled in Raleigh

Dear Rattled—First, we want to let you know how sorry we are about your pregnancy loss. We don’t say that lightly. Every loss is truly a loss and we want to honor your unique experience. If you ever want to spend more time addressing your feelings surrounding loss, or even lack of feelings, there are some awesome resources out there.

Your question is a common one and there are many parts to it. We don’t know the specifics of your situation and would defer to your doctor for individualized recommendations, but we can offer you some general advice. I am going to try to tackle the multiple issues separately.

1. Many pregnancies, unfortunately, end in miscarriage. In general, about 15-20% of pregnancies result in miscarriage. As women increase in age, miscarriage rates also increase, independent of other factors. We believe the reason for these early pregnancy losses is a chromosome imbalance that is unique to this particular pregnancy. It does not mean that your next pregnancy will be a miscarriage. The fact that you have conceived 2 healthy babies in the past is encouraging for your next pregnancy. 
2. A women is born with all of their eggs she will ever have. Every month, 1 egg is ovulated and other eggs are lost. Even if you are not ovulating, use birth control, etc., there is continuous loss of eggs. This is why fertility rates decrease as women age. Anti-mullerian hormone (AMH) is one test that assesses ovarian reserve. It is a reflection of the quantity of remaining follicles (where eggs are housed and ultimately grow and mature) in the ovaries. A low AMH is a reflection that egg numbers are “low.” It does not mean you are entering menopause, but a low AMH provides a hint to your doctor that you may not respond well to ovarian stimulation medications. Without medication, you release 1 egg when you ovulate. Ovarian stimulation medications are designed to help you develop multiple mature eggs for ovulation. With a low AMH, when you are given medications to help you ovulate, you may not respond well and may not have multiple (or sometimes any) mature eggs. For this reason, some clinics do not recommend IVF because of the high cost and low potential for a successful outcome, even if a few eggs are retrieved. Use of donor eggs may be recommended, if this is an option you would consider.
3. For women with Diminished Ovarian Reserve, as reflected by your AMH levels (and the new irregularity of your cycles), some clinics will offer natural cycles for insemination or IVF. This means that you receive no ovarian stimulation medications, but you are evaluated with multiple ultrasounds to determine follicle growth, and the assumption of egg maturation. At time of maturation, IUI may be performed, or a single egg may be retrieved for in vitro fertilization. This may be particularly challenging as your cycles have become irregular. It will be difficult to determine when you are near ovulation, and it may take weeks or months for ovulation. 
4. Some clinics may also offer minimal-dose/low-dose stimulation medications for IVF. The idea is that with Diminished Ovarian Reserve, even maximal dose stimulation may only achieve a low number of mature eggs. Giving lower dose medications may help you ovulate one or a few eggs, which may be the same as maximum dose stimulation, but at lower financial cost to you. Studies have shown that pregnancy rates are similar in patients with Diminished Ovarian Reserve if they use low-dose or max-dose stimulation. It’s a hard concept to grasp, though. If you only get 1 egg, you may wonder if you would have had a better yield with higher dose, and we may never know. As your cycles are irregular, if you respond to medication, this may be an option to help your doctor know when you ovulate. 
5. You may want to ask your clinic if they are willing to try a natural or mini-stimulation cycle for IVF. If your clinic is willing to consider IVF using your own eggs, or if you use donor eggs, unfortunately, there is no guarantee of a pregnancy or baby. With low AMH, your chances are better using donor eggs than using your own eggs. Also, without doing genetic testing of any embryos conceived, there isn’t a way to know if the embryo would be a boy or a girl. Genetic testing will identify many embryos with chromosome imbalances that would not result in a baby if transferred, so clinics generally do not transfer genetically abnormal embryos. If you use your own eggs, you will likely have fewer embryos to test for gender, than if you use donor eggs. And, some clinics do not offer family balancing/gender selection of embryos, even if they do genetic testing. Transferring the best quality, chromosomally balanced embryo, regardless of gender, will give you the best chance of a baby. 

So, Rattled, this was a very long answer to your short question. To try to summarize, I don’t generally recommend that women “hang up their ovaries and call it a day,” but it is important to know that using your own eggs may be expensive and may not be successful. Some couples need to know they have exhausted all efforts using to try to conceive using their own eggs before “calling it a day” or considering using donor eggs. For some couples, the low likelihood of a baby may not be worth the financial and emotional costs. This will always be a personal decision about how much potential heartache you can handle and if you will have regrets about what you did, or didn’t do, in your efforts to grow your family.

We hope we met your Eggspectations—An Eggspert

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Disclaimer: All of the comments on this page are for basic information only. They are based on the opinions and expertise of the authors and are not meant to provide a substitute for medical care or specific treatment recommendations. Each person is unique and requires individualized diagnosis and treatment plans. Any specific questions should be directed to your personal healthcare provider.