IVF for women with low AMH levels - #IVFWEBINAR

WhereIVF.com has invited Dr. Valeria Sotelo Kahane from UR Vistahermosa Clinic, Spain to talk about your treatment options and chances if you have low AMH levels. The doctor also talked about infertility connected with low AMH levels and IVF prognosis for those patients.

IVF for women with low AMH levels: treatment options and IVF prognosis.

Questions and answers:

Question:
I have a low AMH of 0.8, am aged 28 with no male factor.

Answer:
In terms of the time scale that she gave, 0.8 is a low level, taking into account the age so it’s considered a low ovarian reserve. Probably the results of ovarian stimulation will be low.

Question:
What scale was that? I’m 1.1 and considered low but according to that table it seems OK. Is this the US or European measurement?

Answer:
In the European measurement between 1-3 is considered normal. However, as you can see, less than 1 is already a low reserve. So, 1.1 will be in the lower limits of the normal configuration of ovarian reserve. So, it’s normal but tending to low.

Question:
Mine is 1.1 pmol/l. Where does it sit?

Answer:
1.1 pmol/l is a different measure. That covers counts to 0.15 ng. So, it would be on the lower side, because it’s less than1nanogram. That’s a low ovarian reserve.

Question:
If there are more than 15 eggs, does the quality of the eggs drop?

Answer:
The thing is that the quantity isn’t related to the quality. It’s not a matter of the number of eggs we have. The more we have does not mean that we have lower quality eggs. So, we won’t know the quality of the eggs until we use them. So, we can have a very good number of eggs and have an excellent quality or a very good number of eggs and have low quality. It depends, we will find out once we use the egg and the sperm and produce an embryo.

Question:
I have an AMH of 8.7 pmol/l and an AFC of 12. Should I consider an egg donation?

Answer:
When we have these levels, we have to take into account the age also. So, it’s not the same that we have 8.7 pmol/l of Anti-Müllerian hormone and an Antral Follicle count of 12. Being 40 or over 40 years old, we consider this prognosis as more indicative of egg donation because of the quality of the eggs. If we look at these measurements with someone less than 39 years old, we consider doing IVF instead of egg donation. 
So, according to one of the doctors’ tables, one of the measures with an Anti-Müllerian hormone level of 1-3.5 ng/ml would be considered not normal responders and we should expect between 10-15 eggs. We wouldn’t know the quality of the eggs because that depends on the age, but it should respond well.

Question:
Are there any possibilities to improve AMH levels, like ovarian rejuvenation with PRP or any others?

Answer:
There are no studies on improving the AMH levels. So far it hasn’t been proved. What we do is use growth hormone to try to increase the quality of the eggs. We don’t have experience of ovarian rejuvenation in any of our patients. As the doctor said before, we are born with a certain number of follicles, of eggs and once our ovarian reserve starts decreasing, this is completely irreversible. There is no treatment that will reestablish the amount of lost eggs.
At Harvard University, they are working with mother cells to try to increase the birth factors. This is a study and they are trying to defend this study, but it still hasn’t been proven.

Question:
When is the best time to get AMH and FSH levels tested during your cycle?

Answer:
There is a difference. The AMH levels can be tested at any time of the cycle so the patient doesn’t need to wait until the beginning of her cycle to do the test. However, FSH and LH are hormones that need to be studied during the first days of the cycle, between day 1-5 of the cycle approximately.

Question:
My AMH is still above 1, however, no period. What should I do?

Answer:
Having an Anti-Müllerian hormone measure of over 1 but no period indicates that there is a problem. We need to specify the patient’s case. We need to find out the age. If the patient is around 30, we need to see what is happening with this patient and complete all the studies. Anyway, it’s a low Anti-Müllerian hormone level and there are no periods so this shows that perimenopause is starting and this should result in a low ovarian reserve.

Question:
My age is 46, what should I do?

Answer:
One of the most important factors is age. If the woman is advanced in age, this is the most important factor in a diminished ovarian reserve. Obviously, we must do all the rest of the studies but it’s clear that this age won’t help so she should be more directed towards egg donation than using her own eggs.

Question:
My AMH was 0.8 but FSH, LH, and estriol were normal so my doctor said that I have a good chance of stimulations.

Answer:
This happens to many patients. They have low AMH with normal FSH, LH and estriol levels. The AMH is not just about the number of eggs but it also gives a prognosis. This means a low ovarian reserve. Usually, when the Anti-Müllerian hormone level is less than 1, we should obtain a low number of eggs — around 3. Obviously, this will depend on the age of the patient, on the Antral Follicle Count scan and everything else. But the prognosis is not good.

But obviously, the doctor doesn’t want the patients to get stuck on the idea that low Anti-Müllerian hormone equals no pregnancy. You can have a low AMH but still have very good quality eggs and even if we collect a low number of eggs, these eggs are very good so we can obtain embryos. We can still obtain a pregnancy. In younger patients, this should work very well because of the quality of the eggs. This always depends on the specific case of each patient — age, Follicle Count and everything. We still have patients with these levels and pregnancies.

Question:
I did a stimulation in May and got 10 eggs. Then again in September but only got 5 eggs. I am almost 40 years old with an AMH of approx. 1.1. In between the two cycles I was diagnosed with gallbladder stones and my liver enzymes are very high. Could that have been the factor why I only got 5 eggs in the last cycle?

Answer:
I had a patient with the same case. The patient didn’t have stones but I had to remove the gallbladder and this may have influenced the metabolism of the hormones. This could have been the reason for having 10 eggs first and then 5 eggs. Or it could have been a normal cycle with 10 eggs and the other cycle had 5 eggs, just because that cycle worked like that. But probably it was influenced by the gallbladder stones.

Question:
My age is 40. Should I still continue with IVF or try with egg donation?

Answer:
Firstly, this patient is asking if she should continue with IVF so she may have had some treatments before. If she has had more than 2-3 cycles with a low response then we would recommend looking for egg donations because the response won’t improve and egg donation will give better results and increase the chances of success. If she has never tried stimulation before, IVF, or maybe 1 cycle, we could recommend that she continue to try because obviously, every patient has the right to try her own eggs. We can never say ‘no’ because you never know. You must go ahead with the treatment and find out for yourself with proof whether or not it works. So, it depends. If she has had 2-3 cycles with low response, we would recommend egg donation. If she has never tried before, we would recommend trying IVF.

Question:
What about using Chinese herbs and acupuncture to help with egg levels and quality before and during IVF?

Answer:
We should be open-minded. We should consider all the options. We can never say ‘no’ to something if this is not negative for the patient obviously. These alternative medicines or alternative options will not increase the quality of the eggs or the ovarian response but they will help. They are complementary. Acupuncture will help to reduce stress and anxiety and also increase blood irrigation. They will not improve the quality but will help the process in other ways.

Question:
I was recommended an egg donor with 0.15 ng/ml and had no period back then, maybe because of stress. My periods are back now and regular so can I still try with my own eggs? I’m 36.

Answer:
You’re 36 so I perfectly understand that you still want to try with your own eggs. You’re very young. That Anti-Müllerian hormone is low so the prognosis is showing a low response. Stress is often a reason for losing periods and menstruation regularity. The bleeding is back but that does not mean that the AMH will be higher. Obviously, you will have a better chance with egg donation. However, you’re only 36 so we understand that you want to try with your own eggs.

Question:
Does the AMH level change over time? I mean, if I get tested today and then again after 3 weeks, might it show different values?

Answer:
The first and most important thing is that if you want to check the differences between Anti-Müllerian hormone levels or any other hormone levels then you have to use the same laboratory because different laboratories have different measurements and the levels will always turn out different. Now, you want to check in the same laboratory. A difference of 3 weeks in between tests will not show a difference in AMH levels. When you test FSH or estradiol you will find differences because it depends on the moment of the cycle. AMH does not depend on the moment of the cycle. 3 weeks is too short a time to consider any difference. AMH changes throughout the years but not over 3 weeks.

Question:
I am 39 years old. My AMH is 1.2 and AFC is 12. I had two IVFs with my own eggs but no pregnancy (even no positive pregnancy test). Should I move to egg donation? This is important for me.

Answer:
This case is very well specified. If there is no male factor here — 39 years old, 1.2 AMH, a good follicle count — then it may be an egg factor. Probably the quality of the eggs isn’t that good and that is why you haven’t achieved a pregnancy. Here at our hospital, we could consider a 3rd IVF trial. We’ve done 2 and we could maybe try a third and if not, then maybe try something else.

We also have to take into account psychological and financial factors. Obviously, if we had treated you here, we would have had more information about your cycles and why this didn’t work, if we had had a good number or embryos or not, what day they were transferred and so there are many other factors that we should consider. There could be other factors too — psychological or financial — so we could consider other options, to go directly for egg donation, but this is something very personal. This is something that should be explained and discussed in consultation with a doctor, taking into account all the factors. But with this information given right now, why not try a third one. But this will depend.

Question:
Does using birth control medicine prior to stimulation (one or two months before the stimulation) help the quality and quantity of the eggs?

Answer:
No, the use of contraceptive pills does not help, does not increase the quality or quantity of the eggs. We use contraceptive therapy to regulate the cycles or synchronise the cycles but not to help the quality or quantity of the eggs. That will not help.

Question:
Does it help at all to take CoQ10? If so, what’s the recommended dose? 100 mg? 400 mg?

Answer:
Obviously, there is scientific evidence that Coenzyme Q10 helps. This is a bio-element that produces energy and helps the normal functioning of the ovaries. Through the years, we experience cell damage, so Coenzyme Q10 may help, but we can also consume Coenzyme Q10 through food. We use this more on men than women. Although it may help, it will never increase. It’s only a help but it doesn’t help to increase the quality. 

There has been a study in Canada of patients between 36-43 years old and they didn’t find any results. In any case, when we prescribe this medication here, we do so with doses of 100 mg.

Question:
How can I improve the thickness of the endometrial lining?

Answer:
Well, this depends on the specific case of the patient. Obviously, we need to know what kind of treatment she has undergone, if she has gone through a natural cycle, if she’s been stimulated, if she’s had IVF or egg donation, if they’ve focused on the endometrial thickness. So, there should be a study to see why she’s not improved the thickness. So, if when we know why or what treatment she’s had and why it’s not increased, then we can focus on increasing it.

Question:
I am nearly 47 and had a low AMH of 0.4 and only 1 follicle in a scan 2 years ago. I had 5 egg donations. All failed for no known reason. All the conditions were considered to be perfect. What next? My partner’s age is 35. Good quality.

Answer:
This patient is 47 so 5 egg donations is a good number of cycles. When there is no male factor, she should consider a study of the uterus, maybe perform a hysteroscopy to see if there is a uterine factor, or any pathology, any implantation failure, auto-immune illnesses, NK cells test to show why the uterus is not implanting.

Question:
What do you think about egg banking? Is it better to freeze it as an egg or fertilise it first and freeze it as an embryo?

Answer:
A few years ago, there was no vitrification. There was freezing of the eggs or embryos. So the eggs or the embryos went through major stress through the freezing so it was better to freeze embryos than to freeze eggs. But nowadays, there is a vitrification process where the gametes go through less stress and there is not much difference between vitrifying eggs than vitrifying embryos. All things considered, it might be better vitrifying embryos but there’s no big difference.

Question:
Do you recommend doing an endometrial receptivity test for egg donation IVF success?

Answer:
If the patient has been through many IVF cycles and she’s going in for egg donation for the first time, we don’t recommend the ER test, the endometrial receptivity test, but if in a case like the one like we had before with 5 egg donations, we do consider the endometrial receptivity test when we should consider when the endometrium should be more receptive during the cycle.


Valeria Sotelo Kahane - UR Vistahermosa

About the author:
Dr. Valeria Sotelo Kahane is an experienced obstetrician and gynecologist specialized in infertility problems. She studied at the University of Buenos Aires and the Ministry of Health and Social Affairs in Argentina and is accredited in Obstetrics and Gynecology by them as well.