Saturday, November 7, 2009

Low Ovarian Reserve & Previous Placenta Accreta

Hi, I had placenta accreta with my son's delivery in 2007 and lost quite a bit of blood. I did keep my uterus but had to have uterine embolization to stop the bleeding. My doctors alsways said to wait 2 years before trying to conceive, but after seeing numerous doctors recently, I was told I would be risking my life again to consider another pregnancy. I also have a large fibroid about 4 centimeters in my uterus along with a distorted uterus.

The doctors feel the embolization probably caused my ovaries to stop functioning, or even the massive blood loss could have caused it.

We have looked into surrogacy but found out that I have very small ovaries, about 1 centimeter each and low ovarian reserve. The doctor did an ultrasound and said there was blood flow, but feels I am pre menopausal. I went off birth control pills in January and was tested in February. My FSH was 9 and my estradiol was 9. I did 3 days of injections (45) and the doctor only saw one follicle so said to stop treatment. In March, My FSH was 16.75 and E2 was 10. The doctor saw 2 follicles on day 2. The doctor said if I did a full round of IVF the chances would be very low and the quality most likely low. The plan was to do IVF and then have a surrogate. I went to a doctor this week that said I could try knowing the chances are low and to retrieve the eggs, even if there were only 1 or 2.

I am not quite ready to give up, we have also considered egg donor. I am 36 years old. Any suggestions or success rates would be great. Thanks so much!



I am sorry to hear about your experience. It sounds like you have very low ovarian reserve as demonstated by an elevated FSH level and poor response to stimulation. Certainly, your best option would be donor eggs. That would have a 34 - 63% pregnancy rate per IVF attempt depending on the clinic (our program is 63%). Of course, there is the alternative of trying with your own eggs. Because the stimulation would be low i.e. few eggs retrieved, the chances would go down, but there is still a chance. I have done many older (older than you) patients that have only had one egg produced, one retrieved, one fertilized and one transferred and gotten pregnant and had a baby. So in my opinion, it is more a personal decision on whether to try with your own eggs, al long as you know that the chances are reduced. There is not a specific statistic for your case that I can quote as no one has looked at pregnancy rates based on the number of eggs retrieved. In your age group, I average replacing 3 embryos with a pregnancy rate of 50%. It would probably be less if only one was replaced. European data, where they only transfer 1 embryo, shows pregnancy rates of approximately 33% in your age group. That assumes a higher number of eggs retrieved, fertilized and available to choose from. In any case, I think that if money were not an issue, and you were willing to try with your eggs at least three times (you might even need more), knowing that the chances are significantly reduced, then you should give it a try. If it fails, at least you know that you gave it your best shot, and will be ready to go to donor eggs. I certainly would allow you to have that opportunity in my program.

In terms of your pregnancy risks, you are certainly at risk for a recurrent placenta accreta if you were to become pregnant. However, that can be mitigated by being followed closely and planning for a hysterectomy at the time of cesarean delivery. I would not recommend an attempt at natural delivery in your case. I would also recommend that you consider having the fibroid removed prior to any IVF cycle to maximize the chances that they will not interfere with the IVF cycle or pregnancy. Regarding the surrogacy option. Certainly surrugacy is a good alternative and would eliminate the problems with your uterus, whether you choose to use your eggs or donor eggs. If you go this route, be sure you go with a reputable agency and retain the services of a surrogacy lawyer.

I hope this helps!
Edward J. Ramirez, M.D.,FACOGExecutive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf

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