Thursday, September 22, 2011

Secondary Infertility: Decreased Ovarian Reserve And Low Morphology May Be The Culprits


I just turned 33 and I have one beautiful 18 mo little girl who is the love of my life. She was conceived on our 3rd iui using 5mg of Femara. My husband has low morphology (6%) and I have no regular periods. We both exercise / eat as we should and have no other health issues. We are considered unexplained infertility.

For the past 6mos we have been trying to conceive. I just had a large polyp removed and my fsh levels were tested. 2 1/2 years ago they were 7.0. 6 weeks ago they were 12.1. We are trying to figure out what to do next. We definitely want another child (And we would be open to 3). My questions are:

1) What do you recommend for medication? Is Femera a good starting point? Should we use the same dosage or higher?

2) Should we try an IUI or go straight to IVF?

3) Are there any "rules of thumb" for why FSH increases and how quickly it increases? I've heard stress can impact it. Thanks in advance for your help. C. from Washington State


Hello C. from the U.S.,

Congratulations on achieving your first baby relatively easily. You do not have "unexplained" infertility as you have two reasons: sperm abnormality/low motility and irregular periods (ovulation dysfunction). Those are reasons enough to prevent spontaneous pregnancies.

In terms of your FSH level, I have to presume that it was drawn on cycle day #2 or 3, because that is the proper time to do this test and the only way that it an be interpreted. If it was, the elevated FSh level of 12.1 is not a good finding. This is called "decreased ovarian reserve", which basically means that your ovaries will be more resistant and less productive if stimulated with fertility medications. It is not an indication of ovarian function, but is somewhat of a time clock. Once the FSH level reaches 15, most IVF clinics will require you to use donor eggs. When it reaches 20, it means you are in menopause, which in your young age would be classified as premature ovarian failure. So from a time perspective, that means you don't have a lot of time to waste.

Certainly IUI is an option for you, and somewhat reasonable since it worked before. The FSH level will have no bearing on its chances of success. Chances of success depends on age and the sperm problem. If you wanted to do IUI first, I would limit it to no more than 4 attempts. You can use Femara, Clomid or injectables for these attempts and even alternate them, but don't waste a lot of time. Keep in mind that the chances of pregnancy with IUI in your age group is 20% per attempt. By four attempts you should be pregnant, otherwise the statistical chances drop dramatically after that.

If the IUI's fail, then you need to progress aggressively and quickly, especially if you want to have more than one more child. In that case I would recommend proceeding to IVF with ICSI. This will give you a 74% chance of pregnancy per attempt in my clinic (and is the treatment level that most infertility specialists would recommend with an FSH level above 10. Most would recommend not even to try the IUI).

I can't tell you why the fSH is elevated. That is an unknown.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

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