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Egg Reserve and Infertility

Egg Reserve and Infertility

Egg reserve means the number and quality of eggs remaining in the ovaries at a given age. It reflects the fertility potential of a woman irrespective of the cause of infertility, even male factor.

Benefits of Testing for Egg Reserve

Testing for egg reserve results should be interpreted with caution. Abnormal values should not be a cause for denying fertility treatment because the predictive power for pregnancy with own eggs is modest. For women, ovarian reserve tests give women insight into the chance of pregnancy with there own eggs. It also may indicate the need to promptly avoid delay in seeking fertility treatment.  For reproductive endocrinologists, the tests have value in designing fertility treatment and selecting the most appropriate fertility treatment protocol. They predict response to fertility medications and allow infertility specialists to select treatment protocol and gonadotropin dose. Egg reserve also predicts the number of eggs retrieved for IVF or egg freezing.

Egg Reserve: Egg Number

Although the number of eggs in the ovaries decrease with age there is significant individual variation in initial number endowed in the ovaries and the rate of decrease. Some young women has low egg number and older with large number of eggs. Ovarian reserve tests are used to estimate this number.

Egge reserve: the number of eggs in the ovaries drops with age

Egge reserve: the number of eggs in the ovaries drops with age

History

Medical history may indicate low egg reserve in women with prior excision of ovarian cysts, endometriosis of the ovaries,  women who smoke and with family history of early menopause

Antral follicle count

The number of antral follicles in the ovaries (the structures that contain the eggs) can be seen and counted using vaginal ultrasound. Performed by an experienced reproductive endocrinologist, it can accurately estimate ovarian reserve. Low count e.g <10 in both ovaries points to low reserve.

Day 3 FSH, Estradiol

FSH is produced by the master gland in the base of the brain. Estradiol is made by the follicles themselves. Measured in the second or third day of menstrual cycle, high FSH (>12) of high estradiol (>75) points to low egg reserve.

Antimullerian Hormone (AMH)

AMH is produced by the cells surrounding the eggs in small follicles and is a more direct measure of egg reserve than FSH. It can be accurately measured any day in the cycle with  little variations in between cycles. Levels <1.5 ng/dL generally indicates low egg reserve. It correlates well with antral follicle count.

Genetic Screening

Low egg reserve in few women is due to a genetic cause. Fragile X syndrome is a genetic disease that causes low egg reserve and mental deficiency in newborn males. Chromosomal abnormalities e.g Turner syndrome, translocations are also associated with low egg reserve. Genetic screening is performed using a simple blood test before starting fertility treatment.

Egg Reserve: Egg Quality

What does egg quality means ?

Good quality eggs are chromosomaly normal (has 23 chromosomes). The most important factor that prevents the achievement of pregnancy or leads to early miscarriage is an abnormal egg (has extra or missing chromosome or piece of a chromosome). Many eggs at any age in any woman are abnormal and the normal eggs are the ones that are successful in being fertilized with sperm, implant and achieve a pregnancy. These errors takes place when the original cell that produce the eggs divide to reduce the number of chromosomes to half. The division (meiosis) is many times unequal leading to an egg with an extra or missing chromosome.

Age and egg quality

The ovary releases better quality age earlier in life and lower quality age later, for unknown reason. Female age is the most important indicator for egg quality, chance for spontaneous pregnancy and after fertility treatment. Older women need to try longer to achieve pregnancy and at an increased risk for miscarriage, ectopic pregnancy and delivering a baby with chromosomal abnormalities e.g Down Syndrome. This effect of age become clinically evident at age 30 or even earlier. Age is more important than the number of eggs in the ovaries. Young women with few eggs in the ovary are more successful in getting pregnant than older women with many eggs in the ovary.

Meiosis

Meiosis

Testing for egg quality: PGD

Age is the only available noninvasive method to estimate egg quality. Healthy eggs cannot be identified using any non invasive method. It is possible to identify chromosomal errors in the egg during IVF fertility treatment after biopsy of the first polar body of unfertilized egg or after removing one cell from an embryo after the egg is fertilized then test this material for chromosomal abnormality. This process is called PGD or preimplantation genetic diagnosis. It is important to remember that PGD is not proven so far as method of enhancing fertility potential. It simply detects if the egg or embryo is chromosomaly normal or not but will not make an unhealthy egg healthy.

Read more about ovarian reserve and low response to ovarian stimulation in my review here.

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Endometriosis & Infertility

Endometriosis & Infertility

Endometriosis & infertility commonly coexist. Endometriosis can have profound effects on woman’s fertility and the ability to conceive in the future, either by virtue of the disease itself or its treatment. Endometriosis means that the tissue that lines the uterus is found in other areas, most notably the ovaries and the lining of the pelvis, frequently causing pelvic pain and infertility. In early stages of endometriosis, the implants in the pelvis may chemically affect various stages of reproduction including fertilization and implantation. In later stages, endometriosis incites scarring that can block the fallopian tubes and can produce cysts in the ovaries called endomertiomas. Experienced reproductive endocrinologist can diagnose endometriomas with high degree of accuracy using ultrasound. In other areas the diagnosis of endometriosis may requires laparoscopy.

Treatment of Endometriosis

Women seek treatment for endometriosis because of pain or infertility. Treatment for endometriosis is either medical or surgical.

Medical treatment For Endometriosis

It entails suppression of ovulation and estrogen production. Estrogen stimulates the growth of endometriosis. Medical treatment has side effects and is not suitable for women seeking pregnancy now. It, however, does not have a long lasting effects on fertility. Medications used include oral contraceptive pills, androgenic medications or gonadotropin releasing hormone agonists as depot leuprolide. Women on these medications does not need to consider fertility preservation strategies because of treatment.

Surgical Treatment For Endometriosis

Surgery aims at removal of endometriosis spots in the pelvis or excising endometrioma cysts from the ovary. Cutting the ovary and stripping the wall of the endometriomas is associated with loss of eggs during the procedure. The ovary, where the procedure is done commonly have less reserve and may show lower response to fertility medication. The risk for decreased fertility is higher if the procedure is done on both ovaries. It is also higher after extensive surgery, commonly associated severe disease in the pelvis. Sometimes the ovary need to be completely removed . Removal of endometriosis deposits in the pelvis-usually burning them using cautery-can also incite scarring that can block the fallopian tubes. Women undergoing surgery for endometriosis should consider fertility preservation. Aspiration of endometriomas is generally not a recommended treatment as they tend to recur and can cause infection.

Fertility Treatment in Women with Endometriosis

Severe Endometriosis mechanically blocks the fallopian tubs due to scarring. IVF appears to be the best treatment option. Although endometriosis reduces the response to ovarian stimulation, it does not appear to reduce the pregnancy rates

Mild endometriosis does not distort the fallopian tubes. Two treatment options are available: laparoscopy with excision or burning of endometriosis or ovarian stimulation + IUI. Both can increase the chance for pregnancy but IUI is less invasive.

Fertility Preservation strategies in women with endometriosis

Reproductive age women diagnosed with endometriosis and advised to undergo surgery by their physicians should inquire about the possible effects of surgery on future fertility and consider fertility preservation strategies. Strategies include embryo cryopreservation, egg freezing or ovarian tissue freezing.

Embryo cryopreservation

Its the standard method for preservation of fertility. It requires stimulation of the ovaries using fertility medication for approximately 10 to 12 days, followed by egg retrieval. Eggs are fertilized using partner or husband sperm. The resulting embryos can be frozen indefinitely. One risk is that endometrioma cysts can get infected at the time of egg retrieval.

Egg freezing

It can be used in women not in stable relationship and declining the used of donor sperm. It require ovarian stimulation. This is followed by retrieval and freezing. Eggs are frozen using vitrification. Vitrification is associated with better survival after thawing than slow freezing. When desired, the eggs are thawed and fertilized using intracytoplasmic sperm injection-ICSI and the resulting embryos are transferred to the uterus.

Endometriosis and Ovarian Cancer

It was noticed that women diagnosed with endometriosis has a small increase in the risk for certain rare types of ovarian cancer. Its essential that endometriomas in the ovary be thoroughly investigated using ultrasound and other imaging modalities and sometimes blood tests. Surgery may be needed to remove the cyst and submit it for pathological examination to exclude cancer.

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