Wednesday, April 14, 2010

Poor quality eggs - doctor or patient ?

I just received an email from a patient who wanted a second opinion. She was 25 years old and had just completed an IVF treatment cycle at another clinic. She had got only 3 eggs and 2 poor quality embryos; and her doctor had told her that her problem was "poor quality eggs" and that she needed donor eggs. She was very upset and frustrated, and wanted to know how we could help her.

Now while it is possible that young women can have poor quality eggs, this not common. Step number 1 was to review her IVF medical records, so I asked her to send these to me.

Unfortunately, she did not have any records at all ! " My doctor refuses to give these " was what she told me. This is extremely frustrating and makes my blood boil. I cannot understand why IVF clinics do not routinely provide patients with their medical records. This is their duty and why should doctors want to hide anything.

This meant that I had to try to reconstruct the cycle based on what she had been told. Unfortunately, her information was very sketchy and unreliable. She felt she did grow lots of follicles on ultrasound scanning; and that the doctor initially was happy with her ovarian response, but managed to collect only 3 eggs at egg retrieval.

I had to ask her to start from scratch and test her ovarian reserve, so I could find out whether the reason for the poor quality eggs was poor ovarian reserve; or poor medical care. Often doctors may not do a good job with superovulation, as a result of which even patients with good ovarian reserve end up growing few, poor quality eggs. Superovulation is a skill which takes time and experience to master.

This is especially true for patients with PCOD. Doctors are often so scared of OHSS, that they end up mistiming the HCG injection, as a result of which they get poor quality embryos ( even though they may collect lots of eggs). We use a special technique and have extensive experience in doing IVF for PCOD patients, which means our pregnancy rates are better than 45% per cycle for PCOD patients. You can read more about this at !

If you get poor quality eggs, remember that there are only 2 things you can change :
  • the doctor - find a new IVF clinic;
  • your eggs - use donor eggs.
While many doctors are quite happy to push you towards using donor eggs ( this has a high pregnancy rate and is much more profitable for the doctor), this should always be Plan B. It makes much more sense to change the doctor first !

So if your doctor says you have poor quality eggs, what should you do ?

Step number one is to ask for a copy of your IVF medical reports ( make this request in writing, so that it is honoured !)

Review your IVF chart, and look especially for the following details.

Number of follicles on ultrasound scanning
Number of eggs collected and their maturity
E2 ( estradiol) levels

If you have lots of follicles but not enough eggs , this suggests poor egg collection skills. This could be because of anatomic problems which make the egg collection technically difficult. An experienced and skilled doctor can usually do a much better job !

Did you have lots of eggs but not enough embryos ? This suggests the eggs were immature and that perhaps the HCG was not timed properly, which means egg collection was mis-timed. The other problem may be a lab problem. You will need to drill down deeper ! Was IVF done ? Was ICSI done ? How many eggs were mature ( metaphase II) ? What was the egg damage rate ?

The key step is to test your ovarian reserve. The best way of doing this is to check your AMH levels. This is a new test which many IVF clinics still do not offer, because they still use the old fashioned ( and unreliable) FSH level to check ovarian reserve. If your AMH level is normal, then suggests you have normal ovarian reserve, and you'd be better off finding a new doctor. This is especially true if the AMH is high, because this strongly suggests you have occult PCOD, a diagnosis your doctor has most probably overlooked.

If your AMH is low, then this does suggest you have poor ovarian reserve. In this case, your best option would be to change the superovulation protocol and use more aggressive superovulation. If your doctor insists on using the same old rigid protocol ( because their clinic policy does not allow them any flexibility), then it's a good idea to change your doctor. As Albert Einstein said, Insanity is doing the same thing over and over again and expecting different results !

Using donor eggs is an option, but this can often be very hard to come to terms with, which is why this should be Plan B !
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