DOR: Decreased NOT Depleted Ovarian Reserve
The topic of tonight’s show is decreased ovarian reserve, also known as DOR.
The first thing that a lot of people think of when they hear DOR and look it up is that it means “depleted ovarian reserve,” and that if they have this diagnosis, they’ll also need donor eggs.
But, The reason I’m talking about this is that I want people to know that it doesn’t mean “depleted”, it actually means “ decreased ovarian reserve,” and there’s a huge difference between the two.
The fact is that decreased ovarian reserve is like having teeth. Most, if not all, of us have teeth. And, at some point in our lives, every single woman is going to have DOR.
The problem is that many women have DOR before they’re actually done with their family. What do you do if that happens to you? What do you do if you feel like all of a sudden you’re at this “egg cliff?”
The truth is that eggs decrease over time — it doesn’t just happen all of a sudden. The average age of menopause is 52, approximately, and it’s really hard to get pregnant in the 10 years leading up to that age.
But, before you’re facing the “egg cliff,” I want you to know how to figure out where you are with your fertility and the real story of your DOR. That’s what we’re going to talk about.
Dr. Aimee:
First of all, what are some things that can actually cause DOR, or a decrease in ovarian reserve? Most of the time, it’s just genetics and how many eggs you’re born with, and simply age.
Smoking is actually one thing that could cause DOR. From my standpoint, eggs and sperm exposed to cigarettes are basically being killed off. Cigarettes are egg killers and sperm killers to me. If you were to, let’s say, take the fluid around an egg from someone who is a smoker, that will actually give you fluid full of nicotine byproducts, and that is really bad for our DNA. One of the best things that you can do is stop smoking and avoid second-hand smoke to prevent DOR.
My point is while there aren’t that many studies that we can point to that allows us to quantify stress and the impact on our fertility, I do think that if there is one thing that you can do that’s in your control, that is reduce stress. At the end of the day, reducing stress doesn’t mean that all of a sudden you’ll get pregnant, but it might increase your chances just a little bit.
Diagnosis: how do you know if you have DOR?
I’m going to talk to you a little bit about how you test. One of the first tests that you do is called the FSH level. FSH stands for follicle stimulating hormone. It’s a hormone secreted by the brain and it tells the ovaries to make eggs, stimulate the follicles. Each follicle has an egg inside.
If you were to Google Image search menstrual hormones during the cycle, you’ll actually see a nice chart that shows you what FSH does over the cycle. That’s why we like to check it between cycle days one through four. If your period starts, the next day is considered day two. If you’re confused about what’s cycle day one or two for you, just ask your doctor, and your doctor will guide you as to the best day to get your levels checked.
I hear patients say to me all the time, “My doctor said that I have the FSH level of a 25-year-old.” But an estradiol wasn’t checked and an AMH wasn’t checked and an antral follicle count wasn’t done. I would really urge people out there when it comes to figuring out what’s going on with you to make sure that you get the full picture, and that includes the FSH, the estradiol, and we’ll talk about the other aspects as well.
As you can see on this chart, your age and your FSH level kind of relate to your pregnancy rate. The higher your FSH level, the lower your chances of pregnancy. This is actually the higher FSH level. Up here is the lower FSH level. When you meet with a doctor, they’ll be able to guide you as to what your FSH levels mean for you.
To have the diagnosis of DOR, most people agree that a level over 12 equals maybe having a lower amount of eggs. Remember, it’s decreased, not depleted. I actually like to alert patients that maybe something is going on with their eggs when their FSH is 9 or above. I don’t think that it’s fair to tell someone that everything is great just because your FSH is less than 10. Certainly, everything is great, but you want to make sure that people know the full picture of what their story is, especially if they want more than one child and they’re planning their future family.
The other two things that we do is look at ovaries. We have a picture of an ovary right here. Each follicle has an egg inside. We can do a count called the antral follicle count. Very easy to do, you just count up the number of follicles and each follicle should have an egg inside.
Let’s go back to the ovary. I can’t talk enough about the ovary and the eggs. An antral follicle count of 15 or above tends to be a sign that a woman has really high fertility levels, but the level changes over time. Some studies show that over six months or so that follicle count will actually go down. A follicle count of 15 for a 30-year-old means different things than a follicle count of 15 for a 40-year-old or even a 45-year-old.
Each egg has a percentage rate of being genetically viable. That rate is determined by your age. If you’re 40, an egg has a 10% chance of being genetically viable. If you’re 30, that egg has closer to a 50%, if not more, chance of being genetically viable.
When you’re facing some diagnosis that makes you feel like there is something wrong with you, before you internalize it and make yourself feel like you have levels tattooed on your forehead, realize that every pregnancy just takes one egg. These diagnostic tools just give you an idea as to what treatment options you should consider for yourself. None of the tests tell you that you have bad eggs, that you cannot get pregnant. Certainly, real life experience, trying, and actually seeing your eggs as embryos and then finding out how they look is something that can offer you a lot more information.
The other thing about DOR is that it doesn’t mean you need a donor. There is also no such thing as an egg donor emergency. Seriously.
A lot of people think that you can’t change the path to pregnancy unless you have really healthy ovaries. Let’s just say you’ve tried for six months, and you’ve tried to be as aggressive as you possibly can be with a diagnosis of DOR. Then you sit down with your fertility doctor, you reevaluate, and you say, “I’m 37. I think I want to try six more months.” Well, let’s say now you’re 38. Your chance with an egg donor is still going to be very good.
You don’t need ovaries to carry a pregnancy. The one thing I think that women with DOR worry about is that even if they change the path to pregnancy, they might have a lower chance. That’s not the case.
I’m going to tell you a story…
Paula, give me the name of someone.
Paula: Missy.
Dr. Aimee: Missy. I like that name, it’s a very cute name. I’m going to tell you about Missy…
Missy started birth control pills at 17 because she had irregular menstrual cycles. Then at 25, she went and got her boobs done, she went and got a boob job. Then what did she do? She went and she got married.
The funny thing is, at the altar, no one says “I can’t wait to meet Dr. Aimee.” Let me go back and talk a little bit more about Missy, because this story is not about me, it’s about Missy.
Missy got married. After one year of trying, what did she do? She went and she got her levels checked. What did she find out? What she found out was that she had the diagnosis of DOR. Now she is ready to be proactive about procreation.
I really want to change Missy’s story. I want to back up and say where did we as a medical community fail Missy?
If she was on birth control pills from the time she was 17 until when she got married, there were so many opportunities for her to get her levels checked so she’s not feeling like she’s standing right there at the egg cliff after one year of trying after marriage.
When she went in for her medical procedure for a breast augmentation, another opportunity. People make arguments and say egg freezing is so expensive. I would argue that getting a breast augmentation is actually just as expensive, and young women find money to do that. If family is important, then they may also want to consider egg freezing.
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But if we’re not educating the public about how to check your levels and what they mean for you, how are you going to know what you need to be thinking about or doing?
There’s this idea that you should try for a year before you even start getting checked. Let’s talk about Missy and say that while that might work for a lot of people, I think that most women should consider getting their levels checked by the time they’re 25.
The best time to have a baby, according to scientists, is between 25 and 29 years of age. My patients are over the age of 39. That’s the average age of my patients. Certainly, I have patients that are 25, I have patients that are 45, even 49, or 26. Everyone’s story is different.
I want no one to be Missy. I want everyone to be…. Give me another name, Paula.
Paula: Jenny.
Dr. Aimee: Jenny. I want everyone to be Jenny. There are so many Jennys out there, and Jenny is getting her levels checked. Jenny is getting her levels checked at 25. Jenny is considering starting her family early so that she doesn’t have to be Missy on the cliff.
I want everyone to do what they can to get ahead of infertility.
Now let’s say you have the diagnosis. You have the diagnosis of DOR. Now what?
You’re wondering why the heck am I showing a castle. I couldn’t find anything that demonstrated hocus pocus to me.
It seems like a lot of hocus pocus when I start to talk to patients about supplements, but I do think there are some patients that actually respond to supplements better than others. As far as which ones would or wouldn’t, I don’t really know why, let’s say, someone would respond to a supplement like acai berry more than CoQ10.
What I want to do is go through just a list of the hocus pocus supplements that I recommend for my patients. I tell this to everyone, just because I’m here talking to you on this show about supplements that I want you to use, it doesn’t mean that these are right for you. You have to get your levels checked. You have to meet with your physician. You have to talk about the supplements that they recommend for you in your particular situation. This show is just for informational purposes only so that everyone is like Jenny and no one is like Missy.
Melatonin is actually a supplement that I recommend to patients. I tell patients to take 3 milligrams per night, but I ask patients to get 1-milligram tablets. The reason is everyone emails me their dreams when they’re really funky and weird, and I can only handle so many funky and weird dreams. So, the goal is to take it at night only, and if you don’t have any side effects, continue it. It’s a very potent antioxidant.
We’re going to post a really nice link right now to the studies that have been summarized in a really nice article about melatonin and how it might help. When it comes to stuff like this, it’s really hard to do a really large study and take two groups of people and say no melatonin for you, melatonin for you, and then follow them and see what their pregnancy rates are. I think this summarizes how it could possibly help by improving the mitochondrial DNA in the eggs, giving it more energy, so that hopefully you’ll have a higher implantation rate and pregnancy rate.
The other supplements out there are acai berry, and there was a nice study done through CCRM showing that — the dose isn’t in the study, I don’t think, from my memory, but I tell patients to take 1,000 milligrams two to three times a day, and that might also improve egg health.
The other things that have been studied are CoQ10, at a dose of close to 600 milligrams per day. Resveratrol, I also tell patients to take about 1,000 milligrams per day. The other one is turmeric, an anti-inflammatory supplement that may help for some patients.
Again, before you start taking these things, be sure to talk to your personal physician about whether they’re right for you, because only they know what your medical history is. I wouldn’t want you to start something just because you heard it here, and let’s say for example you have really bad mood issues and you take melatonin and then all of a sudden you’re really depressed. I don’t want that to happen to anybody.
The other thing that I tell my patients who have DOR to do is take HGH. HGH is a drug abused by bodybuilders, and I wish that I could take it and look like her, but that’s not what it does for us. While we’re used to thinking of it as a drug taken by bodybuilders, hearing about Lance Armstrong and famous baseball players, what the HGH studies have shown, and the difference is subtle in the patients who took it, but it actually may increase your pregnancy rates.
If you’re facing a diagnosis where you’re being told that you have a smaller amount of eggs than someone at your age who has a good chance for pregnancy, then I think that HGH is something to consider. This is who I offer it to. I offer it to every one of my patients over the age of 40. I offer it to patients under 40 who have had one previous IVF cycle at least who haven’t been successful. I offer it to every woman, regardless of age, with an elevated FSH level.
Certainly, I talk to all of my patients about it, and if it seems like it makes sense for them, I can add it to their protocol. But for the most part, I definitely recommend it to patients who have DOR. It doesn’t come at a cheap price tag, unfortunately. A vial costs approximately $400. When you’re already spending a lot of money, that $400 can be a little bit much, so think through whether it’s right for you before you order it.
What about some other treatments? In the news, recently especially, is talk about three-parent IVF being available. Three-parent IVF is actually nothing new. It was legal and then became illegal. Now the doctor, and I don’t like what they call him, this has been all the chatter, especially this last week, is about Dr. Zhang doing three-parent IVF in Mexico.
Go to Mexico for something that is illegal in the US? Well, he actually might help patients have babies, but at what cost? No one wants to be the guinea pig. What he’s doing is definitely pushing the envelope. It sounds quite out there, three-parent IVF, it sounds like a threesome. Right, Paula?
Paula: It does. Missy, Jenny, and Tom.
Dr. Aimee: Missy, Jenny, and Tom are going to make a baby. With three-parent IVF, you have a donor egg and you swap out the nucleus with, let’s say, my egg. That gives my DNA energy to turn into a healthy pregnancy. It’s basically nucleus swapping.
So, three-parent IVF may actually be something that women with DOR who have not had successful IVF cycles should consider, but right now it is way too new for US doctors to be sending their patients to Mexico for this treatment. I do, however, ask my patients if it’s something that they’re interested in exploring, to talk to the doctor and see how it is done. I think when it comes to having a baby with your own eggs, you want to do everything you possibly can to see if it’s something that you should be pursuing. I would say most patients, especially the $100,000 price tag, they’re going to consider other ways of having a pregnancy.
The other thing a lot of people are talking about that’s also been in the news is platelet-rich plasma, or ovarian rejuvenation. It’s basically where they take your own white blood cells and plasma and they inject it into your ovaries. It takes about 10 minutes or so, and it’s similar to doing an egg retrieval procedure where it’s an ultrasound while you’re asleep, but rather than extracting eggs, they’re just pushing a little bit of fluid into each ovary while you’re asleep. Then you go home and hopefully that can somehow help you regenerate eggs.
But the pregnancy rates are super low. From what I can tell, there has been one live birth from it. There were two pregnancies; one was abnormal, and one resulted in a live birth in a woman who was under age 40. We’re talking about a 1% chance so far, from what I’ve seen. When you’re considering anything and everything to have a baby, and again we’ll post a link to that trial and to doctors who are doing it, just so you feel like you’ve seen everything that there is out there and then you’re making an educated guess about what is right for you. But I don’t recommend PRP or ovarian rejuvenation to my patients because I don’t feel like statistically speaking it’s going to give my patients the pregnancy rate that I want for them.
Another technology that a lot of patients ask about is OvaScience and their Augment treatment. I’ve actually coordinated approximately four to five cycles now, I think maybe closer to six. I have one patient who is close to delivering with the technology. This is a patient who had only one genetically normal embryo, it was very low quality, from her IVF cycle. Then she went to Canada for the therapy, and is now, like I said, almost ready to deliver. It is potentially something that patients should at least consider before trying egg donors, in my humble opinion.
Again, that’s my humble opinion, no one else’s. I always want patients to know what is available to them so that they feel like they’ve explored every option before they move on to plan B. How do you know what plan B should be if you don’t know the options in plan B?
One of the biggest recommendations I can make for patients with DOR, and I tried to find a picture that reminded me of ‘jackpot,’ and instead I found fireworks, but I think the most important thing when you have DOR is to find a doctor that believes in you. I believe in the fertility of every single person that walks through my door. It doesn’t matter what your levels are. It doesn’t matter what your FHS, your estradiol, your AMH, your antral follicle count, it doesn’t matter what they are.
I showed these pictures in a separate show. These are pictures of the patient. She actually made them for me, and I love them, they mean a lot to me, and I’ll show them again. These are two embryos that turned into twins, and they came from two eggs. She only had two eggs. She obviously had DOR because her antral follicle count was only two.
That’s not my only story. The highest FSH level that I’ve ever seen turn into a healthy pregnancy is 80. I’ve certainly had patients who are at the cusp of where their fertile window is almost closed. I’ve tried to retrieve an egg, didn’t get an egg, tried to retrieve an egg, didn’t get a healthy embryo, and then they were pregnant.
If you have this diagnosis, the best thing that you do is, like I said, find a doctor that believes in you. So, get your levels checked. It’s FSH, estradiol, AMH, and antral follicle count. Then ask why this is happening. There are fertility genetic tests that you can do looking at Fragile X or your fertility genetic profile so that you can understand more about what you should consider doing to have the family that you want.
I’m going to turn to questions if anyone has any questions for me tonight. Paula, do we have anyone asking us questions?
Paula: Somebody is asking “what were you talking about in Canada?”
Dr. Aimee: If you go to OvaScience.com. Again, I am not a representative for any of these companies. I just like talking about what’s out there. OvaScience has a technology called Augment. I really want them to be successful. I want the company to actually be right about what they think they’ve found. They think that they can potentially reverse menopause in a woman and her ovaries. I think that would be awesome, especially for women like us, Paula, who we’re going to be hitting menopause soon.
Paula: I’m right there.
Dr. Aimee: We’re right there. And maybe not have to take hormones. If they’re right, hook me up so that I don’t have to take hormones.
With Augment, what they’ve found is that they have isolated this cell in the cortex of the ovary where they can concentrate it and then inject it into the eggs after an egg retrieval, and it may in some women help the eggs grow into healthy embryos. That is what Augment is. They’re very nice if you call them, they’ll talk you through the treatment and you can find out if it’s actually something for you to consider doing or not.
Paula: Great. We also have another question. “How high is too high before the start of a cycle in your experience?”
Dr. Aimee: Most of my patients do genetic testing of their embryos before transferring. When I say most, I’m saying that probably about 95% of patients will do PGS. PGS stands for preimplantation genetic screening. I talk about it as if it’s the closest thing to a crystal ball, although murky, that you can get with IVF medicine.
I’ve done PGS in patients who have had FSH levels in the cycle that I’m treating them as high as 30 and up. I’m not extracting 10 to 15 eggs for these women. I’m extracting one egg. I have achieved success in patients like that.
However, going into something like that, I am preparing my patients for what most of the time will happen. If your FSH level is over 12, the chance of getting a genetically normal embryo is really low. You just don’t know what you’re going to get until you try. I think it’s really important to try to see if you can get a normal embryo.
The other thing is that when you have DOR, and let’s say you’re 30 years old, there is no such thing as I have the eggs of a 50-year-old or I have the eggs of a 40-year-old. I think having a younger age actually protects you. Having DOR at 37 and up is very normal, but having DOR at 26 is not that common. If you have really high FSH levels and a low follicle count, and you’re under 30, I actually think that your egg quality is going to be better than — and not just me, I think most of us as fertility doctors would agree that your eggs will be better quality than someone who has those levels at 43.
That was a good question. Any other questions?
Paula: A follow up there is: IUI versus IVF and chances of success for DOR.
Dr. Aimee: Okay. The question is whether IUI or IVF for chances with DOR. IUI is just basically a turkey baster but a little bit thinner, and in my office, not as romantic as at home or in your kitchen with a turkey baster. Clearly, medicine is my forte and not being a comedian or acting.
It’s just hard when you’re dealing with this kind of diagnosis and someone tells you that your chances of pregnancy are, let’s say, 5%. You really want to be part of the 5% that is now 100% and pregnant.
The reason why I think patients with DOR should consider IVF as soon as they have the diagnosis is because IVF is the only thing that will give you the highest chance for pregnancy. With IUI, your chance for pregnancy would be exceedingly low, but certainly I’ve had plenty of patients who have gotten pregnant either naturally or with IUI with a diagnosis of DOR.
The patients who can’t do IUI are patients with blocked fallopian tubes or low sperm quality. You want to be sure that your doctor isn’t thinking it’s just bad eggs and not paying attention to the sperm. It’s important to look at both things to improve sperm health at the same time as you’re doing everything possible to improve your egg quality if you have a diagnosis of DOR.
Paula: That’s everybody!
Dr. Aimee: Thank you for joining us. We look forward to seeing you next week on our next episode of The Egg Whisperer Show.
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Originally published at https://www.draimee.org.
