Fertility Chronicles is proud to present a special blog series, “From the Fertility Experts,” where leading fertility experts answer commonly asked questions for patients about their fertility health and treatment options.We hope this series can help patients navigate their personal fertility journeys.—Catherine T. Yang, Editor, Fertility Chronicles
Univfy’s “Fertility Chronicles” guest blogger Dr. Ernesto Bosch shares his insights advice on personalizing infertility treatment:
In Part 1 of this series, I discussed the concept of individualized controlled ovarian stimulation (iCOS) and why it is important to match a patient to the best stimulation protocol for them. In my own practice, we find that adding luteinizing hormone (LH) to the controlled ovarian stimulation (COS) cycle produces better implantation and ongoing pregnancy rates for our older patients, specifically under the GnRH antagonist protocol. Patient-specific factors, like age, although not the only consideration, should be taken into account to identify best protocols. Slight modifications to the “one size fits all” follicle stimulating hormone (FSH) protocol, such as adding LH during the stimulation phase of the cycle, can have beneficial effects for the right patient.
Other patient-specific biomarkers have been identified and are already in use, including serum levels of anti-mullerian hormone (AMH) to identify high- and low FSH-responding patients. AMH is produced by granulosa cells within the ovarian follicles. High AMH levels correlate with a higher antral follicle count (AFC), or the number of small follicles (AFC) visible at a baseline ultrasound. I use AFC, Day 3 FSH, and AMH to choose the stimulation protocol, but also previous response in other cycles needs to be considered
If you have low levels of AMH, then protocols suited to poor-responder patients would likely be more effective for you than the standard protocol. On the other hand, if you have high levels of AMH, a milder stimulation protocol is probably safer for you not only to avoid overstimulating your ovaries, but also to improve the quality of the eggs obtained and endometrial receptivity.
It may surprise you to learn that androgens, typically thought of as male hormones, also play a role in normal follicular function. Androgens are substrate molecules that are converted to estrogens in the ovary. The addition of LH to stimulate enough androgen production for good follicle growth can counteract the typical age-related decline in basal androgen levels. Some studies support the idea that determining the basal serum androgen level may also be useful for identifying poor-responder patients and selecting the appropriate FSH starting dose.
Instead of adding LH to encourage androgen production, androgen itself can be given directly to the patient to optimize the controlled ovarian stimulation protocol in poor responders. Because androgens are known to support the survival of early-stage follicles before they become sensitive to FSH and LH, androgen may increase both the number of follicles and the health of follicles in COS cycles. More research is needed to identify which patients will benefit most from androgen supplementation and also to determine the optimal daily androgen dose, time, and duration.