Physician-To-Physician Consult

Dear colleagues
I have a 28 yrs old pt with bilateral endometriotic cyst(left 2x3cm,rt 1.5x2cm),previously undergone surgery for endometriosis 1year back, pt has an AMH of 1.2,AFC 5. which is the best protocol for IVF

Dr Chandrika Kulkarni, MD (obg), Narayana Health city Bangalore

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Answer by Gillian Lockwood

In such a young woman, I would advocate a long (down regulated) protocol (possibly with a depot agonist) and then a moderately high stimulation regimen depending on her BMI and follicular phase FSH.
I need to know the units for her AMH (ng/ml or pmol/l) If it is the latter then the ovarian reserve is very low and she should be warned that egg yield may be low.

Answer by Norbert Gleicher

In order to answer this request accurately, we need to know this woman's functional ovarian reserve. I assume it is diminished but the question is by how much.
If it is diminished, she also need an evaluation of her androgen levels in order to determine whether she would benefit from DHEA supplementation.
Moreover, if this patient, as expected, has low functional ovarian reserve for her age, I would NOT place her into a long agonist cycle. Indeed, I would avoid anything
suppressive on ovaries (I.e., no OCPs, no long agonists, no antagonists), which leaves only a microdose agonist stimulation.
Best regards,

Answer by Marc Germond

The low "iatrogenic?" ovarian reserve is this young pt might indicate as a first step approach a mild ovarian stimulation (150 IU FSH) since D5 with 2-3 Days antagonist in the late follicular phase and single oocyte recovery.

Best regards
Marc Germond, MD

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