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Conclusions and lessons learned from this IUI case with low AMH.

IUI can be a valid treatment that can be offered to patients with low ovarian reserve and low amh. The couple has to understand that they may take multiple cycles to achieve result.
Ovarian stimulation with gonadotropins produces a good ovarian response and may improve pregnancy rates in ladies with low ovarian reserve.

Low AMH IUI Success Stories 
We are discussing about low ovarian reserve success story of an infertile couple and low AMH IUI success. As we are writing about this, she is 24 weeks pregnant and so far having a smooth pregnancy following IUI. the below story is meant for patient education so that you may understand that Low AMH couples are also treatable and should not give up. One should also understand that treatment of low AMH couples is not easy and should not be attempted without specialist advice.

Our patient is a 30 year old home maker married to a 32 year old banker. She has been married or 3 years now and the couple has been anxious to conceive since 2 years now. The woman had visited several general gynecologists and this was her first consultation at an infertility clinic. The couple had undergone several clomid and letrozole cycles and timed intercourse. No surgical interventions in lifetime. Hsg or any tubal patency test not done.

As per our routine, I proceeded with our routine ultrasound examination of the wife that includes a detailed examination by Trans abdominal and Trans vaginal ultrasound. Our experience has shown this method to be the best way to detect infertility causing diseases and conditions. Many a times, this detailed ultrasound has given us the answer to long standing mysteries. The initial examination showed low anteral follicle count (AFC) or egg count for the lady.

You can get a better idea of IUI and its success rate at iui treatment in goa

First IUI cycle

Ovarian stimulation was done with HMG 150 units for 5 days then reassessed with ultrasound. She produced only one developing follicle on day 9. Antag was started and further doses of hmg were given for maintenance of good development. Perifollicular flow was moderate at best. We choose to give antag injections whenever possible. Antag injections prevent premature LH surge and give a better result as per our experience. Yes, this also increases the cost, but quality always comes with a price tag. Dominant follicle reached maturity at 19mm on day 13 of cycle and 10000 units of HCG was used as a trigger. Iui was performed as per our standard protocol.

The IUI success rate in this patient was about 10% at best due to the decreased ovarian reserve and low AMH. The IUI cycle failed and we proceeded with the second cycle of IUI.

 

Third IUI cycle.

Patient underwent a basal ultrasound and started stimulation on day 3 of cycle. We started patient on a combination of rFSH and HMG for this cycle and increased the dose to 225 units per day. on day 9, we had 2 growing follicles with good perifollicular flow. Both follicles reached maturity on day 13 of cycle. Antag was used as standard to prevent LH surge. Ovulation was triggered with HCG 10000 units. IUI was done as per standard protocol of Pai Hospital. We called patient after 21 days for a review and found positive urine pregnancy test.

Ultrasound was done at 7 weeks of gestation to confirm normal heart rate and intra uterine pregnancy. Standard pregnancy treatment was initiated.


The couple took a decision to go straight for controlled ovarian stimulation with IUI.

Second IUI cycle.

Patient presented with menses about 18 days after first IUI. After basal ultrasound done on the second day of cycle, ovarian stimulation was started. HMG was chosen again as the response in the last month was adequate and as per prediction. Again one dominant follicle was produced on day 12 of cycle. Perifollicular flow was better than in first cycle. HCG 10000 iu was given to trigger ovulation. IUI was done as per standard protocol followed at Pai Hospital.

This cycle too failed and patient returned with menses on 16 days after menses.

A 30 year old lady is supposed to have 5 to 7 follicles per ovary and an AMH value of 3. Our patient had total Anteral follicle count of 3. 2 follicles in one ovary and 1 follicle in another ovary. Both ovaries were smaller in size than normal. Amh was 1.2- low for patient age.

The couple was informed in detail about the following:

No fallopian tube status is known. The couple was given choice of laparoscopy or hsg or do nothing and start with treatment. The start directly with treatment also seemed like a good step ahead as the main cause of infertility looked to be low ovarian reserve.
Low ovarian reserve is a serious infertility issue and has a poor prognosis. Many oocytes have poor quality and lead to a genetic condition called aneuploidy. Aneuploidy causes defective embryo formation and may lead to miscarriages. In an IUI cycle, oocyte quality cannot be assessed as oocytes are not seen on ultrasound. Only follicles are seen on ultrasound and follicular assessment will be done as per standard procedure.
Need for controlled ovarian stimulation for a good oocyte yield along with IUI or IVF as per patient choice.
The couple has to understand that due to the poor egg counts, pregnancy rate is lesser and maximum of 105v pregnancy rate can be practically expected. Also this means that we may need 4 to 6 IUIs for pregnancy or multiple IVF cycles.

For more case studies on IUI please click here- IUI Case Studies