Battling the Biological Clock in IVF: Egg Donation vs. Embryo Banking with CGH Testing – A Case Report
Today’s post will utilize a case study approach to explore a potential IVF option (other than egg donation) for women with advancing age and/or diminished ovarian reserve: Embryo Banking with CGH Testing.
LD was 42 years of age when I first consulted with her through Skype. She had 2 children from a previous relationship and had remarried 5 years prior, during which time, she and her new male partner (no male factor issues) had been trying to conceive. After 3 years of trying on their own without success they sought advice from their local reproductive endocrinologist who diagnosed diminishing ovarian reserve (FSH = 14.5 mIU/ml, E2 = 60 pg/ml and AMH = 0.8) and was wisely advised to go straight to in vitro fertilization.
After three failed attempts with this doctor using a Lupron microflare protocol on the first attempt, followed by two attempts where a GnRH antagonist (Ganirelix) was administered from the 6th-7th day of stimulation, her doctor suggested that she consider a protocol of clomiphene or Letrazole plus gonadotropins next time around. Having read several of my articles on stimulation protocols, she and her husband sought me out for a second opinion.
We discussed the pros and cons of doing embryo banking with CGH embryo selection versus IVF using an egg donor, and she ultimately decided to go with embryo banking. Frankly, since she already had 2 of her own genetic offspring (albeit from a previous relationship), while her partner had not fathered any children, I actually recommended that she consider egg donation, but told her that the decision was rightfully her and her partner’s to make.
We took LD through 2 IVF cycles using the agonist/antagonist conversion protocol (A/ACP). Our goal was to secure 5-6 blastocysts over several stimulation cycles, then send all the biopsied DNA in a single batch to the lab for chromosome analysis using comparative genomic hybridization (CGH). In the first IVF cycle, we harvested 8 mature eggs, all of which fertilized via intracytoplasmic sperm injection (ICSI). Three days later, we biopsied the embryos and stored the DNA for subsequent testing. She ultimately propagated 3 blastocysts from the first cycle, which were cryobanked (vitrified).
Two months after her first egg retrieval, she underwent her 2nd IVF attempt using an identical protocol. This time she made two blastocysts that were also cryobanked. She decided at this point that she was ready for us to send the accumulated samples to the lab for testing. This was done, and the results showed that one of the five expanded blastocysts in storage was “CGH normal” (had a normal numeric chromosomal configuration). The following month, she underwent embryo transfer using this single embryo and conceived. An amniocentesis done at 14 weeks confirmed a chromosomally normal female infant, and she is now at 28 weeks along and doing well.
LD’s case illustrates several important points:
- Embryo banking provides an excellent alternative to egg donation in older women and women with diminishing ovarian reserve. This does not mean that the recommendation that I made, i.e., that she and her partner choose egg donation, was not the right one. It was indeed, but clearly it was not the only option as evidenced by the anticipated outcome in this case.What embryo banking does is provide an opportunity for people who produce fewer eggs by virtue of diminished ovarian reserve and because their eggs are likely to produce a lower percentage of chromosomally normal (“competent”) embryos, with the opportunity to try and improve their odds of having their own genetic offspring by stockpiling blastocysts until enough are available to justify testing by CGH. More and more patients are choosing embryo banking preferentially. For many it offers an additional benefit, namely that if they are able to accumulate several CGH normal embryos, they, by “making hay while the sun shines”, might well have the chance to have more than one baby over time.
- This case again serves to illustrate that it is important to down regulate LH in older women and women with diminished ovarian reserve. As I’ve pointed out on numerous occasions, in these patients, increased LH output has the effect of increasing ovarian testosterone production, thereby compromising egg development and subsequent embryo quality.Protocols such as the Lupron “microflare” approach cause increased LH to reach the ovary at precisely the time that ovarian stimulation is initiated and egg development begins. The use of drugs such as clomiphene and Letrazole also increase LH output to the disadvantage of older patients and those with diminished ovarian reserve. The protocol we used (A/ACP) is a long pituitary down-regulation protocol coming off the birth control pill, both of which suppress LH, giving the ovaries a “breather”, and reducing the negative impact on egg/embryo quality.
- The odds are that this patient will not be able to have another baby with her own eggs, given her progressing age and its effect on ovarian reserve and egg quality. Thus, if there iss to be another baby for this couple in the future, egg donation would probably provide the only realistic option.
This case serves to once again highlight the fact that embryo banking indeed offers a realistic alternative to egg donation for some older women and/or for those with diminished ovarian reserve to have their own genetic child.