Premature Ovarian Failure and Ovarian Insufficiency Chat

May 20, 2008 - Tuesday
8:00 PM to 9:00 PM (EST)
Guest Speakers: Eve Feinberg, MD, Fertility Centers of Illinois

Categories

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[Tue May 20 16:54:30 PDT 2008]	Corey_Whelan	Hi everyone and welcome Dr. Feinberg.
[Tue May 20 16:54:37 PDT 2008]	drfeinberg	Hi
[Tue May 20 16:55:16 PDT 2008]	Corey_Whelan	I'm Corey Whelan, your chat moderator this evening. Tonight we will be discussing POF with Dr. Eve Feinberg of Fertility Centers of Illinois.
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[Tue May 20 16:55:51 PDT 2008]	Corey_Whelan	We officially begin in five minutes but please feel free to begin to post your questions now if you would like
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[Tue May 20 16:57:30 PDT 2008]	Corey_Whelan	Dr. Feinberg, would you like to give us a brief synopsis of what pof is?
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[Tue May 20 16:58:16 PDT 2008]	drfeinberg	POF, or premature ovarian failure, ranges the spectrum from severely diminished ovarian reserve to total cessation of ovarian function, or early menopause
[Tue May 20 16:58:50 PDT 2008]	drfeinberg	I like to think of POF not as ovarian failure, but rather ovarian insufficiency
[Tue May 20 16:59:37 PDT 2008]	anna	Hi Dr. Feinberg. Thanks for taking our questions. my question has to do with our 1st IVF/ICSI cycle done last month. I had 7 mature eggs, when the embryologist ICSI'd them, he said I had 4 eggs "fragment" or "lyse". I only had 3 of the 7 fertilize (no pg resulted). I have never heard of eggs "lysing" before. Please tell me what could cause this- does it have to do with poor egg quality or low reserve? I'm 32 with day 10 FSH of 10.1 (husband has 2% morphology). Is it a lab issue? We're changing med protocol for next cycle. (sorry so long!)
[Tue May 20 17:00:22 PDT 2008]	Julie	Hello Dr Feinburg. I have high fsh and pof. I have not responded to meds. I have been on meds as high as 600 FSH a day and only get 1 egg. They have tried protocols for poor responders also to no avail. It has been about a year since my last try....I have a ton of Gonal-F left and rather than waste a thousands dollars in Medicine are there any new protocols that you know of that I could suggest to my doctor to try? Thanks
[Tue May 20 17:00:23 PDT 2008]	drfeinberg	Its hard to say for sure without a thorough review of your records. How old are you? Your FSH is borderline, but should not explain why your eggs "lysed"
[Tue May 20 17:00:46 PDT 2008]	drfeinberg	Hi Julie, How high is your FSH level?
[Tue May 20 17:01:10 PDT 2008]	Julie	ranges from 9 to 14 (I am now 39 years old)
[Tue May 20 17:01:28 PDT 2008]	anna	I'm 32 (day 10 fsh of 10.1). is it a med protocol that "over-cooked" my eggs? or is it premature ovarian decline?
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[Tue May 20 17:01:53 PDT 2008]	drfeinberg	Julie, I would put you into a category of "diminished reserve" and not POF. Has anyone done an antral follicle count on your ovaries on cycle day 3?
[Tue May 20 17:02:07 PDT 2008]	drfeinberg	Anna: how many days were you on stimulation drugs for?
[Tue May 20 17:02:13 PDT 2008]	anna	13 days
[Tue May 20 17:02:21 PDT 2008]	Julie	yes - about 6 on each side.
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[Tue May 20 17:02:47 PDT 2008]	drfeinberg	It may very well be due to a long stimulation cycle. This is unusual and I would recommend a different protocol where you stimulate for a shorter period of time
[Tue May 20 17:02:54 PDT 2008]	anna	we started with pure FSH and added a little menopur at the end. he wants to change and add menopur from the start. have you ever heard of eggs "lysing"???????
[Tue May 20 17:03:21 PDT 2008]	drfeinberg	Julie, with 6 antral folllicles on each side, i would expect that you might be able to stimulate better. Have they tried an estrogen priming protocol (EPP)?
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[Tue May 20 17:04:07 PDT 2008]	drfeinberg	Anna: to be honest, I have not heard of eggs lysing. You may want to consider a program with a different laboratory, or at the very least, seek a second opinion with a thorough review of your stimulation and the laboratory sheets
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[Tue May 20 17:05:14 PDT 2008]	Julie	No - how does that work EPP? --I will suggest it.
[Tue May 20 17:06:21 PDT 2008]	Andrea	Dr. Feinberg: I am 28 years old and just came off oral contraceptive in August 2007 because my husband and I decided to try to start a family. I was having normal cycles and ovulating (confirmed through temp. charting and ovulation predctors) through Dec. 2007. My cycles stopped in January and I was just told my day 3 FSH is 88 (yikes!) and my day 3 E2 is 29. My RE just diagnosed me with POF. I am just confused about how I could have POF since I was having normal cycles for a few months. Do you recommend going back on the oral contraceptives to regulate my cycles or should I pursue HRT? Thanks for taking our questions.
[Tue May 20 17:06:25 PDT 2008]	drfeinberg	No birth control pills, ganirelix and estrace in the luteal phase of your cycle then switch to microdose lupron with menses and high doses of gonadotropins. in poor responders, it is a good protocol for a last try
[Tue May 20 17:07:35 PDT 2008]	drfeinberg	Hi Andrea. I would not recommend going back on oral contraceptives. I would recommend pursuing further testing to find out why you have POF. Also, 5% of women with POF are able to conceive with estrogen replacement therapy which does not prevent you from ovulating as birth control pills do
[Tue May 20 17:08:45 PDT 2008]	anna	does one become "aware" of POF from the pattern of menstrual cycles (i.e., getting longer, shorter, irregular, etc)??
[Tue May 20 17:08:58 PDT 2008]	drfeinberg	Andrea: if you are interested in further testing, the NIH has a great research protocol that you can participate in at no cost. You fly out to Bethesda MD and undergo vigorous testing to help figure things out.
[Tue May 20 17:09:46 PDT 2008]	drfeinberg	Anna: shortening of cycles can be a sign of diminished reserve. This can precede other signs like elevated FSH
[Tue May 20 17:12:17 PDT 2008]	Andrea	Thanks Dr. Feinberg. I have heard of the NIH trial. I wasn't sure if it was for women trying to get pregnant. My metabolic profiles came back fine, I am currently waiting for the chromosomal and anti-ovarian antibody tests to come back. Are there more you recommend?
[Tue May 20 17:12:28 PDT 2008]	KB	Dr Feinberg, can you please explain how you would diagnose POF - what are the standard tests, etc? I did not respond well to stims during my first IVF (only 3 eggs retrieved) and I'm 39, but I never really got a solid diagnosis from my doc. I may be starting up treatment again this summer with FCI, and wondered what tests would be appropriate.
[Tue May 20 17:13:54 PDT 2008]	drfeinberg	The NIH trial is for all women, regardless of whether you are trying to get pregnant or just get more information. You should also be tested to see whether you have a mutation in FMR1, Fragile X testing. More important than anti-ovarian antibodies are anti-adrenal and anti-thyroid antibodes.
[Tue May 20 17:13:58 PDT 2008]	osuzzana	Hello. My cycles have been somewhat irregular within the past 6 months (most likely due to utering polyp, which I had removed in March) and now they're getting back more regular, around 34 days. Is it typically true that ovulation occurs apx 12 days BEFORE the start of the new cycle? Thanks, Susan.
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[Tue May 20 17:15:17 PDT 2008]	drfeinberg	KB: the standard diagnosis of POF is made by loss of menstrual cycles and elevated d3 FSH. Ovarian insufficiency is harder to diagnose, this diagnosis may be made based on the response to ovarian stimulation, based on low antral follicle counts and high FSH. Strictly speaking, POF FSH >20
[Tue May 20 17:16:02 PDT 2008]	drfeinberg	Susan: ovulation typically occurs 14 days prior to cycle day 1. So, if you are ovulating, it would be around day 20. Longer cycles have a tendency to be anovulatory
[Tue May 20 17:16:36 PDT 2008]	drfeinberg	KB: you may also want to consider doing a CCCT, clomiphene citrate challenge test
[Tue May 20 17:17:04 PDT 2008]	rbiggs	Hi Dr. Feinberg. I am 35 and had a failed IVF attempt last October(did not respond to stim. meds). My antral follicle count was 7 and my initial FSH was 28.5 and has been as high as 36.9. My doctor did not want to tell me that I have POF. I have been pursuing TCM since October and got my period back in Jan and Feb (LMP 2/26/08).To complicate things, I have an endometrioma (3.5 cm) on my left ovary. Do you think removing the endometrioma would help me recover some ovarian function?
[Tue May 20 17:17:19 PDT 2008]	osuzzana	Thanks. But this can change from cycle to cycle, correct? When you say longer cycle, do you generally mean >30 days?
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[Tue May 20 17:18:30 PDT 2008]	drfeinberg	Rbiig: What is TCM? I don't think that removing the endometrioma will improve the FSH. Many of the studies published have actually shown a worsening of ovarian reserve with surgery for endometriomas. They should be removed to rule out malignancy or because of pain, but not for fertility
[Tue May 20 17:18:39 PDT 2008]	drfeinberg	Susan, yes, longer than 30 days
[Tue May 20 17:19:16 PDT 2008]	sb10847	I'm 39, with nlm FSH, 4 failed IVF, Gr 2 and 1 embryos (#5-11 fertilized any given cycle), dx w/clotting issue prior to IVF #3 - rx Lovenox/ASA; do you think back - to- back cycles negatively affect egg quality in the latter cycle?
[Tue May 20 17:19:40 PDT 2008]	rbiggs	Traditional Chinese medicine- accupuncture and herbal therapies
[Tue May 20 17:20:13 PDT 2008]	drfeinberg	sb: i always think it is good to take at least a month off between cycles
[Tue May 20 17:20:26 PDT 2008]	Andrea	Do you recommend any alternative therapy (i.e. wheatgrass, royal jelly, acupuncture) to help reduce FSH?
[Tue May 20 17:20:50 PDT 2008]	noranata	for someone that is trying to get pregnant and is being trying to 1year 6months, after undergoing different tests,what can you suggest l do to concieve
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[Tue May 20 17:21:40 PDT 2008]	KB	My doctor had me do three insemination cycles with clomid before moving me on to IUIs and then IFV with Gonal F - would these Clomid cycels be considered the CCT? My guess is not....
[Tue May 20 17:21:53 PDT 2008]	noranata	how does FSH help
[Tue May 20 17:22:10 PDT 2008]	drfeinberg	it cannot hurt, but I am not sure that it really works. I have patients with high FSH stimulate better with accupuncture, but am not sure whether this is due to a reduction in FSH levels or how it works. I do recommend accupunture before, during and after stim, especially to patients with high FSH. I have not seen much improvement with wheatgrass or royal jelly
[Tue May 20 17:22:53 PDT 2008]	drfeinberg	KB: a CCCT is where the FSH is measured on day 3 and again on day 10 after taking CC days 5-9. You can easily combine a CCCT with a treatment cycle and get some more information
[Tue May 20 17:23:07 PDT 2008]	drfeinberg	noranata: can you clarify your question please?
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[Tue May 20 17:24:03 PDT 2008]	drfeinberg	noranata: it depends on what your doctor has found in terms of why you have not been getting pregnant.
[Tue May 20 17:24:57 PDT 2008]	mvhope	.
[Tue May 20 17:26:15 PDT 2008]	noranata	my doctor had me do hormone test which came as balance,sonogram.l have being trying to concieve for more than a year and half,,so far he told me nothing is wrong.l asked him the possibility of going on clomid but said he cannot recommend it for that lm ovulating, though l find it difficult to believe l ovulate because l dont see any stretchy egglike for ovulation
[Tue May 20 17:27:00 PDT 2008]	drfeinberg	Clomid is also good for people with unexplained infertility, even when ovulating. I would get a second opinion and talk to a reproductive endocrinologist
[Tue May 20 17:27:36 PDT 2008]	Andrea	How variable is FSH from cycle to cycle? I feel like it might be impossible to get my down from 88 to within treatment range. My FSH has only been checked once, so I am hoping it may improve. What is your cutoff for IUI are IVF with high FSH?
[Tue May 20 17:28:03 PDT 2008]	Andrea	oops "are"="or"
[Tue May 20 17:29:10 PDT 2008]	drfeinberg	While there is some cycle to cycle variation in FSH, the worst value is always the most predictive. It is definitely worth re-checking just to make sure that there was not a laboratory error, however, 88 unfortunately is very high. In general, I don't like to attempt IVF with an FSH above 20
[Tue May 20 17:29:14 PDT 2008]	osuzzana	Is it probable or even possible to have FSH within the "normal" range (6.5) and not ovulate?
[Tue May 20 17:29:14 PDT 2008]	grace	Hi, I just turned 32 on Sunday. My FSH levelshave fluctuated between 56-3.6. However the 56 was not a day three testing. In the past year, I've tried Clomid once at 150 mg and produced three large folicles. Could this be anything other than peri-menopause?
[Tue May 20 17:29:44 PDT 2008]	drfeinberg	Susan: yes, absolutely. There are many reasons why people don't ovulate and even with a normal FSH it is possible to be anovulatory
[Tue May 20 17:30:28 PDT 2008]	drfeinberg	Grace: what was your estrogen level on the day that you had an FSH of 56?
[Tue May 20 17:30:51 PDT 2008]	noranata	what can l do because lm 34 and will soon be 35, do you think my husband should also check himself of low sperm because he is 53
[Tue May 20 17:31:11 PDT 2008]	sb10847	In your research, have you found that any environmental exposures or toxins contribute to poor egg quality?
[Tue May 20 17:31:13 PDT 2008]	KB	Thank you Dr Feinberg. I have one more question please. I'm trying to determine the appropriate time to visit with an RE again/start another IVF. Although I did not respond well to stims, I did conceive last Aug with 1st IVF with ICSI (with only three eggs retrieved and one viable embryo transferred). Unfortunately, our baby had Trisomy 18 with fatal abnormalities and we terminated with induced labor. I'm 5 months post partum now and having lots of abnormal bleeding due most likely to anovulatory cycles - started Provera today in order to induce period to enable saline u/s and rule out placental remains. If that is ruled out with saline u/s at beginning of June, could I consider cycling, given this hormonal issue? (sorry for lengthy question)
[Tue May 20 17:31:16 PDT 2008]	drfeinberg	noranat: absolutely, I am surprised that he has not been checked yet
[Tue May 20 17:31:30 PDT 2008]	grace	I don't recall exactly. I think 29.
[Tue May 20 17:33:26 PDT 2008]	drfeinberg	KB: I am sorry to hear about your loss. Yes, as long as your cavity is clear and you don't have any retained placenta, you most likely can begin cycling if your baseline ultrasound was and hormone levels were back down.
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[Tue May 20 17:33:46 PDT 2008]	noranata	but he has 3kids from another marriage, what lm worried about is that during his ejaculation he complains that it looks as if nothing is coming out and his sperm does not look more enough when coming out
[Tue May 20 17:34:38 PDT 2008]	drfeinberg	Grace: that is a pretty high FSH level, but if it was not on day 3 it may not represent ovarian failure. You need a thorough evaluation of your ovarian reserve with another d3 FSH, antral follicle count and ovarian volumes
[Tue May 20 17:34:58 PDT 2008]	drfeinberg	noranata: he may be having retrograde ejaculation. Does he have Diabetes?
[Tue May 20 17:35:40 PDT 2008]	noranata	no he doesnot have diabetes, what is the remedy
[Tue May 20 17:35:58 PDT 2008]	drfeinberg	SB: there is some research showing an association with environmental toxins and egg quality, though nothing definitive. I believe there is something to this though
[Tue May 20 17:36:25 PDT 2008]	drfeinberg	noranata: He needs a semen analysis to figure out whether there is sperm and what the volume of the ejaculate is.
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[Tue May 20 17:37:59 PDT 2008]	Andrea	Dr. Feinberg: I had a Provera-induced period during my day 3 FSH bloodowrk. It was a barely-there period with only slight spotting. Could this contribute to the high day 3 FSH?
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[Tue May 20 17:38:21 PDT 2008]	drfeinberg	Andrea: that should not affect the FSH level
[Tue May 20 17:38:31 PDT 2008]	noranata	pending his treatment, what should l do on my own. and moreover he is on norvacs for his blood pressure, do you think it can also affect his sperm. because every month l see my period at the same time but sometimes 4 days late
[Tue May 20 17:38:32 PDT 2008]	sb10847	what is your opinion about autologous co-culture and its contribution to better quatility eggs?
[Tue May 20 17:39:12 PDT 2008]	drfeinberg	SB: Cornell has published some good data on this. If you are considering this, I would go there. I don't know of another program that has reported success with it.
[Tue May 20 17:39:13 PDT 2008]	KB	Thank you. One quick question for clarification. What hormone levels would need to be back down? The only thing that has been tested so far is progesterone, which was low/negative (suggesting anovulatory cause of this uterine bleeding).
[Tue May 20 17:39:25 PDT 2008]	drfeinberg	KB: hCG
[Tue May 20 17:40:27 PDT 2008]	drfeinberg	noranata: you should be treated by a reproductive endocrinologist at this point.
[Tue May 20 17:41:47 PDT 2008]	noranata	l really appreciate your help but do you know of anyone you can recommend for me with an affordable price, l live in Dallas
[Tue May 20 17:42:45 PDT 2008]	drfeinberg	I think the AFA website has listings of reproductive endocrinolgists in Dallas
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[Tue May 20 17:43:02 PDT 2008]	grace	I've had several day 3 FSH levels and they're all over the place. The FSH level of 56 was taken on approximately day 36 (i.e. I had skipped a period and was having menopausal symptoms, so my doctor ran the blood work). Since that initial level of 56 in June of 2007, I've had several readings (2 in the 14 range, 1 at 30, 1 at 24, and several below 10). Since that initial level of 56, I also became pregnant on my own and miscarried. I have one daughter presently and she was conceived quickly without any medical intervention. After I had her, my period was very, very heavy, so I was placed on birth control for one year. When I went off of birth contral (i.e. March of 2007) that's when everything seems to have gone out of whack. I've been diagnosed with premature ovarian failure by one doctor and the doctor I'm currently treating with has advised me that I don't have premature ovarian failure and he's not even sure if I'm peri-menopausal. From what I've read, I am peri-menopausal and it's not worth treating me with Clomid or other follicle stimulating drugs during months that my FSH levels are low. Is this true?
[Tue May 20 17:44:11 PDT 2008]	noranata	thanks,lm signing off now to go to the website
[Tue May 20 17:45:36 PDT 2008]	drfeinberg	Grace: the highest day 3 FSH is the most predictive. With a day 3 of 30, I don't think you would benefit from gonotropins on a cycle where your FSH is low. You should not use Clomid
[Tue May 20 17:45:46 PDT 2008]	Corey_Whelan	folks, we have about ten minutes left so please get your last questions in
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[Tue May 20 17:46:49 PDT 2008]	michal69	what do you think about the anti-mullerian test, how accurate is it?
[Tue May 20 17:47:52 PDT 2008]	drfeinberg	michal69: I think it adds to the complete picture. It is a good test when used in combination with FSH, antral follicle counts and ovarian volumes. The accuracy is still being debated, though it does seem to be pretty good.
[Tue May 20 17:47:56 PDT 2008]	grace	Is there any treatment that might be successful for me other than getting an egg donor?
[Tue May 20 17:48:24 PDT 2008]	Julie	Do you think that you are only as good as your highest FSH. If your FSH flucuates monthly - is it best to weight for a lower FSH month to try to stimulate?
[Tue May 20 17:48:48 PDT 2008]	michal69	have you seen a correlation btwn premature ovarian failure and hypothyroidism?
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[Tue May 20 17:49:03 PDT 2008]	drfeinberg	grace: there is always a chance that you would conceive spontaneously, but I do think that your likelihood would be highest with donor egg
[Tue May 20 17:49:53 PDT 2008]	drfeinberg	michal69: yes, many patients with POF have anti-thyroid antibodies and hypothyroidism. In fact, when the diagnosis of POF is made, you should check thyroid antibodies and monitor annually
[Tue May 20 17:50:13 PDT 2008]	grace	So, are my options donor egg or attempt to conceive on my own? Is there anything in between the two that might work?
[Tue May 20 17:51:42 PDT 2008]	Julie	Do you foresee donor eggs going down in cost as it gets more popular? I could not beleive the cost of it and it is not even guarateed success
[Tue May 20 17:52:04 PDT 2008]	drfeinberg	grace: I would clearly need to review records to make a definitive recommendation, but it does seem that your likelihood of natural conception is the same as it would be with treatment.
[Tue May 20 17:52:44 PDT 2008]	drfeinberg	Julie: yes, I do think that the cost may come down.
[Tue May 20 17:53:03 PDT 2008]	grace	Thank you for your time.
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[Tue May 20 17:53:18 PDT 2008]	Andrea	Thanks Dr. Feinberg..
[Tue May 20 17:53:38 PDT 2008]	KB	Thank you for your time Dr Feinberg
[Tue May 20 17:53:55 PDT 2008]	Corey_Whelan	folks, we have about five minutes left to our chat. I want to take this opportunity to thank Dr. Feinberg for being here and to all of you for asking such great questions. Please feel free to stay as long as you would like to after 9, but we need to let Dr. Feinberg go when she is ready. Thank you all so much!!!
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[Tue May 20 17:55:30 PDT 2008]	drfeinberg	signing off. Best of luck to everyone!
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[Tue May 20 18:37:42 PDT 2008]	michal69	thank you
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