Women are born with a limited egg reserve which starts depleting with age and hence the natural fertility also declines. But there are clinical situations where younger woman of around 30 years of age face an issue of low ovarian reserve. It means that the ovaries have aged more than the biological age. This clinical situation is a challenge both to the fertility specialist and the couple.

We would like to share some interesting cases of low ovarian reserve.

VM, a 32 year old woman approached our fertility and IVF center. She was a case of Primary amenorrhea (MRKH syndrome – a rare genetic case of absent uterus). We did all her tests and found she also had a poor ovarian reserve, as her AMH (blood test to know the ovarian reserve) was low and both the ovaries were small on Sonography. Her husband’s semen analysis report was normal. For her to get her own biological child,an embryo made from her eggs and fertilized by her husband’s sperm had to be transferred in a Surrogate. We used hormonal injections to stimulate her ovaries but there was no response in the 1^stcycle. She responded in the second cycle and on egg retrieval, we got only 2 eggs, these were fertilized with her husband’s sperms. Two good quality embryos were transferred in the surrogate and to everyone’s luck, she conceived and is now 8 months pregnant.

SM, a 32 year old woman approached us for fertility issues. Her husband had no sperms in his semen. On doing some blood tests, it was found that the sperms were maturing in his testis but were absent in the semen. We first did a surgical retrieval of the sperms from the epididymis (PESA) and froze the sperms. A diagnostic Hysteroscopy(thin telescope to visualize the cavity of the uterus) was performed and it showed some adhesions which were released. Her egg reserve was also low. We then treated her with hormonal injections. We were a bit disappointed as we got only one egg. The PESA sperm was injected into the egg by Intracytoplasmic sperm injection (ICSI). The embryo was then transferred in her uterus. To our happiness, she had conceived and to our great surprise she had twins as the embryo had divided inside the uterus. She is now 12 weeks pregnant.

VN, a 36 year old woman with a low ovarian reserve approached us for treatment. She had undergone 2 IVF cycles and had not conceived. After the usual investigations, we used hormonal injections and got 5 eggs, and all 5 fertilised with ICSI. We were really happy. We did a sequential transfer in her. We transferred 3 embryos on day3 and 1 blastocyst transfer on Day 5. She too conceived. Shehad an extremely rare problem in her 6^th week of pregnancy; we had to perform an operative laparoscopy to control the bleeding from the left ovary. Her intrauterine pregnancy was not disturbed and it continued till term. She is now a proud mother of a one year old son.

So as seen here there are many challenging situations for a fertility specialistand low AMH is one of them.  One needs to be perseverant and not give up. Very often we need to use donor eggs from a younger woman. Another important point to remember is that if the woman has not found her right partner, she can freeze her eggs at a younger age and use them at a stage when she feels confident in becoming a mother.