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For older infertile women, AMH ( anti-Mullerian hormone, also known as MIS ( Mullerian inhibiting substance) has become the new FSH . AMH is a very good marker for egg quality - and provides us with a quantitative measure for egg quality and quality.

In the past, we had to depend upon FSH levels. A high FSH level suggests poor ovarian reserve, but FSH levels are not very reliable, because they vary according to which day of the cycle the test is done; and can also be artificially suppressed by a high estradiol level

AMH is a much better marker for ovarian reserve. It does not vary from cycle to cycle; and remains the same throughout the cycle. A low AMH suggests you have poor ovarian reserve - but even if your level is low, this does not mean you should panic !

Remember that it's just a test - and good doctors do not treat tests - we treat patients !

Step number one is to repeat it again - preferably from another lab.
Step number two is to run additional tests to check your ovarian reserve.

You have 2 options: an ultrasound test called the antral follicle count ?
and a blood test called a clomid challenge test.

Even if these are poor, this does not mean you cannot improve it ! While Western medicine does not have much to offer, there are alternative medicine options you can try to improve your ovarian reserve

These include the following:

1. Yoga
2. Acupuncture
3. DHEA, 25mg thrice a day.
4. Wheat germ daily
5. CoQ 10, 100 mg daily
6. Vit D3 ( Calcirol), 60000 IU, once a week for 10 weeks

Read the book, Inconceivable.

Re-test your AMH level after 12 weeks to see if it improves.

Even if it does not improve this does not mean you cannot get pregnant ! Patients with low AMH levels do also get pregnant on their own ( though their chances are reduced). After all, levels provide information about groups of women , and there can be a lot of individual variability !

If you have poor ovarian reserve, IVF is often your best option as it maximises the chances of a pregnancy. IVF allows you to make the best use of the few eggs which are left, by telescoping time.

Plan B would be to use donor eggs, if you are willing to consider this option. This has a much higher success rate

Many older infertile women are very unsure as to whether they need to do IVF; and if they do need IVF, if they should use their own eggs or to use donor eggs. While they understand with their heads that using donor eggs would maximise their chances of getting pregnant, it's hard for their heart to accept this decision, because most of us want a genetic link with our child !

This is especially true for older women who have regular cycles; grow follicles on ultrasound scans ; or have had a miscarriage in the last 2-3 years. If my cycles are regular and I can get pregnant in my own bedroom, doesn't this prove my eggs are fine ?

Gynecologists ( who do not specialise in infertility treatment) will often add to this confusion. Because they see 42 year old women who get pregnant in their own bedroom, they fail to understand there is a big difference in the biology of a fertile 42 year old and an infertile 42 year old. They will often "treat" these older women with clomiphene and follicular monitoring - causing them to waste valuable time !

The more sophisticated doctors will get their patient's FSH levels tested - and if these are normal, this will lull them into a false sense of security ! Not only are FSH levels very poor markers of ovarian reserve, they also vary from month to month; and if they are checked without also testing the estradiol ( E2) level at the same time, you may get an apparently normal FSH level, even if the ovarian reserve is very poor. ( A high E2 level can suppress a high FSH level into the normal range, and fool both doctor and patient !)

Unfortunately, most older women do not want to hear bad news. They are often in a state of denial and are not happy to listen to an IVF specialist who tells them that their "eggs are bad" ! They confuse calendar age with ovarian age - and are even more perplexed when they go online and read success stories of older women with high FSH levels who have got pregnant in their own bedroom !

Who should they trust ? Is the IVF doctor pushing IVF because he wants to make more money ?
Or is he providing medically sound advise ? Will you regret not doing IVF ? Or do you have an equally good chance of making a baby in your own bedroom ? And what if the IVF cycle fails ? Then what ?

While it's true that we do have better tests today for checking ovarian reserve, such as the AMH level and the antral follicle count , it's hard to make such an emotionally charged decision based purely on the results of medical tests. How reliable are these tests ? Can the results improve with alternative medicine ? herbal supplements ? acupuncture ?

If you are unsure what to do , and are emotionally detached enough to make a decision based purely on medical testing, then please ask your doctor to do a clomiphene citrate challenge test ( CCT) for you. This is a simple , inexpensive test, which provides very valuable information; and has stood the test of time. When it's hard to make a decision and you are confused, sometimes basing your decision on an objective test result can help you overcome your paralysis and move on with your life !

How does one do this test ?

Day 1 = day the bleeding of the period starts

On Day 3 , you need to do a blood test to measure your levels of FSH,LH,PRL and TSH; and AMH ( anti-mullerian hormone). Do this from a reliable lab please !

Take 100 mg clomiphene citrate from Day 5 - Day 9.

Repeat the blood test for FSH again on Day 10.

If the Day 3 plus Day 10 FSH levels are less than 25, then we can try to do IVF with your own eggs.

If the Day 3 plus Day 10 FSH levels are more than 25, this suggests you have ovarian failure,
and that donor egg IVF would be your best treatment option, if you are willing to consider this. A low AMH level will help to confirm this diagnosis.

If you are not sure how to interpret your results , you can ask me for a free second opinion !

For the older woman, time is now at a premium for you - please don't waste it ! When you are 60 years old and looking back at your life, you should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment. Treatment can be expensive, but a baby is priceless !

Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

I just saw a patient who was 40 years old; she had had 2 miscarriages; and she wanted me to do surrogacy for her. I spent a long time explaining to her why I did not think this was her best choice. Surrogacy is an expensive and complex treatment option, which is best reserved for
women without a uterus. Research shows that the reason for failed implantation is much more likely to be genetically abnormal embryos ( because of poor quality eggs), rather than a uterine problem.

Her reasoning was completely different. The fact I got pregnant means my eggs are OK ! The fact I miscarried means my uterus is defective because it could not hold the baby. This means that if use a surrogate uterus, I will have a baby !

The reality is completely different. The fact that she conceived means her uterus is fine because it allowed the embryo to implant ! However, because the embryo was genetically abnormal, it could not grow any further ! We know that the commonest reason for a miscarriage is a genetic abnormality in the fetus, and this is Nature's defense mechanism, to prevent the birth of an abnormal baby. While these defects are often random, they are commoner in older women. This is because the eggs of older women have more genetically abnormalities, because they have "aged" and have genetic defects, which cannot be screened for. From a purely medical perspective, using donor eggs would be a much better option as it would give her a much better chance of having a baby ! This was my recommendation to her, which she found quite hard to accept.

Logically, it makes no sense for me to clear her misconceptions. After all, I should be quite happy to do surrogacy for her - this is what she wants and I can charge her much more for it ! However, I refused to treat her, and suggested she find another doctor.

I have observed that there are 2 kinds of patients. One group treats me as a professional. They are looking for medical advise and guidance; and want my professional inputs. They have an open mind, and are seeking to form a partnership with me. They want to tap into my professional knowledgebase, so they can make the right decision.

The other group treats me as a technician. They already know what they want - they just want me to do this for them. While this may not be great for my ego ( after all, doctors expect patients to do everything they tell them to !), I am mature enough not to get offended, and am happy to listen to my patients and weight their inputs.

Does this mean I am wishy-washy and will do everything my patients ask me to ? No !

I use a combination of rigidity and flexibility. I am happy to accept patient inputs and preferences and modify my protocols, as as long as they do not affect the outcome ! For example, if patients want us to use the long protocol rather than the short ( which we prefer because it needs fewer injections !)

Similarly, some patients want to use rec FSH for superovulation, instead of the urinary HMG we prefer ( because it's as good and much less expensive !) and I am happy to comply.

However, I will not allow them to do anything which I feel is not right ! I am a professional , and
the buck still stops with me. I will not let them make a wrong decision, no matter what. Thus, if a patient asks me to transfer 5 embryos , I will request them to find another doctor.

Many patients come to me with preconceived notions, especially if they have done IVF treatment elsewhere. Websites and Bulletin Boards are also powerful sources of information - both good and bad ! These patients can be quite a challenge for doctors . If they are well-informed, we can learn a lot from them - but if they are not, it can be quite frustrating to get them to separate facts from reality !

Premature Ovarian Failure (POF), also known as premature ovarian insufficiency, primary ovarian insufficiency , premature menopause and primary ovarian failure, hypergonadotropic hypogonadism, is the loss of ovarian function before the age or 40. hypoestrogenism. POF affects 1% of the population.

On an average, in a normal woman the ovaries will produce eggs until the age 51, which is the average age of natural menopause. In some women, the ovaries stop functioning much earlier. This is called premature ovarian failure. Most women with POF will have irregular menstrual cycles. Initially, these are light or infrequent; and soon stop completely. The age of onset can be as early as the teenage years but varies widely. If a girl never begins menstruation, this is called primary ovarian failure. The age of 40 was chosen as the cut-off point for a diagnosis of POF. This age was chosen somewhat arbitrarily, as all women's ovaries decline in function over time.

POF is diagnosed by finding abnormally low levels of estrogen and high levels of FSH, which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs. On ultrasound scanning, the ovaries are small ( atrophic) with a very low antral follicle count. Women suffering from POF usually experience menopausal symptoms, which are generally more severe than the symptoms found in older menopausal women. The symptoms vary from patient to patient and the disorder may occur abruptly or spontaneously or it may develop gradually over several years. Women may experience hot flashes, night sweats, irritability, moodiness, sleep disturbance, decreased libido, hair coarseness and vaginal dryness.

In most patients with POF , the cause cannot be determined. Some cases of POF are attributed to autoimmune disorders, others to genetic disorders such as Turner syndrome and Fragile X syndrome. Radiation treatments for cancer can sometimes cause ovarian failure. Family history and ovarian or other pelvic surgery earlier in life are also implicated as risk factors for POF.

Serum follicle-stimulating hormone (FSH) measurement can be used to diagnose the disease. Two FSH measurements with one-month interval have been a common practice. Because the eastradiol levels in patients with POF are low, the FSH levels are very high. The typical FSH level in POF patients is over 40 mlU/ml (post-menopausal range). Many women get confused with their FSH levels. They feel that the high FSH is the cause of the POF; and if this can be treated, then their problem with get solved. The fact is that while it’s very easy to suppress the high FSH level back to the normal range by using estrogen tablets, this will not help the patient with POF to grow eggs or to have a baby.

A new and more reliable marker for ovarian function today is the blood test for checking the AMH level. The diagnosis can be confirmed by checking the AMH level, which is very low in patients with POF.

Often the diagnosis comes as a rude shock – both to the patient and the doctor. Most young women have irregular periods because of another disorder called PCOD, which is much commoner. Many doctors assume that a young woman with irregular periods have PCOD, as a result of which the correct diagnosis of POF is often missed for many years. The cessation of menstrual periods is often incorrectly attributed to a variety of conditions, such as stress, without appropriate testing or consideration, delaying the diagnosis even further. In addition, many women who are affected by POF may have been incorrectly treated for irregular bleeding with oral contraceptives, which may have masked symptoms. All too often, POF is not diagnosed until the woman becomes interested in fertility and the oral contraceptives are stopped when the patient wants to conceive.

Currently no fertility treatment has been found to effectively increase fertility in women with POF. While some women with POF can and do become pregnant on their own, this is unpredictable and uncontrolled. Medically, the best treatment option is the use of donor eggs. While it can be very difficult for young women to come to terms with the fact that they may have to use donor eggs to have a baby, the good news is that this option has a very high success rate in patients with POF. Other options include: embryo adoption; childfree living; and adoption.
Patients with POF have low estrogen levels and this can result in painful sex ( because of lack of vaginal lubrication); as well as osteoporosis. Hormone replacement therapy ( HRT) with estrogens and progesterone can help to deal with these problems very effectively. However, while HRT can help women with POF to have regular cycles, it will not help them to have a
baby !


Many women find this very confusing, because they feel that if the medications can help them to have regular periods, they should be able to help them to have a baby as well. Sadly, the woman with POF has no eggs left in her ovaries, which means we cannot help her to grow these.

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Many infertile women have irregular cycles and they know that the reason for their infertility is related to their irregular cycles. However, many are quite confused as to the relationship. Some naively believe that if the cycles are regularised, their fertility will also automatically improve ! This is why they waste months taking birth control pills, without trying to address the underlying problem !

Today, we know that the commonest cause for irregular cycle is PCOD - polycystic ovarian disease. Unfortunately, many gynecologists blindly diagnose every patients with irregular cycles as having PCOD , without bothering to rule out other possibilities !

Let's look at some basics.

Women who ovulate regularly get regular periods. The reason a woman's periods are irregular is because she does not ovulate. This is called anovulation. While it is true that the commonest cause of anovulation is PCOD, it's equally true that this is not the only cause. A good doctor will do a careful workup to evaluate ovarian reserve, in order to determine what the reason for the anovulation is.

Thus, in some women the reason for the anovulation is poor ovarian reserve - a condition called the oopause. However, if this is mis-diagnosed as PCOD, precious time is wasted and the patient never gets a chance to get the right treatment !


If you have irregular cycles, please insist that your doctor do the following simple medical tests.

1. Blood tests for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of your cycle, ( to check the quality of your eggs).

2. A vaginal ultrasound scan on Day 3, which should check for the following.

a. ovarian volume
b. antral follicle count

Patients with PCOD typically have a high LH:FSH ratio; a high AMH level; large ovaries; and increased ovarian stroma with many small antral follicles.

Patients with poor ovarian reserve, on the other hand, have a high FSH:LH ratio; low AMH levels; small ovaries and a reduced antral follicle count.

If you are not sure how to interpret your reports, please send me your medical details by filling in the free second opinion form , and I'll be happy to help !

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I had just advised a young woman who had oopause ( poor ovarian reserve) to try empirical therapy, with DHEA, wheat germ , yoga and acupuncture , before we started her IVF treatment.

She wanted to know the rationale behind my advise. " Doctor, on one hand you are saying that I have poor ovarian reserve, which means that I only have few eggs left in my ovaries. Women are born with all the eggs they will ever have and I cannot make any new eggs any more. In that case, how will taking all these medicines help me to grow more eggs during my IVF cycle ? "

This was my reply.

" Yes, it is true that we cannot make you grow new eggs. Your ovary contains all the eggs you will ever have. These eggs are in a resting phase, and are contained in primordial follicles. Each month some of these these follicles are selected and start growing. This group is called a cohort, and this is a response to the high FSH levels during the follicular phase. Of these follicles , only one will mature, while the others will die ( a process called atresia). It is our hypothesis that yoga and acupuncture will help us to recruit more of your follicles , so that if the cohort is larger, hopefully more follicles will mature when we superovulate you during your IVF treatment."

I enjoy being a doctor because my patients keep me on my toes !

I just saw a young woman who was sobbing as if her heart would break. She had had irregular cycles for many years, and I had just informed her that the reason for her irregular cycles was the fact that her egg quality was very poor, and that the only way she could have a baby was by using donor eggs.

She was very upset - and was actually quite angry with me ! She had been going to a gynecologist for the last 3 years in order to try to have a baby. He had diagnosed her as having PCOD ( polycystic ovarian disease) and had told her that this was the reason for her irregular cycles. She was given Duphaston every month to induce a cycle - and had even had 2 IUI cycles done.

On reviewing her records, I pointed out to her that her FSH level on more than 2 occasions had been very high - and this confirmed the diagnosis of ovarian failure.

Now she was angry with her gynecologist ! Why hadn't he made the right diagnosis ?
How could he miss the significance of the high FSH level ?

It was not until she came to me for a second opinion did she realise that her high FSH meant she had entered the oopause. She was very bitter, because she had always been very worried about her irregular cycles. However, her gynec had always reassured her, saying - " Don't worry - you are young ! Your eggs are fine !"

It's important to differentiate between calendar age and ovarian age - and not all young women will have young ovaries ! Unfortunately, for many of these women, the diagnosis is not made in time. The eye only sees what the mind knows, and many gynecs do not even consider the possibility of premature ovarian failure when treating young women, because the majority of their patients are fertile !

It's even worse when they are misdiagnosed as having PCOD. The reason her periods were irregular is because she did not ovulate. This is called anovulation. Now while it is true that the commonest cause for anovulation is PCOD, the other common diagnosis which needs to be ruled out is premature ovarian failure. The high FSH level should have allowed the gynec to make the right diagnosis !

When patients have irregular periods, we advise them to do the following tests.

1. Blood tests for the following reproductive hormones - FSH ( follicle-stimulating hormone),LH ( luteinising hormone),PRL ( prolactin) , AMH ( anti-Mullerian hormone) and TSH ( thyroid stimulating hormone) on Day 3 of the cycle, ( to check the quality of their eggs).

Patients with PCOD have high AMH levels; high LH levels; and a normal FSH levels. Patients with ovarian failure, on the other hand, have high FSH levels and low AMH levels.

This diagnosis can be confirmed by doing a vaginal ultrasound scan which checks for ovarian volume and antral follicle count. Patients with PCOD have large ovaries, with an increased antral follicle count. Patients in the oopause have small ovaries and a reduced antral follicle count.

The worst tragedy occurs when a patient with anovulation because of poor ovarian reserve is misdiagnosed as having PCOD. Some doctors will do an ovarian drilling for these patients - and this destruction of their normal ovarian tissue will cause them to have iatrogenic ( produced by a physician) premature ovarian failure !

Conversely, we also to see patients with PCOD who have done IVF and have been told by their doctors that they have poor ovarian reserve, because the doctor did not do a good job superovulating them ! It's a pleasure to treat these patients, because with the right superovulation, they have very high pregnancy rates !

If you are unsure of your diagnosis, the single most important test you can do is to check your AMH level. This is a reliable test - and makes it very easy to differentiate between PCOD and oopause !

One of the most frustrating diagnosis for infertile couples is that of unexplained infertility. In once sense, this is a " non-diagnosis" - it's a confession of our ignorance, and means that we do not know why the couple is not getting pregnant.

Infertile patients find it very hard to understand why doctors cannot pinpoint the problem. Their major fear is that if the doctor cannot even find the problem, how will he be able to solve
it ? Even worse, every menstrual cycle is a mixture of hope and dread. Every missed period may represent a pregnancy - finally ! And every time the period starts, the hopes are dashed and the waiting begins all over again !

The good news is that as our technology improves, and we learn more about about reproductive biology, we have developed better tools to diagnose problems which remained undiagnosed in the past.

A very good example of this is the blood test for checking AMH levels.

Women with regular cycles usually assumed that they had good quality eggs. Most gynecologists did so as well, because we really had no good technique for assessing egg quality. Eggs are microscopic, so it's hard to track these ! Doctors would have to depend on indirect tests to check egg quality, such as measuring the follicles in the ovary ( antral follicle count); or testing the FSH level.

While ovarian age usually does correlate well with calendar age, this can sometimes be misleading . Some young women are infertile because they have poor quality eggs . After all, being young does not protect you from having poor quality eggs ! However, they were lulled by their regular cycle into a false sense of security regarding their egg quality , as were their doctors. Most would tell young women who were trying to get pregnant - " Just relax and continue trying - it's the stress ( such a hurtful word !) which is preventing you from having a baby naturally. "

The diagnosis of poor quality eggs in these young women with regular cycles was often missed with great regularity because doctors did not test for this possibility. These women had reached the oopause - but many gynecologists were not even aware of this condition !

The good news is that we now have a simple blood test to check for ovarian reserve. This is a blood test to check for AMH levels. This test is :

• easy to perform
• easy to interpret
• reliable
• does not vary from cycle to cycle
• can be done on any day of the cycle
  

Just because you are young does not mean you cannot have have poor quality eggs - fertility problems can occur at any age. Telling a young woman that her egg quality is poor is difficult for a doctor, but it's better to know the truth, even if it is bitter ! I believe that no patient should be diagnosed as having unexplained infertility without getting an AMH level done to assess her ovarian reserve. Not having the right diagnosis made in a timely fashion can cause a lot of heartburn and needless distress later on !

I just received an email from a patient who wanted a second opinion. She was 25 years old and had just completed an IVF treatment cycle at another clinic. She had got only 3 eggs and 2 poor quality embryos; and her doctor had told her that her problem was "poor quality eggs" and that she needed donor eggs. She was very upset and frustrated, and wanted to know how we could help her.

Now while it is possible that young women can have poor quality eggs, this not common. Step number 1 was to review her IVF medical records, so I asked her to send these to me.

Unfortunately, she did not have any records at all ! " My doctor refuses to give these " was what she told me. This is extremely frustrating and makes my blood boil. I cannot understand why IVF clinics do not routinely provide patients with their medical records. This is their duty and why should doctors want to hide anything.

This meant that I had to try to reconstruct the cycle based on what she had been told. Unfortunately, her information was very sketchy and unreliable. She felt she did grow lots of follicles on ultrasound scanning; and that the doctor initially was happy with her ovarian response, but managed to collect only 3 eggs at egg retrieval.

I had to ask her to start from scratch and test her ovarian reserve, so I could find out whether the reason for the poor quality eggs was poor ovarian reserve; or poor medical care. Often doctors may not do a good job with superovulation, as a result of which even patients with good ovarian reserve end up growing few, poor quality eggs. Superovulation is a skill which takes time and experience to master.

This is especially true for patients with PCOD. Doctors are often so scared of OHSS, that they end up mistiming the HCG injection, as a result of which they get poor quality embryos ( even though they may collect lots of eggs). We use a special technique and have extensive experience in doing IVF for PCOD patients, which means our pregnancy rates are better than 45% per cycle for PCOD patients. You can read more about this at www.drmalpani.com/pcod.htm !

If you get poor quality eggs, remember that there are only 2 things you can change :

• the doctor - find a new IVF clinic;
• your eggs - use donor eggs.

While many doctors are quite happy to push you towards using donor eggs ( this has a high pregnancy rate and is much more profitable for the doctor), this should always be Plan B. It makes much more sense to change the doctor first !

So if your doctor says you have poor quality eggs, what should you do ?

Step number one is to ask for a copy of your IVF medical reports ( make this request in writing, so that it is honoured !)

Review your IVF chart, and look especially for the following details.

Number of follicles on ultrasound scanning
Number of eggs collected and their maturity
E2 ( estradiol) levels

If you have lots of follicles but not enough eggs , this suggests poor egg collection skills. This could be because of anatomic problems which make the egg collection technically difficult. An experienced and skilled doctor can usually do a much better job !

Did you have lots of eggs but not enough embryos ? This suggests the eggs were immature and that perhaps the HCG was not timed properly, which means egg collection was mis-timed. The other problem may be a lab problem. You will need to drill down deeper ! Was IVF done ? Was ICSI done ? How many eggs were mature ( metaphase II) ? What was the egg damage rate ?

The key step is to test your ovarian reserve. The best way of doing this is to check your AMH levels. This is a new test which many IVF clinics still do not offer, because they still use the old fashioned ( and unreliable) FSH level to check ovarian reserve. If your AMH level is normal, then suggests you have normal ovarian reserve, and you'd be better off finding a new doctor. This is especially true if the AMH is high, because this strongly suggests you have occult PCOD, a diagnosis your doctor has most probably overlooked.

If your AMH is low, then this does suggest you have poor ovarian reserve. In this case, your best option would be to change the superovulation protocol and use more aggressive superovulation. If your doctor insists on using the same old rigid protocol ( because their clinic policy does not allow them any flexibility), then it's a good idea to change your doctor. As Albert Einstein said, Insanity is doing the same thing over and over again and expecting different results !

Using donor eggs is an option, but this can often be very hard to come to terms with, which is why this should be Plan B !