Gynecologist and obstetrician Op. Dr. Aret Kamar from Istanbul Women's Health and IVF Center gives information about low egg reserve and IVF treatment.
What is low egg reserve or reduced egg capacity in women? When we think of low egg reserve, we always think of a woman who has reached menopause and after menopause. Can low egg reserve actually be seen at a younger age?
"Low egg reserve means that we have few eggs. Menopause, as you know, is when the egg ends. The egg will end and we will not menstruate so that we can talk about menopause. If a woman has a low egg reserve, but she can still menstruate every 15 days, once a month, sometimes every 45 days, sometimes every 2 months, then it is not menopause. That is pre menopause. In other words, she is in the pre-menopausal period. The woman is close to menopause, her egg has decreased, but it is not clear when the egg will run out.
LOW AMH IN WOMEN IS A SIGN OF DECREASED OVARIAN RESERVE!
Now, how do we diagnose low egg reserve? Our first diagnostic source is ultrasound. The woman comes, we look at her with ultrasound. When we look at the ultrasound, we see that the ovaries are smaller than they should be and there are fewer egg candidates, which we call “antral follicles”. In general, if we classify it in a simple way, when we look at the ovary with ultrasound, if we see the number of eggs below 5 egg candidates, the egg reserve is considered to be reduced. There are also biochemical tests for this. The most commonly used one used to be FSH. But FSH is a test that should be checked during menstruation and should be checked when there is no egg. Therefore, if it is checked at any time during menstruation or when the woman is menstruating, when she has an egg by chance, we will get a misleading result. Therefore, FSH measurement is a test that should be performed under the supervision of a doctor. But we are currently using AMH the most. AMH is a hormone secreted by the eggs.
It is a test that is independent of menstruation, independent of the eggs in the ovary at that moment, that we can do whenever we want, whether you do it during menstruation or when you ovulate, it is a test that shows us the reserve. And if this test is below 1, then we say that our ovarian reserve is decreasing. When we fall to 0.2s, 0.3s, 0.1s, these are the results of “Let's take precautions as soon as possible, let's have children if we are married or freeze our eggs if we are not married”. Therefore, low egg reserve is actually a situation that we encounter very frequently, perhaps because we are dealing with it. In other words, in daily practice, most of our patients are actually those with low egg reserve. Because women with high egg reserves, even if they do not get pregnant in the first attempt, they somehow get pregnant in the second or third attempt because they have a lot of eggs and a lot of embryos. They usually have one retrieval and several transfers. Because there are many eggs and many embryos. But this is not the case for women with few eggs. In this group of women, we look into the eyes of the ovary to make it produce one egg. One egg comes and we collect it. We say this egg is not good. We collect it again. So it is a laborious process. The important thing is to recognize this situation and find a solution before the woman reaches that limit. This is only possible if the woman knows the status of her ovarian reserve. So women should always check their ovarian reserves. They should have their AMH measured. They should be very careful especially when it falls below one."
You said that it is important to intervene before the ovarian reserve decreases, especially in women. For this, women should especially have their AMH hormones monitored.
“They should have it checked annually.”
So, who is in the risk group? In other words, which women are in the risk group in terms of low egg reserve?
REPRODUCTIVE HEALTH CAN BE NEGATIVELY AFFECTED IN WOMEN UNDERGOING CANCER TREATMENT!
"Now, those who have previously undergone cancer treatment for one reason or another are definitely in the risk group. Because as you know, cancer drugs can reduce the egg reserve. But the number of eggs is actually an inheritance. If a woman has polycystic ovaries, there is a possibility that her child will also have polycystic ovaries. Or if a girl's mother, aunt, grandmother or great-grandmother somehow went through early menopause, she is also a candidate for early menopause. So, how can a woman understand that her ovarian reserve has decreased? There is actually no direct way to understand this. Because the ovary normally produces one egg every month. In other words, even those with many eggs produce one egg. Therefore, as long as an ovary can produce one egg every month, it may not give a very big symptom about menstrual cycle. But often the first sign that the egg starts to decrease is that the periods start to come a little early. So, just when you are completing the month, you see that it started to come every 27 days. Then it starts to come every 26-25 days. It comes every 24 days. Unfortunately, our country is not a country where people go to the doctor without getting sick in terms of health checks. This is why the AMH test is extremely important.
“OVARIAN RESERVES OF WOMEN WHO WANT CHILDREN SHOULD BE MONITORED”
In the past, we used to say to young girls with few eggs, “You need to get married as soon as possible, you are running out of eggs.” But now there is no such thing. We can freeze our eggs. And when we freeze them, think like this, for example, a girl's egg reserve is very low. She can hardly give one or two eggs. You will accumulate eggs with one or two eggs. So that you can use them if she goes through menopause in the future, if she runs out of eggs. We say to save at least 20-25 eggs. Because on average, an IVF is tried with 5-6 eggs. In other words, in order not to say that I tried once and it didn't work and I ran out of eggs, you need to save as many eggs as possible. Now, how many times do you need to try to save 25-26 eggs in someone who gives 1-2 eggs. Also, those eggs may not be good every time. This egg is not good, let's collect it again and it becomes a stressful process. Therefore, I say again, girls and women should definitely have their reserves monitored if they have not had children and if they are thinking of children in the future or if they are not married."
CAN FOREIGN PATIENTS FREEZE EGGS IN TURKEY?
Turkey is really in a very good place in the world in egg freezing, embryo freezing and sperm freezing, with very successful results. So, considering the legal regulations, is there a chance for women from Greece or Balkan countries or women from various countries of the world to freeze their eggs in Turkey? If the legislation does not allow this, can't the eggs collected here somehow be transferred to the country where the person is located?
"Unfortunately, they cannot be taken. They cannot be frozen here either. There is such a gap in the legislation in Turkey at the moment. I guess they will find a solution for this soon. Because in Turkey, a woman who wants to freeze her eggs needs to get a report from a training and research hospital or a university. Actually, the nature of the report is also clear. It is a report saying that her AMH is low and she needs egg freezing. She gets the report once and can try many times. But in Turkey, you need to have a Turkish ID number to apply for this. Otherwise they cannot apply. Therefore, foreign nationals cannot freeze eggs in our country because they cannot get a report on egg freezing in Turkey. In order to prevent any abuse, I think there is an obligation to get a report from a training research hospital or a university. The restriction on this issue should be lifted."
WOMEN WITH FEW EGGS CAN ALSO GET PREGNANT!
Let's imagine a woman with a low egg reserve who comes from abroad or from Greece. Well, when she arrives, if eggs can be collected immediately, can in vitro fertilization be performed with the collected eggs?
"Of course. There is no problem with IVF. We have no problems with IVF. Because there is a husband and wife. After they have a civil marriage, they can try IVF in Turkey. Well, how is this possible for women who can give 1-2 eggs instead of 20, 30 eggs? Let's say we collected 2 eggs. We got lucky. Two eggs are good. We insert sperm into them. Then we follow the development of the embryos. Let's say the woman is over 35 years old and we plan that our chances will be higher if we give her two embryos. Let's say we have one good embryo and one medium quality embryo from two eggs. We say let's collect them again. Let's make a few more embryos. Let's select the good ones and put them in. Now, those who have many eggs have a lot of embryos at once, so it is easy to choose. You say, "Should I put this one or that one? You take the good one and put it in. You have more chances. In the other one, we actually artificially increase the number of eggs. We increase it by collecting it several times. Again, we have an embryo pool. When we select the good ones and put them in, they conceive with the chance of pregnancy appropriate to the woman's age. So there is no such thing that those with few eggs cannot get pregnant. It's just that we may have to work a little harder to get enough good embryos."
Well, I would like to ask something I am curious about the patient abroad. A patient came from Greece or any other country in the world. Now, the infrastructure of the application center is also very important. Isn't IVF treatment a team work?
“Absolutely.”
THE IMPORTANCE OF THE EMBRYOLOGY LABORATORY IN THE SUCCESS OF IVF TREATMENT
How important is the embryology laboratory and embryo specialist, especially in IVF treatment? What should patients coming from abroad pay attention to when choosing a center and a doctor?
"Now the most important criterion is actually occupancy. I mean, of course, neighbors or those who have been pregnant here will have a recommendation, but a good place is already full. Now let's think of two restaurants. You walk through the door of one of them, flies are buzzing around inside, it's an empty restaurant. The restaurant next to it is packed. Now, why do we choose the one we prefer? Do we want to go into an empty restaurant so that we can sit comfortably and eat our meal? No, you're going to the crowd. If this place is crowded, you think people must know something. Therefore, experienced centers, centers that see many patients can be preferred in this respect. As you said, the laboratory is very important. The laboratory is our kitchen. The waiter can be as good as he wants. If the food he carries is not good, he cannot satisfy his customers. Therefore, it is important that the laboratory is good, brings good pregnancies, freezes and thaws the eggs and embryos well. An embryo is a collection of cells. When you freeze and thaw an embryo, even if one cell of an 8-cell embryo is damaged, the embryo can continue its life with the remaining cells. But an egg is a cell. So if that egg is damaged while you freeze and thaw it, there is a problem. Therefore, especially egg freezers should prefer very good centers, centers with very good laboratories."