Beating Ovarian Issues and Polyps with Blastocysts for Pregnancy Success

▲ Ms. L with Dr. Nikorn’s team after successful pregnancy confirmation

Basic Case Information

Primary Doctor: Dr. Nikorn
Case Type: Advanced age, low ovarian reserve, endometrial polyps

Female Patient Profile (Ms. L)

Age: 42 years old
Pregnancy History: 3 pregnancies
- 2 cesarean sections
- 1 miscarriage
Ultrasound Findings:
- Right ovary: 2 follicles
- Left ovary: 4 follicles
Hormone Levels:
- Prolactin: 13.89 ng/mL
- Follicle-Stimulating Hormone (FSH): 11.49 mIU/mL
- Luteinizing Hormone (LH): 2.34 mIU/mL

Male Patient Profile

Age: 39 years old
Semen Analysis: Semen volume 4.0 mL, total motility 54%, normal morphology 3%

Key Issues Identified

The female patient’s advanced age has led to diminished ovarian function and low ovarian reserve.
The female patient also has endometrial polyps.

Case Summary

Diagnosis

At 42 years old, the patient has an AMH value of 0.76, which is low, indicating significant ovarian function decline. This not only reduces follicle count but may also affect egg quality, increasing the risk of chromosomal abnormalities in embryos, which negatively impacts IVF success rates.

Additionally, the patient’s history of cesarean sections may have resulted in a uterine scar diverticulum (isthmocele), with fluid accumulation observed at this site. This fluid could elevate inflammation risks and interfere with embryo implantation in the endometrium. The patient also has endometrial polyps, which may hinder embryo implantation by disrupting the endometrial environment, further reducing IVF success rates.

Therefore, before starting an IVF cycle, it is recommended that the patient undergo thorough preconditioning. Hysteroscopy to address the polyps is advised prior to embryo transfer to optimize the endometrial environment and improve success rates.

Controlled Ovarian Stimulation (COS)

Pre-Stimulation: For one month prior, the patient consistently took supplements including Embryo Treasure, DHEA, vitamins, and bromocriptine. It is recommended to address endometrial polyps via hysteroscopy before preparing the endometrial cycle.

Stimulation Protocol: Antagonist Protocol

- Day 3 of Stimulation (Thailand)
  - Ultrasound Findings: 7 baseline follicles
    - Right ovary: 3 follicles
    - Left ovary: 4 follicles
  - Hormone Levels:
    - FSH: 7.2 mIU/mL
    - LH: 5.1 mIU/mL
    - Estradiol: 26.6 pg/mL
    - Prolactin: 3.02 ng/mL
  - Treatment Plan: Pergovaris 250 IU, Clomiphene, Bromocriptine, Inositol

- Day 6 of Stimulation (Thailand)
  - Ultrasound Findings:
    - Right ovary: 6 follicles
    - Left ovary: 6 follicles
    - Uterine scar diverticulum noted
  - Hormone Levels:
    - LH: 7.6 mIU/mL
    - Estradiol: 1169 pg/mL
  - Treatment Plan: Pergovaris 250 IU, Menopur 75 IU, Cetrotide 0.25 IU, Clomiphene, Bromocriptine, Inositol

- Day 9 of Stimulation (Thailand)
  - Ultrasound Findings:
    - Right ovary: 6 follicles
    - Left ovary: 6 follicles
  - Hormone Levels:
    - LH: 2.1 mIU/mL
    - Estradiol: 2327 pg/mL
  - Treatment Plan: Pergovaris 250 IU, Menopur 150 IU, Cetrotide 0.25 IU, Clomiphene, Bromocriptine, Inositol
  - Trigger Shot: Cetrorelix 250 mcg + Diphereline 0.1 mg

Embryo Development Results

Oocytes Retrieved: 16
Mature Eggs: 14
Normally Fertilized: 13
Day 3: 9 embryos with 8 cells, 2 with 6 cells, 2 with 4 cells
Day 5: 10 blastocysts formed and biopsied
Chromosomal Screening: 2 normal embryos

▲ Ms. L’s blastocyst culture report

▲ Ms. L’s embryo screening report

Pre-Transfer Endometrial Hormone Preparation

Preparation: Hysteroscopy was performed to remove endometrial polyps, followed by a one-month rest period before preparing the endometrial cycle.

- Day 2 of Menstrual Cycle (China)
  - Hormone Levels:
    - Estradiol: 30.67 pg/mL
    - Progesterone: 0.17 ng/mL
  - Ultrasound Findings: Endometrial thickness 11 mm
  - Treatment Plan: Estradiol valerate (Progynova), aspirin, prednisone
- Day 12 of Menstrual Cycle (China)
  - Hormone Levels:
    - Estradiol: 287 pg/mL
    - Progesterone: 0.13 ng/mL
  - Ultrasound Findings: Endometrial thickness 11 mm
  - Treatment Plan: Estradiol valerate (Progynova), aspirin, prednisone
- Day 15 of Menstrual Cycle (Thailand)
  - Hormone Levels:
    - Estradiol: 241.1 pg/mL
    - Progesterone: 0.15 ng/mL
  - Ultrasound Findings: Endometrial thickness 12.5–13.9 mm
  - Treatment Plan: Estradiol valerate (Progynova), aspirin, prednisone, dydrogesterone, vaginal progesterone suppositories, Ventolin, estradiol gel

Embryo Transfer Day

Procedure: Transferred 1 normal embryo (Grade: B, CB-)
Additional Measures: Embryo glue used + injection to prevent uterine contractions

Pregnancy Confirmation

Gestational Age	B-hCG (mIU/mL)	Progesterone (ng/mL)	Ultrasound Findings
4 weeks	34.5	37	–
5 weeks	851.8	22.37	Gestational sac: 1.5×1.0 cm; November 5, 2024: Fetal heartbeat detected, crown-rump length 0.7 cm
6 weeks	–	–	NT value: 0.15 cm, crown-rump length: 6.6 cm, heart rate: 160 beats/minute