Premature Ovarian Failure
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The probability of getting pregnant with premature ovarian failure (POF) discussed by Dr. Vitaly Kushnir.
CHR is a leading fertility center in New York City with extensive experience in treating women with premature ovarian failure (POF) who want to get pregnant. With POF, making the correct diagnosis (distinction from premature ovarian aging) and developing an individualized treatment plan with the patient are the two main pillars of CHR's treatment philosophy.
What is Premature Ovarian Failure (POF)?
Premature Ovarian Failure (POF), also known as Primary Ovarian Insufficiency (POI), is a loss of ovarian function before the age of 40. POF can affect women at various ages from teenage years to thirties. Women with POF are at a greater risk of a range of health issues, including osteoporosis, estrogen deficiency (hot flushes, vaginal dryness, etc.) and heart diseases. These POF-related issues can usually be managed well with hormonal replacement. However, in an infertility context, POF poses a challenge, as the loss of ovarian function means that the probability of pregnancy in women with POF is greatly reduced.
Although it is sometimes called early menopause, POF is different from menopause in that POF is not a result of natural (normal) aging process of a woman. Women with POF, in addition, may continue to have menstrual cycles, though their cycles will be irregular. A small percentage of women with POF can conceive naturally, while menopausal women will never get pregnant.
Diagnosis of Premature Ovarian Failure (POF)
Even if you have been told that you have POF, it may be too soon to despair. Quite often, we are surprised who is diagnosed with POF. Many patients with a supposed diagnosis of POF actually don't really suffer from POF. Many "POF" patients, when tested at CHR, turn out to suffer from premature ovarian aging (POA), not POF.
While these two conditions sound similar, correct distinction between POF and POA is crucial. Women with POA can get pregnant: CHR physicians have demonstrated, and reported in the medical literature, remarkably good pregnancy results in women with even severe POA (with DHEA supplementation and proactive ovarian stimulation). For women with true POF, chances of pregnancy with their own eggs remain, however, unfortunately quite small. Pregnancy attempts in POF, therefore, always involve experimental treatments, as no effective treatment has so far been established for POF patients.
Distinction Between POF and POA
The distinction between POA and POF is not difficult. It is based on the maximum level of follicle-stimulating hormone (FSH). Patients with FSH levels above 40.0 mIU/mL, a post-menopausal level, are diagnosed with POF, while patients with elevated FSH levels that do not exceed this threshold are diagnosed with POA.
Causes of Premature Ovarian Failure
There are several known causes for premature ovarian failure, amongst them genetic conditions that affect the X chromosome, such as Turner Syndrome and Fragile X syndrome. Autoimmunity (immunity against oneself) has also been implicated. In addition, surgical loss of excessive ovarian tissue (for example, after surgery for endometriomas, also called "chocolate cysts") can put the patient into early menopause. Chemotherapy and radiation can also cause premature ovarian failure.
Getting Pregnant with Premature Ovarian Failure (POF)
As already noted above, even in the best of hands, pregnancy in women with POF is a rare event, and most will end up having to use egg donation. CHR does offer experimental treatments to POF patients, but we usually recommend donor eggs as the treatment of choice. However, at CHR, it is always the patient who decides which way she wishes to go.
Most POA patients, in contrast, will have an excellent pregnancy chance with use of their own eggs at CHR. Our success in treating POA patients is primarily based on the introduction of DHEA supplementation into fertility treatment.
Unfortunately, DHEA appears much less effective, and maybe even not effective at all, in patients with outright POF. Very low pregnancy rates in our past DHEA study in POF patients showed us that pregnancy chances in POF patients would, at best, be affected by DHEA only in a much more limited way, in comparison to POA patients.
POF and Egg Donation
In our opinion, nobody should enter an egg donation cycle without being absolutely convinced that it is their only realistic chance of having a child. We, therefore, not only respect our patients' desire to "at least try once" with their own eggs, but actually encourage such attempts if patients still believe they have what looks to them like a reasonable chance.
Definition of "reasonable," of course, varies between patients, and what one patient considers reasonable may be too low for somebody else. We, at CHR, do not feel that we can make these judgments for our patients. We, instead, see our responsibility in making certain that our patients have accurate and comprehensive information when making these decisions. Only the patients can decide what represents a "reasonable" chance for them! Once they decide, CHR will do its best to maximize pregnancy chances, whatever treatment patients choose.
Egg donation is, undoubtedly, the most successful treatment option for women with POF. With their own eggs, POF patients have a pregnancy chance, at most, in the low single digits. In CHR's egg donor program, the same POF patient will have a cumulative pregnancy rate in the high 80s to low 90s, from a single egg donation cycle.
Since about 95% of an embryo's quality derives from the egg, and egg donors are typically young, recipients of donated eggs will have the pregnancy chances and miscarriage risks of a young woman. Imagine if we could do this in other areas of medicine!
Proactive Steps for Premature Ovarian Failure
Recent infertility research into the FMR1 gene at CHR suggests that FMR1 genotype may predict whether a woman is more likely to develop POA/POF later in life. FMR1 genotypes and sub-genotypes as genetic predictors of risk towards POA/POF represent another exiting new development, spearheaded at CHR. It should, in the very near future, allow for much more selective fertility preservation.
Fertility preservation, whether through ovarian tissue cryopreservation, egg freezing or embryo freezing, is still a developing and largely experimental medical treatment (with the exception of embryo freezing, which has been in use for many decades and has a proven record). However, fertility preservation may become a major part of proactive POA/POF treatment in the future.
Key Facts about Premature Ovarian Failure
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Written by David Barad, MD
Last Updated: December 18, 2013