POA Diagnosis - Premature Ovarian Aging Diagnosis
Early Diagnosis and AMH Test Results
Effective treatment of low ovarian reserve (OR) starts with a timely diagnosis. Timely diagnosis is crucial because once the OR begins to decline, it continues to decline with time, and we cannot tell how fast POA will progress. At CHR, patients are evaluated based on age-specific hormone values (such as AMH and FSH) instead of universal cut-off values that are still used at many fertility centers. Use of age-specific values allows us to make a premature ovarian aging diagnosis at early stages of the condition when treatment outcomes are much better.
Early POA Diagnosis Leads to More Effective Treatment
CHR's Medical Director and Chief Scientist, Dr. Norbert Gleicher, explains a treatment method that led to a tripling of pregnancy rates for patients diagnosed with POA.
Using an AMH or FSH Test to Reach a Diagnosis
Each patient’s ovarian reserve is evaluated by comparing her FSH and AMH levels to the age-specific levels of these hormones, first established by the physicians at CHR:
< 33 Years
< 7.0 mlU/mL
= 2.1 ng/mL
< 7.9 mIU/mL
= 1.7 ng/mL
< 8.4 mIU/mL
= 1.1 ng/mL
= 41+ Years
< 8.5 mIU/mL
= 0.5 ng/mL
A diagnosis of POA is reached when age-specific FSH levels are too high and/or age-specific AMH levels are too low. Some colleagues use antral follicle counts (AFCs) to assess OR. At CHR, we do not consider this method to be as reproducible as AMH and FSH levels. However, if AFCs are used to make a premature ovarian aging diagnosis, they should also be age-specific. Without the use of age-specific diagnostic levels, it is virtually impossible to identify women with POA, and treatment plans can end up being ineffective because they may not address the basic issue of abnormally low ovarian reserve.
Incorrect Diagnoses Without an FSH or AMH Test
A premature ovarian aging diagnosis is likely the most frequently overlooked of female infertility. Even good infertility centers fail to identify POA as a cause of infertility because most centers still use universal ovarian reserve parameters, independent of patient age. For example, most centers still consider a follicle stimulating hormone (FSH) level under 10.0 mIU/mL as “normal” at all ages. This makes absolutely no sense, considering that this hormone increases with age. An FSH of 9.5 at age 20, therefore, means that the woman has an abnormally high FSH level for her age, which is very different from having the same FSH level of 9.5 at age 45! The 20-year-old patient with an FSH of 9.5 should receive a POA diagnosis and her POA treatment should be personalized to address this diagnosis.
The same principle also applies to AMH, which in recent years has become increasingly popular in assessing ovarian reserve. CHR's team was the first to propagate the use of age-specific FSH and AMH levels in a number of publications, a routine slowly accepted by colleagues around the world. The figure below demonstrates age-specific FSH and AMH levels, as established at CHR [Modified from Gleicher et al, Reprod Biol Endocrinol 2010;8:64].
Premature Ovarian Aging Symptoms
Premature ovarian aging is often an insidious condition. Many women with POA do not have any symptoms of premature ovarian aging and are unaware that they have this condition. This is another reason POA is under-diagnosed or misdiagnosed as unexplained infertility at many fertility centers.
POA vs POF
The distinction between a premature ovarian aging diagnosis and premature ovarian failure (POF) is of crucial importance: POF, also called primary ovarian insufficiency (POI), is defined by FSH level above 40 mIU/mL (which is a range found in post-menopausal women). Women whose FSH levels are high but still below 40 mIU/mL are considered to be suffering from premature ovarian aging, also called OPOI (occult primary ovarian insufficiency), rather than POF. "Early menopause" or "premature menopause" are also terms used to refer to POF.
Even in the best hands, pregnancy in women with a premature ovarian failure diagnosis is a rare event, unless donor eggs are utilized. CHR does offer experimental treatments to POF patients, but we usually recommend donor eggs as the treatment of choice, although at CHR, it is always the patient who decides which treatment she wants to pursue.
In contrast, POA patients still have an excellent IVF pregnancy chance with use of their own eggs, if given appropriate POA treatments. As a result of CHR's ongoing research on diminished ovarian reserve and its clinical application, an ever-increasing number of POA patients from all over the world has been seeking treatment at CHR. Today, indeed, no other diagnosis brings as many patients to CHR, which is now considered the "center of last resort" for patients with a premature ovarian aging diagnosis and diminished ovarian reserve.
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.