short supply

About 11 years ago I heard Jonathan Tilly speak at the American Society of Reproductive Medicine (ASRM) meeting. His research suggested in mice new eggs could be made. This raised the question "what if our understanding that women are born with all the eggs they'll ever have, is wrong?" What if we could make new eggs for women? Huh. A basic premise of human reproduction is that you can't. All evidence so far has supported the idea that women are born with about a million eggs and rapidly lose them, running out at menopause. Tilly was able to regenerate eggs in a menopausal mouse. If we could do this in humans everything would change in fertility treatment. Afterall, about a third of my patients are infertile because of an egg issue: poor quality or poor numbers. If we could use, say, her own stem cells located in her bone marrow to make new healthy eggs, many more women would be able to conceive. All those women who have been told their eggs are too few or too poor quality to make a baby would have a treatment. And surely, Tilly would win the Nobel Prize.

Well so far it hasn't happened. No one has figured out how to renew or create eggs in a woman's ovaries. There was some promise in AUGMENT treatment to essentially re-fuel exisiting eggs with mitochondria (batteries) from other cells in a woman's ovaries, but honestly, the pregnancy rates have been lower than hoped and the cost out of reach for most people.

So, as sit here with a list of patients I need to call to either discuss their poor eggs, low eggs or what we are going to try next time to get better eggs I am frustrated. I hate not having a solution, a fix. The couple who have blocked tubes, a little low sperm count, a polyp in her uterus, infrequent ovulation or other fairly mild issues causing infertility are so much less frustrating - I am almost always get them pregnant. The egg issue patients I am always less sure.

A review article I've been reading this morning supports my frustration and uncertainty. The article looks at all interventions that have been published to help women with low egg counts in IVF. Here is a list of the interventions that have been tried:

Low egg count interventions

I have tried every one of them at some point in my career. Every single one of them and often many of them at once. There is no magic here - it's a combination of really considering the patient's story, how they responded to previous treatments, how their ovaries look, what their hormone profile says and good luck.

Now, if you keep reading through this paper they outline all the studies that looked at benefit versus no-benefit or harm to these interventions and not surprising (to me at least) for almost every one of these interventions there are the same number of papers saying benefit as those saying no-benefit.

Alas, this is all we have to work with for now until Tilly's work can be done in humans, until we come up with a new evidence-based therapy/treatment or until we can reverse time. It's like Jason Hitkari said to me once when I was so disraught for a patient with poor eggs, "you didn't make her eggs poor," while it made me feel a bit better it doesn't solve the patient's problem. Only research, trial and error and good luck can do that.

May your eggs be surprisingly healthy.

Reference: Papathanasiou A, Searle BJ, King NM, Bhattacharya S. Trends in 'poor responder' research: lessons learned from RCTs in assisted conception. Hum Reprod Update. 2016 Apr;22(3).