AntiMullerian Hormone (or Mullerian Inhibiting Factor) 

I would like a share a story about the perils of believing that all that is new and modern is better. 

I have a patient who is about 42 years old. She had one child about 4 years old and she desperately wanted another. I took her through the basic infertility workup that I have described on these pages and we found that she had nearly run out of her supply of eggs. So try as she might, and push fertility meds as far as she can (Follistim, Perganol, Menotropin, Menopur, Repronex, urofollitropin, Gonal-F, Fertinex, and many more), she could not make her own good eggs or embryos. 

So for a woman such as her, all hope is not lost. Nowadays, she can still have a baby or babies. The problem becomes how does one get good eggs? What she frequently does, is she borrows them! What she does is, she finds an Egg Donor. The egg donor is usually a younger woman, who is willing to share her eggs with the other woman, the one who no longer has enough good ones of her own. Lets call this one the patient. Once the donor is selected and screened for an appropriate family history, and infections like HIV are ruled out, the donor is put into an IVF cycle. But the donor will not use her own eggs, she will give them away to the patient. The donor is usually paid for her time and effort, and risk, but I think the ethics of the transaction have to be that the eggs are not the purchased item. The eggs are given freely. 

The IVF specialist doctor will then give fertility medications to the donor, to deliberately hyper-stimulate (to a moderate degree), and make 10-25 eggs or so. Then the IVF specialist will retrieve the eggs from the donor. This involves some anesthesia, a sterile operating room, a sonogram to find the follicles, and a longish needle to aspirate the eggs. One egg from each follicle. A follicle is about 2.5 cm, a little less than an inch. But the egg is much smaller than a period at the end of a sentence. Then the IVF specialist will hand the eggs over to a specialist called an Embryologist, who will mix the egg with sperm from the patients husband (or whoever is selected to be the genetic father. Sometimes sperm donors are used as well). If the eggs cannot be penetrated by the sperm, the embryologist can force a sperm into the egg with a tiny needle. This is called Intracytoplasmic Sperm Injection, or ICSI. ICSI is very common nowadays. It is used, for instance, if the husband/father has only a few sperm to work with. Or if the sperm are weak. 

ICSI is well established, it works, and the babies seem to be fine. I have delivered a lot of ICSI babies, no problem. For awhile, the MFMs were worried about chromosomal damage, heart problems, growth problems, etc. The MFMs were scanning these babies up down and sideways, doing invasive amnios or amniocentesis to see the chromosomes, and ordering all of these babies to have cardiac echocardiograms. I guess that is what MFMs do. MFMs will reach to the ends of the earth to find ways to make sure that everything is ok. And if they don't know, they will order every test under the sun. I don't say this because I begrudge their skill, and they are a very valuable service. But sometimes their need to analyze really piles up to uncomfortable levels. I think part of my job as a compassionate physician and counselor is to explain to my patients what the odds are in any given set of stressful circumstances. This way, people can take control of their own risks and plans and hopes. Sometimes we just have to say no and stop the testing. And sometimes we just have to say that not knowing the science is different from knowing the science shows risk. 

In my practice all of the ICSI babies have seemed normal to me. 

Anyway, this 42 year old I was telling you about was really really careful and picked her egg donor from clear across the country. This way many things matched up just right. (height, color, eyes, intelligence, ethnicity, etc). The egg donor was an otherwise healthy 27 year old. She was going to fly to New Jersey when her follicles were just about ready to be aspirated for the eggs. 

But, there was a sudden fly in the ointment. Just before she started the egg stimulation cycle, it was found that her AMH was a bit low. Her Anti Mullerian Hormone. This implies that the donor was short of her own eggs. If the donor couldn't make eggs then the whole plan would fall apart, including the patients own hormonal preparations to accept the embryos in a few weeks. Since I don't do IVF, but I do counsel my patients to the best of my ability, my patient called my up in a seriously stressed out condition. She still was thinking clearly. But to cancel her preparations up to this point would have delayed her family another 4 to 6 months. And she would have to do all of this hard work all over again. 

Mind you, this patient is an extremely intelligent executive for a large successful corporation. She knew as much as anyone would about her entire story. She did not suffer from any kind of character flaws. She was psychologically very strong. 

So I reviewed the entire history with her. We knew that the young donor had no gynecological problems. By all the evidence other than AMH she was able to make normal eggs, and normal menstrual cycles. 

And when I looked at the scientific literature of various sorts around the value of the AMH test, it was said that the AMH test should not be used in an isolated manner, because it was not 100 percent reliable. 

But, wait a minute, they say that about all tests. No tests are 100 percent about anything. In something as complicated as human biology, there are no certainties about anything. (except maybe death and taxes). But I thought about it for awhile. 

Her IVF docs told her to cancel the cycle, as they don't like IVF failures. Why? Anything that throws their stats off will make the IVF docs look like buffoons when potential patients look up the ever present success rates that are published all over the place. Everyone, every potential patient, wants to go to the best IVF doctors, so they look up success rates and wants to get an appointment at the best place. If someone else is zero point eight percent lower in the success rates, then they are going to take their business to the best place. Which is elsewhere. 

So IVF docs hate failures, and hate anything that might affect their success rates. If any IVF docs have a tiny bit higher success rate than anyone else, and they are getting a lot of patients because of it, those IVF doctors are not going to advise any marginal cases to go forward with IVF. In other words, they will give IVF mostly to the people who need it the least, and avoid given IVF to the patients who need it the most. 

This leaves some patients dejected.  And many marginal cases that have some hope for IVF are turned away. 

This is, I suppose, an extension of the law of unintended consequences. When the powers that be forced the statistics out into the open, then the statistics became more important than the patients. And then some docs who provide IVF only to the easy cases, even to those who didn't even need it, became really busy. They formed giant clinics. The docs who did IVF only on young heathy women,  whe were nearly guaranteed a good result every time, had the best published statistics.  

There are some statistical methods that can tease out the success rates of the difficult cases from the easy ones, but the law of unintended consequences still holds. 

So anyway, I advised my patient to go ahead and continue the cycle with the young donor with the poor AMH. I figured the biggest loss would only be the money and the time if the one cycle failed. This would at most be a month. But...think about it... the gain would be a family maybe 5 months sooner that a cancelled cycle. And an isolated AMH doesn't mean that much anyway. I figured that statistics were 5 to 1 in my patients favor that the cycle would work, even with the low AMH. How could a healthy 27 year old donor suddenly run out of quality eggs? The statistics did not favor failure, even with the IVF clinic telling her to quit. 

Then a most beautiful thing happened...

She got pregnant with twins...

The pregancy was very eventful, with placenta previa, some bleeding, hypertension, some working bedrest, some hospitalizions, some bit of temporary gestational diabetes (due to steroids given to help the babies when they were threatening to come early), some meds to quiet the uterus, lots of MFM consultations (and using their excellent information with proper discretion to keep it real and simple), and big babies. 

Then... 38 week healthy full term, nice and big, twins. Born via a repeat C-Section, in an OR with big smiles, nice soul music playing, and a big team of very experienced support staff. 

I shared a story about the perils of believing that all that is new is better. 

What is the moral of the story?  

Don't let an isolated antimullerian hormone test wreck your life. Two beautiful living babies are proof of that. In fact, don't let any isolated test result wreck your life. 

And think about the young egg donor. She now has proven her eggs, and the worth of her ovaries. If the cycle was cancelled, she might have thrown away contraception, had an unwanted pregnancy, lost her life's partner for possible infertility, gone into a depressive spiral, or worse. Now she knows she is good and healthy. AMH be damned. 

Another even more important moral is that Statistics are Abused. Because the IVF programs are forced to divulge their stats, they become slave to the stats. And they will cancel cycles if there is even a 20 percent reduction in possible success for one woman. They live and die by the statistics numbers. Everyone does. If my patient did not call me, those babies would not have been born. 

Pretty soon Obstetricians are going to have their stats published. CS rates, mortality rates, etc. But since every obstetrician does things a little bit differently, they will be punished in what may be completely unexpected manners. And maybe rewarded unfairly. By the statistics that are misused. 

I would like my patients to retain freedom of choice. Freedom of C-Section or vaginal birth, for instance, who can take that away from them? I would not want to. I will do everything I can to make sure their decision is not only proper for them, and that they have thought about all the alternatives to what they have chosen, but I will also do what I can to support them to believe that their choice is valid, proper, and comfortable. 

So after an 18 hour labor and pushing a baby out, and a women is laying there with beautiful new baby on her chest, and she is all sweaty, and the nurses are cleaning up last nights dinner from her gown, and the floor is getting mopped up, and her vagina is sore from stitching, she will have the biggest smile of victory she has ever had. And the baby is in that comfortable spot that they love on top of her mom. Then, she will have known that it was all worth it. And she will have a megawatt smile and a beautiful relief. 

But, if she elected to have the baby the other way, because her own mother's life is wrecked by urinary incontinence and sexual disability, or her brother was strangled in labor and she can't bear the thought of it, and no one offered her mother a C-Section, or maybe she just didn't want to stretch her vagina out, then she can be confident that she will have her baby just the same. And she can be confident that her wishes were honored in a safe and caring manner. 

Who would take her ability to choose away? I would not willingly take that choice away. 

The statistics may be misinterpreted and the bean counters will get involved, and the politically active ones will get involved and make a ton of misinterpretations, and the world will change. 

I will do my part to keep it real, and honest, and proper. 

By the way, I have once again been elected to the position of Associate Director of  my Department of Ob/Gyn. It is my second stint in this position. 

In the past I have been elected or assigned to be the Associate Director, the Chairman of the Department, the Director of Education, the Director of the Oncology Committee, the department secretary, the treasurer, and who knows what else. I have also been the director of the Bergen County Medical Society. 

One of these days I will post my full CV. 

Thanks for reading. 

My blog is at http://doctorjohnmarcus.blogspot.com 

John W Marcus MD Ob/Gyn FACOG 

Obstetrics and Gynecology 

89 North Maple Ave 

Ridgewood NJ 07450 

Phone 201-447-0077 

Fax 201-447-3560