Found this post on Women Over 40 With High FSH:
Dr. Check Consult - Summary of Info
FSH: a Cornell 2005 study said that once someone's FSH has been above 15 (even once) then they must use donor eggs. He doesn't believe this and has had plenty of success encouraging women to try both naturally and with minimal stim cycles. He said once you can achieve a 6-7-8 cell embryo then 65% of the time it should work if you are under 35 and if you are over 35 then 38 - 42% success (in the absence of other factors such as immune issues). A normal live pregnancy rate for someone 41 - 42 should be 20% per cycle (without distinguishing FSH as normal or abnormal).
WHY LOW DOSE STIM: he believes a high dose stim regime doesn't "fry" our eggs but it does somehow affect implantation and this leads to lower success rates.
HOW DOES LOW STIM WORK: their premise is that you don't add FSH on high FSH, ie they like to use estrogen to bring down your FSH if it is elevated. After this he likes to let your own FSH drive your follicle growth - so whether or not they add FSH, and how much, is driven by your own levels during your cycle.
ANTAGNOSIST VS AGONIST: although there are some published studies suggesting lower success rates for an antagonist cycle, he believes these were earlier studies and it is no longer the case. He believes there are benefits to an antagonist cycle in that it is easier.
ESTROGEN PRIMING PROTOCOL: while he was the first to introduce estrogen to lower FSH before a cycle, he's not in favour of the full EPP because it means a whole month (while you're 1st on BCPs) is lost, ie. it takes 2 months in total and that seems to be wasting time.
BACK TO BACK CYCLES: this is case by case, but generally where there is no risk of hyperstim then it should be OK.
ANY DIFFERENCE IN DRUGS: in their experience (and no studies have been done to confirm), very high doses of GONAL F seem to have had the lowest pregnancy rates. However when you use low doses it doesn't seem to matter whether you are using Gonal F, Follitism or Bravelle - they are all essentially the same ... He does seem to prefer Cetrorelex vs Ganerlix (sp?) though for antagonist cycles.
WHEN IS ENOUGH, ENOUGH? So long as you are producing nice embryos then even if you are over 40 yrs, you have a chance of success with your own eggs. On the other hand he is a "pragmatist" so if you do want to increase your chances in any given cycle then donor eggs could boost success rates to 55%.
ABNORMAL FERTILISATION: I had a 3PN fertilisation on my last cycle and he suggested that it wasn't that my eggs are "suddenly old" but more likely a result of the protocol (very high stim of 900 Gonal F).
ICSI: in general he thinks "arranged marriages aren't that good", ie. your eggs probably know how to pick out the best partner better than we do. But he can see why in my case (where I only get 1-3 eggs) it might seem better to use it - even psychologically, because if you don't use ICSI and then they don't fertilise well you'd be upset (although the same could even have happened with it).
ASSISTED HATCHING: should definitely be done for older than 40 years, as the embryo is avoiding vital enzymes available to it on it's way down the fallopian tube.
DAY 2 OR 3 OR BLAST: on Day 2 you can't hatch embryos so for this reason DAY 3 is better. On the other hand, on Day 3 some think the uterus is more sensitive/cramps more, so ... the only real advantage to blast is if you have lots of eggs and don't have a good freezing program ... on the whole, the best environment for them is inside you not in the lab.
IMMUNOLOGY: his background is reproductive immunology. If you have NK Cells in your uterus then they can have a protein that acts as a progesterone blocking factor and this can cause implantation problems. He thinks the studies show that LIT can work but it is hugely expensive and he thinks something like Intralipids (a free fatty acid from soybeans which can bind to the NK cells and "deactivate" them) works well too and is much cheaper ...
On the other hand he doesn't think there are any tests that reliably determine if you have got an NK Cell problem so it would probably be best to just go off your history (ie, multiple IVF failures etc) ... Basically he doesn't think anything else (like IVIG etc) is needed and he wouldn't advocate them.
STERIODS: no good data to support the use of steriods (prednisone/dex) in IVF cycles. Doesn't think they are necessary.
HEPARIN: only really helps people with implantation issues associated with APA. You can use it but he doesn't really see a reason to do so.
MTHFR: I am homozygous and he says it's quite common and heparin isn't really warranted - especially if you haven't got elevated homocystein levels.
ASPIRIN: he hasn't seen any studies showing a difference in blood flow to the uterus or endometrial thickness based on aspirin. He thinks no aspirin (even low dose) is better.
VIAGRA/VAGINAL ESTROGEN: no good studies showing significant difference in endometrial thickness with use of these, ie. wouldn't bother with them.
DHEA: he knows the Gleitcher (sp?) study showing higher implantation rates but apparently it also showed higher miscarriage rates. Plus, he says it was a study on women around 30 years old where none of them had an FSH higher than 12. In other words, it's not convincing and he think pregnancy rates might be better without it.
ENDOMETRIOSIS: the studies are a little mixed. Some show no lower pregnancy rates in women with endo, some do. 2003 data showed IVF overcomes endo abnormalities and 2005 studies showed endo does inhibit IVF success. If you have had multiple failed cycles w/o IVF then laparoscopy - a study showed 61% of women falling pregnant afterwards vs 18% before. However in my case where I have already had multiple laps for endo he wouldn't advocate any more.
HYDROSALPINX: I recently had my tubes removed due to hydosalpinges (bilateral) and he said this is a good idea as plenty of research shows it impacts IVF success rates.
DIET/EXERCISE/SUPPLEMENTS: doesn't advocate anything special - regulary healthy living etc ... don't have to give up exercise, sugar, meat or use only organic food etc etc etc.
GOLDEN EGG THEORY: the premise behind the high stim approach is the higher the better. The argument is that our bodies are like a lottery such that the higher the number of eggs achieved the higher the probability of getting that "one golden egg" from the (presumably) bad lot. Check feels that our body knows how to identify the best of the eggs in our basket and kicks out this one each month - so even if you use a low stim approach and get only 2 embryos, it's not necessarily a worse outcome than someone using high stim and getting 9 embryos ...
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