What are the next fertility treatment options after two failed Intrauterine Insemination (IUI) cycles with low Antimullerian Hormone (AMH) levels?

From the Guidelines

After two failed IUI cycles with low AMH levels, the next recommended fertility treatment option is typically in vitro fertilization (IVF), possibly with protocol modifications to address diminished ovarian reserve. This recommendation is based on the understanding that low AMH levels indicate a reduced ovarian reserve, which can significantly impact the success rates of fertility treatments. Given the limited time available to achieve pregnancy before further decline in ovarian reserve, more aggressive treatment options like IVF are considered to maximize chances of success while viable eggs remain.

The decision to proceed with IVF after failed IUI cycles, especially in the context of low AMH, is supported by the fact that IVF offers higher success rates than continuing with additional IUI cycles when AMH is low, as it bypasses several fertility barriers 1. The treatment typically involves ovarian stimulation using higher doses of gonadotropins, often with a GnRH antagonist protocol starting when follicles reach a certain size.

Some key considerations in the management of low AMH levels include:

• The use of letrozole or tamoxifen to antagonize the effects of high estrogen levels during ovarian stimulation, as noted in the context of fertility preservation 1.
• The potential for double stimulation to increase the number of oocytes retrieved in women with low ovarian reserve, although this approach requires careful consideration of the patient's specific circumstances and the potential risks and benefits 1.
• The importance of timing in ovarian stimulation protocols, with the goal of completing the process before any potential decline in ovarian reserve or the initiation of other treatments that may impact fertility 1.

For patients with extremely low AMH, alternatives such as egg donation or embryo adoption might be discussed as options with potentially higher success rates. The choice of treatment should be individualized, taking into account the patient's overall health, fertility status, and personal preferences.

In terms of specific treatment protocols, the use of higher doses of gonadotropins (such as Gonal-F 300-450 IU daily or Menopur 150-225 IU daily) and GnRH antagonist protocols (like Cetrotide or Ganirelix 0.25mg daily) may be considered to optimize ovarian stimulation in the context of low AMH 1. Additionally, adjuvant treatments aimed at improving egg quality, such as growth hormone, DHEA, or CoQ10, may be discussed, although their effectiveness can vary and should be considered on a case-by-case basis.

Ultimately, the management of fertility issues in the context of low AMH requires a comprehensive and personalized approach, considering the latest evidence and guidelines to optimize outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Next Fertility Treatment Options

After two failed Intrauterine Insemination (IUI) cycles with low Antimullerian Hormone (AMH) levels, the next fertility treatment options can be considered:

• In Vitro Fertilization (IVF): According to 2, IVF may be associated with higher live birth rates than expectant management or unstimulated IUI.
• IVF versus IUI with ovarian stimulation: The study 2 found that in women pretreated with IUI + clomiphene, IVF appears to be associated with higher birth rates than IUI + gonadotropins.
• Consideration of intracytoplasmic sperm injection (ICSI): As mentioned in 3, the use of ICSI could be considered after poor fertilization in a previous IVF cycle.

Effectiveness of IUI in Women with Low AMH

• A study 4 found that ovulation induction and IUI are equally effective in women with diminished ovarian reserve (DOR) and in women with normal ovarian reserve in terms of pregnancy rate, multiple pregnancy rate, and miscarriage rate per IUI cycle or cumulative pregnancy rate after four cycles of IUI.
• The study 4 also found that neither age nor AMH predicted pregnancy after ovulation stimulation and IUI.

Factors Predicting Pregnancy

• According to 4, infertility duration, post-wash sperm count, and follicle number greater than 11 mm on the day of human chorionic gonadotropin trigger were independent predictors of pregnancy.
• The study 5 suggests that IUI with ovarian stimulation by low-dose gonadotrophins using strict cancellation criteria may be a viable alternative to IVF as the first-line treatment of unexplained infertility.