PCOS or low ovarian reserve?


0 Posts
Reply PCOS or low ovarian reserve? Posted on: Dec 20, 2010 at 8:19am
My history as follows

1)Age 30. Normal day 3 FSH /estradiol/ prolactin. Ovulate regularly (34 day cycles). I am thin.

2)Conceive with 1st unmedicated IUI (I'm a single mom by choice and this was my first ever attempt at conception). Normal 7 week scan. Missed miscarriage at 12 weeks. Karyotyping of products of conception- Normal XY

3) Find I have PCO-looking ovaries (17+ follices per each ovary), but this PCOS diagnosis falls by wayside as testosterone is low (around 17 ng/ml). Note DHEAS was in PCOS range- 251

4) also discover I have anti-TPO antibodies (titer 107), and TSH is in high 2s.

5) Start on synthyroid. Conceive 2 weeks later with 2nd unmedicated IUI. Normal 8 week scan, missed miscarriage at 9 weeks. Karyotyping of POC- Turners syndrome 45 XO

6)New RE suggests revisting the PCO diagnosis. Shockingly, AMH, levels were low (1.1 ng/ml, the testing labs reference ranges are 1.23-8). Testosterone comes back at 83 ng/ml, its increased from the first test but is still in 'normal' range. DHEAS is similar to first test (231). Interestingly, I'm also Vitamin D3 deficient (16 ng/ml). Most of this fits with PCOS ,including vitamin D3 deficiency. Its the AMH that is confounding, especially given the high AFC only 3-4 months ago. This hormone is supposed to be increased in PCOS.

Given my history, one would think my losses could be attributable to less than stellar egg quality. One possible cause can be PCOS, but the AMH levels make you wonder if this is also because of a failing ovarian reserve.

What should I make of all this? I'm going to get antral follicle count and AMH retested on the same day.

I'm wondering if the AMH levels were messed up because vitamin D3 is low- I looked for links between the two and all I could find ishttp://www.ihop-net.org/UniPub/iHOP/pm/13522796.html?nr=1&pmid=19056816, which talks about how Vitamin D3 can stimulate aMH production. Sadly nobody has done studies correlating these two

I'm a scientist so all of this is very familiar territory (though my field is immunology). My results are confusing me greatly, nothing adds up. I need expert opinions!

Dr. Braverman

2026 Posts
Re: PCOS or low ovarian reserve? Posted on: Dec 25, 2010 at 3:10am
We need to talk , why dont you give me a call and lets go over your history in detail. There are many clues in what you have given me. Realize that most cases of PCOS are never "typical" they only have certain features. Did you have a fasting insulin, HgbA1C? I agree there is also a suspicion of poor ovarian reserve based on AMH alone but not c/w your antral follicle count. There are two things to tell you. First there is 'nothing new under the sun" (meaning there is an answer for everything) and Two Sherlock Holmes famous quote "when the likely is no longer likely , time to consider the unlikely" . This seems like a challenging case but trust me we will get to the bottom of it.
I hope I can be of service to you. Ask for Kim and schedule a telephone consultation. As you must be aware there is also a strong crossover between PCOS and immune issues. If its not PCOS (and also be aware that PCOS "ovaries" that dont have a postive blood workup for PCOS still respond nicely to PCOS treatemtns) we will find out what is your issue because there is certainly one. The antithyroid antibodies might be the clue as well.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.