Best Practices in IVF Nursing

Ovarian reserve: Explaining the tests, interpreting the results

Shannon Gwartney is interviewed by Carol Lesser, Editor of this newsletter series

Carol B. Lesser, MSN, RNC, NP, is a Nurse Practitioner at Boston IVF, Boston, MA.

EDITOR’S NOTE
Predicting pregnancy potential: Never say never

In vitro fertilization (IVF) is an assisted reproductive technology (ART) technique initially developed to help women with tubal disease in uniting egg and sperm. Several years after this breakthrough, through serendipity and against expert prognostication, it was observed that injecting less-able sperm into eggs yielded excellent fertilization rates. Thus began the era of IVF with intracytoplasmic sperm injection to treat male factor infertility, and countless couples now had an alternative to donor sperm for procreation.

As time passed and experience with IVF techniques accrued internationally, maternal age became recognized as a powerful indicator of fertility potential. In addition, we discovered that a woman’s age has a significant role in egg and embryo quantity and quality, as well as pregnancy potential. What seems elementary now was not evident in the early days of IVF.

Several key reproductive endocrinologists deserve our respect and gratitude for observing this age-related phenomenon. They helped us understand why women of similar ages and backgrounds would have such disparate cycle experience and outcome. They helped focus our attention on precycle fertility measurements that would explain why some couples had multiple oocytes and embryos while others struggled to produce even a single egg or embryo. They helped us predict who would require higher doses and more elaborate combinations of fertility drugs to provide optimal support for a cycle.

These reproductive medicine giants not only accurately described the impact of age on fertility, but also quickly developed tools to help us quantify what we now refer to as “ovarian reserve.”

Today, IVF nurses understand the importance of maternal age as a determinant in ART outcome. Part of our daily responsibilities is explaining to our patients what the various infertility tests measure and interpreting the results for them. For example, what is the difference between a day 3 follicle-stimulating hormone (FSH) level, an antral follicle count (AFC), an anti-Müllerian hormone (AMH) level, and a clomiphene citrate challenge test (CCCT)? What do the levels mean, and how can you predict outcomes for patients when test results seem to contradict each other? Is 1 test better than another?

IVF nurses convey these test results to the patient so that she can understand them and use them to consider her best treatment options. This is a complex task because, as helpful as these tests are, we still lack the perfect biologic test that can always predict an individual’s fertility fate. The best we can do is describe trends and speak in generalities; while this provides perspective and probabilities for success, it is imperfect. The nurse’s role is often to share this reality and help balance the patient’s hopefulness with a realistic sense of her chances for success, while understanding the tests’ limitations and the patient’s need for useful information.

To cope with this challenge, IVF nurses look at multiple variables, not a single laboratory result. We have all met the exception to the rule on more than 1 occasion. She may be the older patient with an elevated FSH level, multiple failed IVF attempts, with a 1% chance of pregnancy, and a history screams for the need for other ways of family building. She then conceives naturally or with treatment despite her dismal history and our negative predictions. We learn the hard way to “never say never,” while maintaining humility when it comes to predicting pregnancy potential. Nature remains in charge, and as long as a woman ovulates, she will have a chance, albeit remote, for pregnancy.

When patients are well informed and well cared for, they will usually “forgive” us if they are not successful. However, patients who have been told they will never get pregnant with their own eggs may not be so forgiving if nature cooperates despite their poor prognosis. We all learn from experience, and despite the limitations of these tests, we rely on them to guide our patients, keeping in mind that there are always exceptions to the rule.

When counseling patients, it’s important to be aware that while poor ovarian reserve testing can tell us who may not be the best candidate for ART, it cannot always predict who may or may not conceive with her own eggs. This is especially true when a younger patient presents with abnormal levels. Although elevated FSH levels, elevated AFCs, and decreased AMH levels indicate decreased ovarian reserve, age is also a powerful predictor of ultimate success.

To simplify: age and obstetrical history describe relative oocyte quality, and ovarian reserve testing describes the relative quantity of eggs that remain and how responsive one will be to ovulation induction medications. As nurses, we educate our patients and guide them through challenging decision making.

In this issue’s interview with nurse practitioner Shannon Gwartney, RN, MSN, we explore the methods available for testing ovarian reserve, how to interpret test results, and using results to help patients make treatment decisions. Shannon provides her suggestions for how to best share the meaning of test results with patients and helping them to balance hopefulness with realistic expectations.

This supplement is supported by

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