In this episode, we dive into the differences between Premature Ovarian Insufficiency (POI) and Decreased Ovarian Reserve (DOR) — two terms that are often misunderstood and used interchangeably, but have distinct implications for reproductive health. Join Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Abby Eblen from Nashville Fertility Center, and Dr. Susan Hudson from Texas Fertility Center as we break down the medical definitions and treatments for both conditions, while highlighting how they can impact fertility. Whether you’re navigating these issues personally, or just want to understand the science behind them, we’ll provide clarity on these important topics. Tune in for expert insights on these two conditions.

Episode Transcript:

Susan Hudson (00:01)

You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.

Carrie Bedient MD (00:23)

Hello everyone and welcome to another episode of Fertility Docs Uncensored. Happy New Year’s Eve. This is Dr. Carrie Bedient from the Fertility Center of Las Vegas and I am joined by my glittering, gallivanting and gorgeous co-hosts, Dr. Susan Hudson from Texas Fertility Center and Dr. Abby Eblen from Nashville Fertility Center.

Abby Eblen MD (00:43)

Hey guys, happy new year.

Carrie Bedient MD (00:46)

Alright, so do you guys do resolutions? Yes or no?

Susan Hudson MD (00:49)

I don’t officially do resolutions, but I always have like a little something that I’m like, ooh, this is what I’m gonna work on 

Abby Eblen MD (00:57)

Me too. That’s exactly how I am, Susan. I hate to it out loud, but deep down I do have some resolutions, yes.

Susan Hudson MD (01:03)

I kinda treat them like birthday wishes.

Abby Eblen MD (01:06)

Ha ha!

Carrie Bedient MD (01:06)

So are these resolutions or are these just secret deep-seeded desires of, hope X will happen?

Susan Hudson MD (01:13)

No, but it’s something I want to focus on. instead of it being a wish, like I wish it just like fell in my lap. It’s a, I really want this to happen. So I’m going to really dedicate myself to doing something this year.

Carrie Bedient MD (01:30)

Like manifesting your dreams, goals, whatever you wanna call it. Okay, okay. So are either of you willing to give any specifics?

Susan Hudson MD (01:33)

Yes, exactly, exacty.

Abby Eblen MD (01:42)

Well, mine usually are more, kind of like Susan, mine usually focus on health and happiness. I feel like a lot of people that are, women that work a lot like we do, that are, kind of driven, you focus a lot on work and that’s great, but I think you need to be well balanced. You need to have things you enjoy that are outside of work and that keep you healthy as you go along. I focus on my exercise goals and also focus on what, if there’s some new hobby I wanna do or how I wanna change the way that I do the hobbies that I do now. I always have to have something to motivate me, something to keep me excited about, going forward and having free time.

Carrie Bedient MD (02:19)

Mm-hmm. I’m thinking more along the lines of just having spent an entire life and career always striving for whatever the next thing is and having lists of accolades and awards and things like that. And now trying to flip that focus of, none of that stuff really matters. And now let me focus on the relationships that I have in my life and focusing on this moment here and now, enjoying it for what it is without being so constantly stressed about striving for whatever the next thing is going to be. Because that’s fun and I do like thinking about that and it keeps me on my toes and it keeps me fresh. But I think I’ve been neglecting all of the other areas in pursuit of that and that it’s probably about time to change.

Abby Eblen MD (03:05)

Yeah.

Susan Hudson MD (03:09)

I love that Carrie.

Carrie Bedient MD (03:11)

Yay. Okay, so now that we are warm and fuzzy, what kind of questions do we have today? Are we doing one today?

Susan Hudson MD (03:18)

We’ll do one question today. Our question today is, I am 34 years old with one previous pregnancy, now have a two and a half year old son. My husband and I began trying for a second baby in mid 2023 when our son turned one. I continued nursing my son until two years, three months. I also thought that my period returned about one year postpartum and that she would be able to conceive. Shortly before one year of trying to conceive, her husband and she decided to see an REI to find out what was going on. They concluded that they had unexplained infertility. Before jumping into treatment, they sought a second opinion from another REI at a different practice. That REI recommended that they wait at least six months post weaning to seek treatment. What are your thoughts on nursing and impacts to fertility? How long after weaning do you recommend waiting before intervention?

That’s actually a really good question. We have a lot of patients that come with secondary infertility, especially patients of ours that we’ve helped get pregnant in the past, and they’re going to be very proactive about not just trying forever and getting frustrated again, but jumping more quickly into a fertility treatment. But one of the number one things I ask in all their appointments are, are you currently breastfeeding? So what do you all think?

Carrie Bedient MD (04:42)

So when I’m asking about breastfeeding, there’s two things that I’m thinking about. One is, you doing that currently with an eye to, is there anything that I need to give you that you can’t be breastfeeding while on? And so that really doesn’t hit during the diagnostic phase. That is much more relevant during the treatment phase. More relevant to this question though, is to what degree does breastfeeding impair fertility? And that in part depends on how far out you are from breastfeeding. And in a part depends on what what is the frequency of breastfeeding? Because when you have someone who is breastfeeding and that is the only source of nutrition for that child, they’re probably breastfeeding, especially when the kid is itty bitty all the time. I mean, every couple of hours, they’re breastfeeding, they’re pumping, and they’re doing all of those things. By the time you get further out to a year or two, even if they are still dedicated about their breastfeeding, odds are a lot higher that it’s maybe in the morning and then at bedtime or considerably more stretched out and the kid is also getting nutrition from outside sources, milk, food, what have you, where there’s not as much impact of the breast milk and it’s in part nutritional but also a bonding experience. And what that means physiologically is that the suppression of ovulation that you get from breastfeeding gets lifted because if you’ve got someone who is in a society where formula is just not available, there is no external source of baby’s nutrition, it is very helpful and very proactive for the mom to not get pregnant because if she gets pregnant again, her milk supply goes down and that first child’s life is jeopardized by lack of nutrition due to the second pregnancy. So that’s kind of the physiology behind why…breastfeeding and getting pregnant again is much harder to do and is not really an advantageous thing. So when you’ve got someone who’s further one to two years out, the likelihood that they’re breastfeeding with that frequency and magnitude is much lower. And so it’s much less likely to impair their fertility. What do you think, Abby?

Abby Eblen MD (06:49)

Yeah, I would agree. Because certainly we know patients, women who’ve gotten pregnant breastfeeding, so it’s certainly not an absolute birth control method. But like we say here a lot, it’s like layers of the onion. If you know that you’re trying to get pregnant and we want to do everything we can to optimize your ability to get pregnant, probably it would be best to kind of wean. And I don’t have great data to back this up, but generally, as long as you’re not having breast discharge, as long as you can’t express breast milk, We can always check her prolactin level too, but like Carrie said, generally prolactin only goes up at the time you’re breastfeeding, it goes back down to normal when you’re not. So that’s not as big of an issue. But if you’re still having some breast discharge, that makes me worry a little bit that it might have a negative impact on implantation and pregnancy. I don’t think there’s a certain timetable where you say, because for most women, it doesn’t take six months for breast milk to dry up. I think it takes three or four weeks, sometimes a month or so. And so I think it’s reasonable once the breast milk has dried up to go ahead and start trying to get pregnant at that point.

Susan Hudson MD (07:45)

I would say in this case, as she’s already been trying to conceive for a year and she’s implying that she’s having monthly periods, that means she’s likely ovulating. I would not not do an evaluation at this point, just to say you need to wean and then come back in six months time. I think that’s kind of kicking the rock down the road. I would go ahead and do an evaluation. But as Carrie alluded to, if we’re going to go into any type of treatment, all the medicines that we give are going to pass through breast milk and potentially affect a young child. And so we would want you to not be breastfeeding at that point, but when it comes to the diagnostic phase and then figuring out, hey, am I ready to stop breastfeeding or are we gonna keep on doing this for a little bit later? And then once we’re done, we’ll jump into some sort of treatment. I think that’s very rational and reasonable, but I wouldn’t say you can’t have an evaluation at this point.

Carrie Bedient MD (08:48)

And the other thing is that the medications we give you, in addition to potentially passing through to breast milk, some of them, particularly anything that’s going to increase your estrogen level, will turn off your breast milk supply. And we don’t ever want to be the cause of your weaning. We want you to be the cause of your weaning. And you let us know when you’re ready and we’ll get going because it’s kind of traumatic when you’re stopping when you don’t really want to be stopping. And there’s enough trauma in this world. We’re not going to add any more to it.

That factors in as well. All right, so let’s dive into our topic today. And we are going to explore a different set of letters and acronyms. And we are going to talk about the difference between POI and DOR. So of course, before you can do anything, you have to know what you’re talking about. So who wants to start tackling what does POI stand for and what does it mean?

Susan Hudson MD (09:39)

POI stands for premature ovarian insufficiency. A fancy word for you have essentially gone through menopause early. What does that mean is that in general, you have evidence of diminished ovarian reserve. So poor ovary function on some sort of labs or evaluation, and you have not had a period for a whole year. Basically that’s what POI is. We use this designation if you do this before the age of 40.

Abby Eblen MD (10:16)

And one thing I’ll add to that is sometimes when people have premature ovarian failure, particularly younger women, occasionally, every now and then, your body can do crazy things and you might ovulate once or twice every now and then. And you may feel pretty good on those months. But generally, like Susan said, unfortunately, your ovarian reserve has pretty much gone away. And unfortunately, your ability to get pregnant using your own eggs is probably pretty unlikely. Decreased ovarian reserve, I think of that as more of a wastebasket term. I mean, there’s not really…a set criteria that says you have decreased ovarian reserve, although we try and categorize women with a lower AMH or anti-mullerian hormone level as being in decreased ovarian reserve. It tells us that your egg count is low. It doesn’t really tell us about your egg quality, however. Generally when we see an AMH that’s lower, we put you in that category, just means your egg pool is not the same as somebody else kind of in your age group and that you may have a little bit harder chance

of getting pregnant because of that.

Susan Hudson MD (11:12)

Some other things that can contribute to a diagnosis of diminished or decreased ovarian reserve or DOR also includes elevated FSH or follicle stimulating hormone levels. FSH tends to tell us a little bit more about quality than quantity, though there is some overlap. I generally consider an FSH over 10 as being elevated or abnormal and an FSH over 18 is very, very, very abnormal. We also look at antral follicle count or the number of follicles on your ovaries, ideally at the beginning of your cycle. And we would like to see at least a total of 10 follicles in that situation. We also can diagnose diminished ovarian reserve based on performance in an IVF cycle or an in vitro fertilization cycle. We learn things about eggs and embryos during a cycle that we can’t get from our laboratory testing. And sometimes there’s things that we see and learn that show us we actually do have an egg problem that may not have been diagnosed by one of those aforementioned tests.

Carrie Bedient MD (12:27)

So we talked a little bit about age. Let’s dive into that a little bit more. And so with POI or POF, and I’m bringing up the other set of letters because POF or premature ovarian failure is one of the older terms that you may hear in reference to this. And we switched the name from failure to insufficiency because nobody has failed. It’s the ovaries have gone through a physiologic process that they’re going to go through anyway. They just did it prematurely or earlier. And so this is not a personal, this is not personal in any way, shape or form. With insufficiency, some people, and this is a little bit different how you classify it, but there are some people who still are having periods. But when you check their numbers, they’re considerably off what you would anticipate for them to be. So they may not be fully menopausal in that they’ve not had a period for a year or more, but their levels are way off, their periods are a little bit more inconsistent, things like that. So let’s talk about ages. What makes you suspect age-wise that someone’s going through POI versus DOR?

Susan Hudson MD (13:36)

If I have a young person and I’m meeting her for the first time and we go to go over her history, obviously knowing if she has regular monthly menstrual cycles can be a sign. There’s a lot of people that we diagnose with DOR or POI that may have irregular cycles. They just don’t have enough follicles in their ovaries to do the thing that they need to do. Oftentimes these people are misdiagnosed as having PCOS or polycystic ovaries. And then we go and do an ultrasound and instead of having 20 follicles, we may have two, three, four or five.

That’s a first sign of, we may be dealing with one of these DOR or POI types of diagnoses versus what they may have already been labeled with by their primary doctor.

Abby Eblen MD (14:35)

Yeah, and one thing I would say about POI, somebody truly walking through my door with POI is a lot more uncommon than somebody walking through my door with decreased ovarian reserve. I see a reasonable amount of people that just surprisingly will check one of those values that Susan talked about and will find they’re abnormal. Or like you said, we’ll see that on ultrasound. But it’s pretty rare for somebody to walk through my door and not understand or not already know because a lot of times they’ll have hot flashes, they’ll have mood swings. Unfortunately they’ll have symptoms of same things postmenopausal women in their 50s will have, except they’ll have them potentially much younger when they’re in their 30s or 40s.

Carrie Bedient MD (15:12)

Let’s take not necessarily a detour, but a detour from the fertility component of this. If you’ve got someone with DOR versus POI, what are the other general health considerations that you’re thinking about that are different between those two?

Abby Eblen MD (15:16)

So bone density issues, if someone is seeing me and they’re not trying to get pregnant, but they have POI, I’m worried that they don’t have very much estrogen in their system. There’s several things that help build bone mass. There’s exercise, calcium, vitamin D, those are all helpful, but really the estrogen is the most helpful in building bone density. And so for women that have gone for at least a couple of years without having regular periods and have really decreased estrogen levels, I worry that they’ve got decreased bone density compared to their peers, and then over time that’s gonna continue to get worse and worse. And so for those patients sometimes I would get a DEXA scan, which is a scan to look at the density of the spine and of the hip, and get some sense for where they sit. And then a lot of times it’s good to do that as a baseline, and then every two years or so is when you would wanna get a repeat level to see what’s going on.

Susan Hudson MD (16:15)

With patients with POI, there’s also a couple of additional things that I do maybe once and then some things that I tend to do on an annual basis. The things that I would do once are one, I would do a chromosome analysis. It’s very important to make sure that we don’t have a situation that our patient is a Turner’s mosaic, which is someone who has some of their chromosomes have only one X chromosome and some of their chromosomes have two X chromosomes and so they may have had periods for a while and now they’re not having periods. The reason why that’s important is because patients with Turner syndrome or Turner’s mosaics may have abnormalities in their heart or vascular system that could actually make pregnancy very, very dangerous. I also do a test looking at something called fragile X syndrome.

Fragile X syndrome is the most common inherited source of developmental and mental delay in the population. And we know that sometimes you may have some precursors to Fragile X in your genome and that can inherently increase your odds of having premature ovarian insufficiency, so giving you an actual diagnosis. Now we also know that another major cause of this is autoimmune diseases. And as we’ve talked about multiple, multiple times, people who have one autoimmune disease are at increased risk of other autoimmune diseases. So when I see somebody with POI for their annual getting some hormones type of visit, I make sure that their thyroid’s working well, that we don’t have any type 1 diabetes developing, that their adrenal antibodies haven’t started kicking up and causing a problem there. Whereas if somebody has just diminished ovarian reserve, I do still consider those people at probably a little bit higher risk of autoimmune conditions, but not nearly to the fact that I would be worried about those on an annual basis.

Carrie Bedient MD (18:30)

What do you think about with respect to sexual health with POI versus DOR and are there any treatment considerations that you’re more likely and again, non-fertility gonna go down with a POI patient versus a DOR patient?

Abby Eblen MD (18:47)

Yeah, think with decreased ovarian reserve, a lot of times patients are still making some estrogen and estrogen is really important for vaginal health. With patients who truly have POI, they may have very low or almost nonexistent estrogen levels. And sometimes even when those patients are placed on some hormone replacement therapy, for whatever reason, their vagina doesn’t get the same benefit. Sometimes you need a localized amount of estrogen in the vagina to help with sexual health. Because sometimes you can have vaginal dryness, irritation, pain with intercourse related to that. Just lubrication is just not as good. And so in addition to that, lubricants can be helpful as well.

Carrie Bedient MD (19:23)

All right, so let’s flip back into the fertility component of this. What’s the biggest determinant of whether or not we are likely to be successful with just any patient in general? What’s the very first thing that all of us consider when someone walks into our office with a diagnosis of infertility?

Susan Hudson MD (19:41)

Age.

Abby Eblen MD (19:41)

Resilience. Age and resilience.

Carrie Bedient MD (19:44)

All right, so both of those are true. Resilience really is a huge part of it. So what do you think about for prognosis for those patients? What treatment options are potentially open to POI versus DOR patients?

Susan Hudson MD (20:01)

So in most circumstances, women with POI have about a 9 % lifetime chance of a spontaneous pregnancy. And generally speaking, all the magic that we do in our offices short of using something like donor eggs or donor embryos is unlikely to have a major impact on that success. Now we have actually had a guest on this podcast who broke this rule, which is great. We love it when those things happen. But in general, people truly with POI are not really going to be helped with our mainstream services. Whereas people with diminished ovarian reserve are often going to have a reasonable chance of success, sometimes with ovulation induction with inseminations and sometimes things like IVF. But there’s definitely more of a window of success if you have that label, unfortunately.

Abby Eblen MD (21:05)

Yeah, and would echo everything Susan just said. I usually say 10%, but nine to 10%. And that’s through your entire life. And so usually I tell patients, if pregnancy is really a goal for you, you might get lucky, but probably your best chance of successful conception is with donor eggs or donor embryos. And I too have had one patient in my whole 20 plus year career that got pregnant that had premature ovarian failure on her own. But I’ve had many, many patients, unfortunately, that have seen me that that’s not happened to. So I do think that’s that’s a real thing. When we first started checking AMH, which has probably been, I don’t know, 15 years ago or so now, before we kind of really understood what it told us, some of us would say, well, if you’re AMH, if your egg count is really low, you don’t have a very good chance. You have the same risk, chance of a 40 year old getting pregnant. Well, we know now that’s not true at all. And so I’ve seen lots of women in their early thirties who’ve had unfortunately abnormal AMH levels, egg counts, but have gone on to get pregnant. Sometimes you’ll do ovulation induction, IUI, a few amount of times and boom, they’ll get pregnant. So, when I see a low egg count, I don’t necessarily jump and say, my gosh, you need to do IVF immediately. I think it’s definitely worthwhile in younger women because we do have a little bit more time on our side to try and do some ovulation induction, IUI without moving on to more aggressive therapy immediately.

Susan Hudson MD (22:23)

To piggyback on what Abby was just saying, when we’re talking about things like AMH and quantity of eggs and FSH quality of eggs, I would rather battle a quantity problem any day over a quality problem. There’s just more in our armamentarium to fight that issue. And so I’ve had people with undetectable AMH levels come in spontaneously pregnant.

Abby Eblen MD (22:38)

Absolutely.

Susan Hudson MD (22:51)

I’ve seen this happen multiple times. So it does happen. Whereas, as I mentioned that FSH level, once you get beyond an FSH of 18, there’s about a 5 % chance of pregnancy using our most aggressive options. And that’s just the nature of the disease state.

Abby Eblen MD (23:15)

And Carrie explained that you have a really good analogy that you use about your mom yelling at you to wake up.

Carrie Bedient MD (23:20)

When we’re thinking about FSH levels, FSH is follicle stimulating hormone, the brain hormone that communicates with the ovaries to tell them to start growing an egg at the beginning of each menstrual month. And you want that communication to be in an inside voice. You want it to be at a nice, reasonable level. You don’t want it to be a whisper, like you want it to be loud enough to be heard, but you also don’t want it to be yelling. And what we find in that women with both DOR and POI, is that the ovary has got its fingers in its ears and it’s going la la la la la. I’m not listening to you. And as a result, the FSH needs to really crank up and start yelling. And so that’s how you interpret those levels in the high teens, 20s, 30s, 40s, 50s. mean, highest level I think I can, that I have seen off the top of my head is in the 140s. And it just means that the brain is having to really yell at the ovaries to get a response. And the ovaries just, aren’t doing it a lot of the time. They might, but odds are much greater that they are not because it’s taking the brain that much extra oomph to get any kind of reaction whatsoever. So in looking at POI versus DOR patients, is there any impact on chromosomes of the baby or the child that result with either one of those?

Assuming you don’t have like fragile X or Down syndrome 

Abby Eblen MD (24:39)

Yeah, I think it’s really more age-related. The older a patient, the more likely they are that their chromosomes are not going to be normal. And the reason that is is because, as we’ve said many times, you’re born with all the eggs that you’ll ever have. And so every time, every month when you get that trigger to release your egg, your egg’s stored with two sets of chromosomes and all of a sudden it has to completely divide in two. And that tends to be more of an age-related thing than an AMH-related thing. So the older you are, the less likely your egg will divide correctly. But it’s not to say that young women can’t have a baby with a chromosomal abnormality. It’s just less likely.

Carrie Bedient MD (25:16)

What are some of the similarities as you’re approaching a treatment cycle of someone who’s got POI versus DOR? What are the things that, it doesn’t really matter what the specific diagnosis is, but that you need to consider as you’re going through making that treatment plan with that patient?

Susan Hudson MD (25:32)

One I think is the family size that they’re aiming for. I mean, if we’re aiming for a family size of one child, our aggressiveness and things we may try may be very different than if you come in and tell me that you want three children, you’re 39 with an FSH of 12 or 13. There are things that I know that I need to do now to at least give you a chance of having those children down the road. If you have POI and you’re still wanting to try conventional treatment options, that’s another part of the conversation. I mean, I’m happy to try to get lucky once, but the chance of that happening two, three, four times. That’s, that’s just probably not in the cards, unfortunately.

Carrie Bedient MD (26:18)

How many cycles do you typically talk about with your patients with POI and DOR? Do you tell them like, we’re one and done? How do you prep them for repetition of cycles and how many you may need to do?

Abby Eblen MD (26:33)

You’re probably gonna need to do more and really, there’s not really a number you can say, you need to do this many cycles. Now, we’ll say, if you look at the SART website, there is a mechanism by which you can put your age in and ask you about six questions and it’ll give you some sense for if I wanna have this many children, this is how many cycles I’ll need to do. But we can give you all kinds of analytic data, but what applies to you, we don’t really know until it happens and so I would just be ready to be in it for the long haul if you’re really trying to use your own eggs. The reality of it is, like Susan said, if you don’t have many eggs and if you happen to be over 35, the chances of you having a few eggs and having sperm fertilize your egg and the chance of having a genetically normal embryo is pretty low, depending on what your AMH number is and what your egg count is. And so I would just expect that you’re gonna have to do more than one cycle to try and get even one or two genetically normal embryos.

Susan Hudson MD (27:30)

I always tell my patients that I want them to be hopeful, but I also want them to be appropriately hopeful. And so I think those conversations are very, very important because I’d never say, hey, we need to do three cycles. Because none of us have that crystal ball, be able to tell exactly how many embryos we’re going to get out of an IVF cycle. We’ve all seen those IVF cycles where we got three eggs and we ended up with three chromosomally normal embryos.

Not what any of us ever expect, but we are more than happy to have it when we do. And so I tend to take it more of a, like, these are my concerns, okay? If I don’t think something’s going to work, I’m going to tell you. We may still do what you’re asking, but I’m going to tell you if the odds are stacked against us. And if we’re not successful, it’s really, really important for you not to just disappear, but come back to your fertility specialist.

Have a conversation, have them share what they learned through the cycle. Because often that’s very, very insightful for us to be able to figure out, is there something we can tweak that will make that next cycle more successful? Or is this probably the best that we’re going to do? And we might need to think about what steps we want to take from here.

Abby Eblen MD (28:51)

And just on a side note to that too, I think by not successful, what that means is we could start to stimulate you with medicines and within five or six days, if you only had one egg and we didn’t see anything else developing, that might be where it ends. Or not successful, may be we get you to the egg retrieval and maybe we only get one or two eggs and maybe they don’t fertilize or grow. So the point is at any point along the line, unfortunately, like Susan said, not to be negative, but just be prepared that at any point along the line, it may not go well, it may end at that point. If we don’t have an embryo that grows, and then ultimately we may get all the way to the stage where we have an embryo to test, but we don’t get a normal one.

Carrie Bedient MD (29:29)

What psychological considerations do you have that are maybe different between a POI and a DOR patient?

Abby Eblen MD (29:35)

With a POI patient, I think the good news, bad news about that is when you really talk to a patient about what their chances are with potentially trying to use their own eggs, I think it’s so unlikely that they’re gonna be able to conceive using their own eggs. I think the only good news about that is it sort of helps them move forward. They really have to decide how important is it for me to have a child? How important is it for me to have biological component for my partner. them move forward if they know that their chances are, pretty low by most people’s standards of getting pregnant with their own egg. Whereas with decreased ovarian reserve, that’s kind of a mixed bag. It depends on the age of the patient. It depends on what their numbers are showing us. So it’s a little bit more challenging. But like Susan said earlier, just because you have decreased ovarian reserve doesn’t necessarily mean you’re not going be able to get pregnant, but you may need to do something more aggressive.

Susan Hudson MD (30:26)

What I see in my patients that have POI is they often come in, get their diagnosis, start on estrogen and progesterone because they need hormones, and we start talking about options for the future. Oftentimes, I may see them for a number of years until they’re ready to go on to some sort of intervention for them to hopefully experience pregnancy, delivery, parentage. Whereas with patients with diminished ovarian reserve, and again, we’ve all had exceptions to this rule, most people with diminished ovarian reserve are going to want to try with their own eggs or autologous eggs initially at some level and then potentially progress to something like donor eggs or donor embryos. Again, we’ve all had people who’ve come in and they’re like, I have a diagnosis of that. I just want to go straight to donor eggs. And that’s completely fine. Realize everyone has their own journey to make and what your girlfriend or what the blogger or whoever you’re getting information and advice from.

Realize that your journey is yours and when you’re ready to change courses your doctor is going to be there to help you but really you’re the one who has to steer this ship.

Carrie Bedient MD (31:57)

One thing that I find tends to be much more different is that my DOR patients, many of them have an inkling of what’s going on. I mean, they come in and they know I’m 39. This may not work out really well. I’m in my 40s. This is going to be an uphill battle. This may already be too late. My POI patients, it’s much more like taking a wet fish and smacking them across the face with it. It is just a total shocker.

Because they have thought that they’ve had PCOS, which is not nearly as much of a pain in the neck and has a much better prognosis. They’re thinking about everyone else in my family has gone through menopause at older ages and all the other women in my family have kids and this doesn’t happen in our family. And why is this happening to me? And I’m so healthy and I’m so insert whatever good descriptors here and why is this happening to me? And I find that they’re going through much more of a trauma experience. Yeah, and so at that very first consultation, like as soon as I kind of know what’s going on, I start to give the names of the therapist that I refer to. Because even if they don’t necessarily acknowledge it now, for most people, it hits at some point of this life is not going to be, and this journey is maybe not going to be what I imagined. And there are some huge components to that that other people don’t necessarily recognize because this is not telling someone else, I have a diagnosis of cancer where there’s an immediate outpouring of sympathy and people understand what that means and the implications and blah, blah. They’re just like, so you don’t get your periods anymore? That’s great. You are so lucky. And to someone with POI, they want to take the fish that they got hit with and then throw it at their friend because it hits so hard. And so I tend to pretty strongly advocate for getting some extra mental health support because this does hit in such a different way. And it is so much more unexpected than DOR when you’re 42 years old where you kind of maybe knew that this was coming.

Abby Eblen MD (34:01)

And I find for my patients too, because like you said, sometimes you have the patient who’s like deer in headlights, what do you mean I’ve got DOI? They’re just totally shocked. And so talking to somebody about it, I find always, always makes it better in the sense that it helps them kind of organize their thoughts. Because I think their minds are kind of racing at hundred miles a minute.

They just don’t know what the next steps are. And I think talking to a therapist really helps people clarify what’s important to them and how important a biological component is and why this might be good for them, why it might not be good for them. It just helps them figure out what the next step is because when they leave me sometimes, and I try my best, but sometimes I think when they leave me, they’re can’t even cope with kind of what’s going on. And they can’t even think about what the next steps are.

Carrie Bedient MD (34:46)

I think another thing that’s a little different about the two different types of lower ovarian reserve that we see is that with POI patients, I tend to see more disbelief. Let’s just test again. Let’s do one more level. Let’s wait six months. Let’s try it again. Things have changed. I got a period. Now everything’s fine, right? And it tends to be much more of a process.

I feel like more people do not just jump in going, okay, I know exactly what I want to do. I feel like proportionally there are more people who are going to say, let’s just check these levels again, or they’ll come back much later before they’re really ready to accept that. Going along with what Susan said of, we may see somebody for hormone therapy for several years before they’re at a point where they’re really able to get a handle on, okay, what do I want to do about this? Having kids, building a family part.

Abby Eblen MD (35:42)

I find it interesting too that sometimes people, have this discussion with them, you your egg count’s low and, certainly it’s more ominous if the FSH is abnormal, but sometimes I’ll have patients that’ll come back and go, well, so we’re really just kind of unexplained. Really, no one really knows what the problem is. And I’m like, well, well, no, remember we checked your egg count, your egg count was low. And, I think some people just don’t even like factor that in as like, as being an issue really.

Susan Hudson MD (36:06)

The important thing to realize also though is whether you have POI or DOR, you’re going through a grieving process.

And that grieving process is going to be different for everyone. And it’s going to happen at different rates. And I think that’s what Carrie was alluding to is the grieving process for women with POI tends to be a little bit different than those for DOR. And I think a lot of it is because of how we present it. With POI, we have to be very upfront, frank, and honest about this probably isn’t going to happen.

It may, but it’s probably not. Whereas with DOR, we’ve had lots of DOR people get pregnant. And so there’s more things that we can assist before having to make a big detour to something you seriously weren’t planning on having to utilize.

Carrie Bedient MD (37:03)

All right. Well, that’s a very helpful discussion on the differences between those two. Do either of you have anything more to add that we have not gone through yet about the differences or even similarities between POI and DOR?

Susan Hudson MD (37:17)

Think we covered it pretty well today.

Abby Eblen MD (37:19)

Think we did a great job.

Carrie Bedient MD (37:21)

All right, cool beans. So to our audience, thank you so much for listening. Please subscribe to Apple Podcasts to have next Tuesday’s episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.

Susan Hudson MD (37:37)

Visit fertilitydocsuncensored.com to submit specific questions you have and sign up for our email list.

Abby Eblen MD (37:44)

As always, this podcast is intended for entertainment. It’s not a substitute for medical advice from your own physician. So subscribe, sign up for emails, and we’ll talk to you soon. Bye.

Susan Hudson MD (37:54)

Bye.