When 40-year-old Seema* (* name changed for privacy) came to Birla Fertility & IVF, Jaipur, to consult Dr. Priyanka Yadav, Centre Head and Consultant, her concern was not unfamiliar – she had been trying to conceive again for several years without success. What made her case more complex was the long gap since her first childbirth, nearly 12 to 14 years earlier, and the subtle physical changes she had begun to notice over time. This was a case of secondary infertility, but one shaped strongly by age and ovarian biology.
Her investigations painted a difficult picture. The AMH was 0.1 ng/mL, placing her at the edge of ovarian reserve. FSH levels were significantly elevated at 22 IU/L, with LH at 19 IU/L – values that, in most datasets, are associated with extremely poor response to stimulation and very low pregnancy rates using self-eggs. Clinically, the expectation had to be guarded.
Instead of rushing into stimulation, the team focused on preparation. One to two months of hormone replacement therapy were used to stabilise the endometrium and support overall hormonal balance. Only then was a personalised stimulation protocol initiated, monitored closely in view of the high FSH and the likelihood of limited follicular recruitment.
The response was modest, but meaningful. Two oocytes were retrieved through tightly controlled stimulation. Given the narrow margin for error, intracytoplasmic sperm injection was chosen to maximise fertilisation potential. From these efforts, one viable embryo developed – a small outcome by numbers, but a significant one by context.
That single embryo was transferred. The pregnancy test that followed was positive. The pregnancy progressed without complication, and the patient eventually delivered a healthy baby girl.
In fertility care, success is often associated with scale – higher egg numbers, multiple embryos, repeated attempts. This case stands apart because it worked in the opposite direction. With near ovarian failure, there was little room for repetition. Every decision, from hormonal priming to stimulation intensity and laboratory handling, had to be precise.
Explaining the case, Dr. Priyanka Yadav, Centre Head and Consultant at Birla Fertility &a IVF, Jaipur, said, “In women with extremely low AMH and significantly elevated FSH levels, the challenge is not just the number of eggs, but the unpredictability of ovarian response. Standard stimulation protocols do not always work in such cases, and aggressive approaches can sometimes do more harm than good. Our
focus was to first optimise the patient’s hormonal environment, then plan a carefully calibrated stimulation that respected her ovarian physiology. When reserve is this limited, every step has to be deliberate – from timing and dosage to laboratory handling – because even a single viable embryo can make a meaningful difference.”
It also serves as an important reminder in cases of secondary infertility: previous childbirth does not protect against age-related ovarian decline. Biology changes quietly over time, and treatment must adapt to where the body is now, not where it once was.
Sometimes, outcomes are shaped not by abundance, but by how carefully what remains is understood and supported.