Ectopic pregnancy, 3 miscarriages and unexplained infertility

Dear Professor Winston,
I am 36 and my husband is 29 (both fit and healthy, non-smokers); we have been trying for a baby for the past 3 years.
In 2007 (with a previous partner) I had an ectopic pregnancy, which was treated conservatively in hospital, and to my knowledge did not leave any residual issues/changes. Later that year I fell pregnant again; based on an internal ultrasound scan this appeared to be a healthy pregnancy but I miscarried at 7 weeks.
My husband and I started trying to conceive in 2012. I fell pregnant in 2013 (after 14 months of trying) but I miscarried at 7 weeks. Six months later I had a HyCoSy scan, which was normal. My husband had semen analysis (3 samples tested) which showed low motility but high volume.
Our most recent pregnancy was November 2014 and sadly this pregnancy did not progress either. A 7-week ultrasound scan showed a collapsing yolk sac and I had a medically-induced miscarriage at 9 weeks. Unfortunately no tissue was available for testing.
Following this we were referred to our local NHS recurrent miscarriage clinic. Both our chromosome tests were normal as were my thyroid, diabetes, thrombophilia and chlamydia tests. My FSH was 5.4, LH 4.9 and Oestradiol was 129 on day 4. On the basis of these results my consultant discharged me and encouraged us to continue trying.
I decided to pay for a private AMH and the result was 4.5. My GP indicated that this was low for my age-should we begin to think about assisted conception or other options? If so, what types of treatment would you consider to be of potential benefit? With a low AMH, is it likely that the quality of my eggs is also poor?
We are frustrated that it takes us over a year to initially conceive and then any pregnancy does not progress beyond 8 weeks. Any advice about how we go forward would be very gratefully received-unfortunately we do not feel we have any guidance with future decision making and feel very on our own now our local NHS support has been exhausted. V

Dear V,

I fear I am starting to repeat myself. But let’s get back to basics. I don’t think you’ve been investigated for infertility. If you look back over my previous posts you will see my comments on ectopic pregnancy. Ectopic pregnancy is rare in a healthy woman with normal tubes and uterus. I regret that I repeat that I do not consider HyCoSy as an adequate investigation to exclude pathology in either of these organs. You are having difficulty getting pregnant so clearly there is some dysfunction somewhere and your endocrine results reveal no pathology (which incidentally doesn’t surprise me in the slightest).

If you were my patient I would want a detailed investigation of your fallopian tubes by laparoscopy and I would want to see the detailed configuration of the blood vessels and the lining where visible before dye is placed in the uterus. I would also expect that a full detailed photographic record was taken of both tubes and any adhesions around them or the ovaries. Ectopics do not generally come out of the blue and are usually the result of some past infection and an experienced laparoscopist should be able to identify this as well as any adhesions around your liver, which is often a sign of previous infection somewhere inside your abdomen. If you have had an ectopic, you are very likely to have pathology in both tubes unless the ectopic was caused by a congenital malformation of either one tube or possibly the uterus. So in addition to a laparoscopy a detailed careful inspection of the uterine cavity is necessary because there must be a possibility of a malformation even though your miscarriages are early in pregnancy. In my view a hysteroscopy is not nearly as useful as the cheaper alternative, a hysterosalpingogram, which with careful insertion of radio-opaque dye gives unparalleled information about the the uterine lining and the shape of the uterine cavity.

Believe me when I say I have seen many people with a ‘normal’ HyCoSy who have had an undiagnosed problem in the uterus, and several patients with scarring of the tubes which was not recognised. To undertake IVF in the presence of a congenital malformation of the uterus which has not been recognised (especially as so many of these are very amenable to simple treatment) is reprehensible if not negligent. Only once these possibilities have been excluded should you attempt assisted reproduction.

I am sorry if the tone of this email sounds harsh, but it is really distressing to me to see letters such as yours. Having had an ectopic in the past you are clearly entitled to full investigation, and a laparoscopy and HSG under the NHS should be routine in this situation before undertaking further treatment.

My best wishes
Robert Winston