Is now the time for IVF?

Dear Professor Winston,
My husband and I are both 33 years old and been trying for a baby for three and a half years and have an undiagnosed condition. We are both non-smokers, healthy, normal BMI.
I had an ectopic pregnancy (with a former partner) when I was 24, which led to a major infection and surgery to remove an ovary, one of my tubes, as well as my appendix. Since then I have had no other pregnancies. I have regular cycles (they do vary in length from 21-28 days, usually with 2-3 days of spotting pre and post menses). I have had a number of functioning ovarian cysts (the largest being 6-7cms in diameter) over the past few years which have caused intermittent pain and most recently I had a cyst which ruptured and caused some bleeding but did resolve itself within a few months – I have previously been told that there is no reason why these cysts should cause any issues with my fertility. I have had all the usual blood tests (progesterone test to confirm ovulation/ Day 2 test results: FSH: 4.6/LH: 6.0/E2: 94) and I have been told these results are all within the normal range. I had an HSG 2 years ago which came back normal and my consultant assured me that my remaining tube and ovary were healthy and there were no obstructions.
My husband’s tests have also all been within normal range (Last test: Total count: 200.60 10*6/ Sperm density: 40.30 10*6/ml/Immotile: 52%/Motility: 48%/Progressive: 41%/Rapid progressive: 40%/Typical forms: 6%). The only concern was about his sperm morphology as the number of normal forms was low. But our consultant was reluctant to comment on this and suggested that this alone was unlikely to be the cause of the problem.
We were referred for IVF in May but decided to postpone our first appointment at the clinic, as we are unsure about taking this next step, particularly without a clear diagnosis. However, our local CCG is now proposing to cut all funding for IVF in our area and we would no longer be eligible for IVF. This makes me concerned that we may now miss out on our chance of treatment if we don’t act quickly before the ruling by the CCG. I don’t want to rush into IVF without exploring all our options but equally don’t want to miss out on perhaps our only chance of IVF (it is unlikely we would be able to fund such treatment ourselves).
In the face of the proposed funding cuts is it worth postponing treatment any longer and exploring any other forms of treatment? Who can we ask about different treatment options and/or further tests as our NHS consultant seems to be totally uninterested (and very dismissive) as to our concerns about not having a clear diagnosis and we have been told there are no other options available?
I have recently read your book ‘The Essential Fertility Guide’ which I have found extremely useful. It has been invaluable to have such clear and concise information in one place.
Thank for your help.
Best Wishes,

Dear A,

If you lived in an area where expert tubal microsurgery was available (perhaps it is?) I would recommend a laparoscopy because I am convinced you are likely to have far more adhesions than you realise. But as it is I don’t think you have much choice. I would certainly feel that, with your history, IVF is undoubtedly indicated. I don’t really believe that your remaining tube is healthy – it is unlikely with this background. It is not surprising the HSG ‘looks’ normal but this will not necessarily tell you about adhesions around it. If you send me digital photos (if you’ve got the X-rays) I’ll willingly take a look. Tell me, was the tube that you had removed on the left or the right?

Incidentally, the repeated ovarian cysts are very frequently a feature of pelvic inflammatory disease which is why I feel that IVF is the best option, even though admittedly, your ovarian response may be less than optimal.

I am really sorry to give you the answer you did not want to have, but I think it’s my best shot.
Kindest wishes

Robert Winston