Is our clinic on the right lines?

Dear Professor Winston,
I am 34 years old, as is my husband. We have been trying for a baby for just over four years with no pregnancy at all so far. The initial round of tests (day 3 blood tests, thyroid and glucose tests, hysterosalpingogram, pelvic ultrasound and sperm tests) showed up no abnormalities, although one of my ovaries was described as multifollicular and my womb lining looked thin. The hospital (at which we are treated in France) mentioned possible “ovarian dystrophy”. We tried Clomid for 6 months and I didn’t get pregnant, then we moved on to IUI using gonadotropin injections. Here, I responded very strongly to the injections, even on a low dose of 50 units and two of the cycles out of three had to be cancelled because of the high number of follicles and risk of multiple pregnancy if it worked.
IVF was suggested and I was officially diagnosed with polycystic ovaries. We have so far done one cycle of IVF which failed. I had 16 eggs retrieved, 12 of which were mature. Only seven of them fertilised and, in the end, only two of the embryos were decent quality. One was transferred on day 2 and did not implant. The other was frozen but unfortunately did not survive the thawing process so our frozen embryo transfer was cancelled.
We are currently waiting to start our second IVF cycle but I am having difficulty motivating myself to start all over again. I am finding it increasingly difficult to believe in success and am even doubting the methods and decisions of the hospital.
My husband has never been diagnosed with any problems and yet his sperm test results consistently show he has only 4 or 5 percent normal sperm. Is the hospital missing something here or is sperm morphology just not that important if all the other parameters are okay? He has also had a few minor infections that showed up during sperm tests, requiring antibiotics before treatment cycles.
I was told by one doctor that after our first failed IVF we would be put forward as candidates for ICSI in our second cycle. And yet, when a panel of doctors got together more recently, they decided we had a “satisfactory” fertilisation rate and have not been put forward for ICSI this time, despite the fact that many of my eggs were fertilised by more than one sperm (polyfertilisation in their terms), leading to poor embryo quality and survival.
Their solution for this next cycle is simply to further reduce the FSH dose (I was on 125 units of gonadotropin injections for the first IVF cycle) and combine this with LH in an antagonist cycle. When I asked for some reassurance as to why this protocol was chosen and whether I would have better quality embryos this time, the doctor simply didn’t reply to my email. In France, we are very fortunate that four cycles of IVF treatment is covered by the health system, but I can’t help feeling that, as a result, we are just expected to consider ourselves lucky and not ask too many questions or make too many demands.
I am now very anxious that I will go through another cycle for nothing, with the same poor results. Have you any experience of success with a combination of LH and low-dose FSH in patients with my kind of profile? Do you know of any studies showing the efficacy of this protocol?
I would be grateful for any advice or comments. H.

Dear H,

I am not sure that the protocol is that important but it is clear from our research that the least stimulation to get a good response is extremely advantageous. I am surprised at the comments on the sperm because I would have thought that so a low percentage of abnormal sperm was an indication of something wrong. Whether ICSI will allow the choice of ‘better’ sperm is an open question but I think this would be a preferred route in many clinics. 16 eggs of which 12 are mature with 7 being fertilised is absolutely the normal range for IVF in a person of your age though the fact that there were only two embryos is a bit worrying.

Having said all this it sounds to me as if the clinic you are attending is really on the right lines. I would be strongly inclined to persist with the line of treatment they are recommending. After all, your only complaint is that communication might have been better and I think the fact that a panel collectively decided against ICSI encouraging and shows responsibility. You really do not want to do ICSI unless it is really necessary.

Best wishes
Robert Winston