Natural, gentle IVF

Dear Professor Winston,
I bought your essential fertility guide and I am very impressed with your commitment to helping desperate couples!  Being a GP myself, I will use my increased knowledge in order to help others and will recommend your book.
Last year aged 54 I married a very youthful 45 year old and we tried to get pregnant for the past 18 months with the help of clearblue fertility indicator and in February this year a course of IVF, probably not surprisingly with no success.
I am now 55 and K will be 47 tomorrow.  I have a healthy now 21 year old daughter from a previous marriage , but K has never tried to get pregnant up until she met me in January 2014. She always had perfectly regular periods every 28 days up until the last 2 months when her period came several days late each time.
When we used the clearblue indicator (we stopped this now), K had regular LH surges.  Because I suffered a mumps orchitis in 2010 I had a semen analysis at Burton hospital in 2014 which was reported as “normal”.
Assuming age was our problem, we did not investigate any potential tubal pathology, but went straight for the “magic” of IVF and had a treatment cycle in February 2015.
These were our results then (my semen analysis was repeated there despite normal result in Burton):
K: ovarian reserve results from November 2014.
FSH 10.6
LH 6.5
AMH 12.8
AFC 2+2
TSH 2.23
Conclusion: slightly reduced ovarian reserve consistent with age (46)
Tilo: semen analysis
Count 38 million per ml
39% type A motility
14% type B motility
3% type C motility
44% immotile
4% normal forms
Conclusion: normal semen analysis suitable for standard IVF
Response to stimulation:
On a ‘short protocol with flare’ on 300 HMG, 4 significant follicles were recruited. 6 follicles were emptied, but only one oocyte was retrieved which unfortunately did not fertilise.
An endometrial polyp was noted..”  Apparently the only egg recovered was “immature”.  K seemed to have developed an endometrial polyp in the fundus.
Following this K researched “natural gentle IVF” and we had a consultation in London in June this year.  He did a scan in the Progesterone phase of her cycle which at the time did not show the polyp. K seemed to have ovulated from both ovaries at the time.  Although he apparently had managed a pregnancy in 2 47/48 year old ladies, we decided against gentle IVF treatment.
One reason was that a friend of K’s, who is 29 years old and who had no problems conceiving her 2 children has offered her to become an egg donor for us. K had another scan, again in progesterone phase and no polyp was seen. She is supposed to have this repeated after her period finishes. K again seemed to have ovulated, but her period came late.
Now my questions, apart from the obvious, ” what would you do”?
1. The consultant advised Embryoscope –  Will this be really necessary, giving the fact that there is a healthy young donor?
2. she also advises ICSI, claiming my sperm count only had 4% normal forms, although a Dr from the fertility clinic had said it is “excellent” and Burton said it was “normal”. The one during the treatment cycle also seemed adequate.  Again is this really advisable?
3. Does the possible small polyp really matter?
4. Is genetic testing of the donor a must?  She is healthy with no family history and healthy children and too have no family or personal history of genetic disease.?
The cost is considerable.
We are looking forward to hearing from you,

Dear T & K,

I am unimpressed with claims from a clinic that “natural gentle IVF” resulted in success in two patients age 47 or more. I have scoured the world literature and there are a number of publications (none, I think, from the clinic you mention) where there are records of women over 40 being treated with “natural IVF”. Sometimes claims are made for a pregnancy rate but none for live birth and I think that if this clinic had two live births after this treatment it certainly should have been published by them. Most large series show how deeply disappointing such treatments are in women over 40 but much younger than your wife. The Cochrane data base does not mention any pregnancies in women over 45, and no live births in women over 43. Moreover, I have to say that measurements of ovarian reserve are much less meaningful than clinics claim. They are useful, but only up to a point. AMH can be misleading depending on how the blood is stored and how the assay is done and FSH (which in your wife’s case is raised) is a mere snapshot and may fluctuate upwards or downwards.

Now to answer your specific questions:-

  1. The evidence that the Embryoscope will improve success rates is not clear at all. There may be a very slight improvement but this is simply likely to be because the embryo is held in an hermetically-sealed environment and no oven doors are opened to inspect progress. One very successful major private clinic in London only offers the Embryoscope to patients who demand it because in their view the evidence it is valuable is not there and the extra cost is not worth it to the patient. That I think is a very ethical response.
  2. I would want to see sperm function tests, may be a postcoital test and even sperm egg interaction tests before committing you to ICSI on such flimsy grounds. Clinics do not like doing post coital testing it seems to be a simple basic skill they have lost in the drive to do ICSI, but these tests are useful.. It could be well worthwhile consulting an andrologist who dos not have a conflict of interests first. There are several such excellent people around and at least one or two in London.
    3. It is impossible to say whether the small polyp really matters without seeing it or without reviewing an X-ray of the uterus with contrast. I would be happy to do that if you have any pictures. What is the nature of this polyp – is it, for example, a fibroid?
    4. Genetic testing of donors is not justified in my view in this situation.

I hope these answers are helpful,
Best wishes
Robert Winston