Should I try IVF after diagnosed with poor ovarian reserve?

Dear Professor Winston,
We are trying to conceive our second child, which is proving difficult. I heard one of your recent radio interviews and have ordered your new book and this prompted me to ask your advice about our situation. We had a child in 2012 after trying to conceive for almost 2 years. We were referred to the hospital and after various tests, including a laparoscopy and dye test, we were told we had unexplained infertility. The month following the laparoscopy and dye test, I was advised to start on 25mg of Clomifene, although nothing in my tests had indicated that I wasn’t ovulating. I had an extremely heavy period that month, but still went ahead with the Clomifene on days 3-7. To our great surprise I fell pregnant. The pregnancy and birth went smoothly.

When we decided to try for a second child, we assumed that all I would need to do is take the Clomifene. However, 3 months of 50mg didn’t work and late last year tests revealed that I had an FSH of 16. It was explained to me that this indicated a poor ovarian reserve and I was advised to start IVF as soon as possible.
We have now had 2 unsuccessful rounds of IVF. The first was a short protocol and was done privately, this produced one egg which fertilised. The second at an NTS hospital was a long protocol, and produced 4 eggs (and two embryos). I have an AMH of 3.0 and I will be 40 at the end of this year.
I have recently read that a laparoscopy can increase your chances of getting pregnant, and this has made me wonder if that is what helped us to get pregnant the last time, rather than the Clomifene. I have also been wondering whether natural IVF may be a better option for us given that I’ve only produced one decent quality egg in both IVF attempts so far, and wondered whether the drugs were compromising the quality of the eggs. I’m also unsure about whether DHEA may help to improve the quality and quantity of my eggs, or the value of Cq10, baby aspirin etc. Or might it be worth giving IVF one more go (I have read that unless you give it 3 tries you can’t say for sure that it isn’t going to work for you).
I would really appreciate any advice on what might be the best course of action for us, whether that be a type of treatment, or whether our chances are so slim that it’s time to close the door on this hope and concentrate on enjoying the one child we are lucky enough to have.
P.s I have made a donation to this great charity.

Dear C,

I am really sorry, but I don’t feel I have good news for you. Over 40 years I have repeatedly seen women with elevated FSH levels – over 10 iu/l. And it turns out that no matter what other results show (including AMH) that once FSH has been measured at almost any time at above 15iu/l the chance of any particular treatment (including Clomiphene and assisted reproduction using IVF) being of any benefit is very dubious. FSH levels are notoriously up and down and therefore some clinics wait for FSH to drop below say 12 iu and then perform IVF. I don’t feel that that makes any real difference. Once FSH has been measured high on one occasion it is not a good prognosis. Of course it is true that each lab may have a slightly different ‘standard’ so measurement of FSH may differ slightly from lab to lab, but I cannot deny that your result is not good news.

I have scanned the research literature on ‘natural cycle’ IVF very fully and am very unimpressed that this is likely to be any better. I do know that there are one or two clinics in the UK that argue that it helps but I think frankly they have a conflict of interests and are not always absolutely transparent with the results they claim. So I really cannot advise that this is likely to be much help to you.

In my experience over all those years, I have seen a number of women with very high levels of FSH – sometimes above 20iu – who against all odds have managed to get pregnant simply having regular pleasurable sex when they have had very disappointing results with IVF and a miserable response to ovarian stimulation with drugs. I actually think ‘good’ sex is genuinely helpful in all cases of infertility and I think this is true in women in your situation, too.

Incidentally, it is true that women are slightly more fertile after laparoscopy and after hysterosalpingogram – but not I think when the ovaries are ‘retiring’. Similarly a great deal of work has been done with DHEA but the controlled trials are not encouraging. I don’t know about Cq10 or baby aspirin – I’ll check to see if any randomised trials have been reported and let you know, but I don’t think so.

I am so sorry not to be able to give you better news but I fear that further active treatment of any kind is pretty unlikely to be helpful.

My warmest wishes
Robert Winston