Unexplained secondary infertility

Dear Professor Winston,

Both me and my partner are in our early thirties. We are unfortunately suffering from secondary infertility. We have a 4 year old child who was easily conceived (within 4 months). I had a natural but assisted delivery with no problems throughout the pregnancy and thereafter. We have been trying for a second child for 2 and a half years. In that period we have had the following investigations:

Usual blood tests which showed nothing significant apart from AMH of 3.4 and FSH of 10.3. We were told the low AMH would not explain our fertility problems.
Hysteroscopy which showed no problems.
Hysterosalpngogram which showed no problems.
Sperm analysis which showed no problems apart from morphology of 2%. We were advised this was not issue due to all other aspects within normal limits.
Sperm DNA fragmentation test which came back at 29% fragmentation. Advised this was not significant.

We have therefore been diagnosed with unexplained secondary infertility.

Before the birth of my child I suffered with very painful periods. Since the birth of my child I have had no such problems. The consultants I have seen say that I display no symptoms of endometriosis now and that they would not advise a laparoscopy be undertaken.

We had our first round of IVF a year ago. They retrieved 2 eggs, both fertilised with IVF, both were put back on day 2 but the result was negative.

We had our second round a month later. They retrieved 2 eggs, both fertilised with IVF, both were put back on day 2 and the result was a positive single pregnancy. Unfortunately we lost the baby at 13 weeks due to fetal hydrops, cystic hygroma and Turner syndrome. We were advised that this was a random occurrence and should not happen again.

We began our third round following 4 months of taking a break since the loss. They retrieved 5 eggs, 4 fertilised with IVF, only 1 made it to blastocyst. It was put back but the result was negative.

Following this this consultant advised we may as well do modified natural IVF due to low numbers.

We began our fourth round the following month with modified natural IVF. A hemorrhagic cyst of 16mm was noted but I was advised this was nothing to be concerned about. They retrieved 2 eggs, both fertilised with IVF, both were put back, the result was negative.

We began our fifth round the following month with modified natural IVF. Cyst was still present. This cycle was cancelled due to one follicle further ahead than all the others.

My AFC is normally around 6 or 7.

We have had karyotyping done. My results were normal. My husband has a para-centric inversion on the 5th chromosome which we have been advised is common and is not an issue.

My question is where do we go from here really? It is frustrating that they can not find the cause of our secondary infertility. Do we just keep trying? Are there any other investigations we should look at? Should we carry on with modified natural IVF? Should I be investigated for having a fragile x premutation due to my low AMH?

I hope that you are able to offer some advice on what steps to take next.

Thank you in advance. This service is very much appreciated.


Dear I.,

Several issues come to mind.

1.  You say you have had a child already.  A common cause of infertility is off course, therefore, something which happene4d during pregnancy, delivery or immediately after delivery.  You mention you had an assisted delivery but do not tell me anything about it.  How long were you in labour, how big was the baby and how was it delivered?  Did you have a fever, however small, after delivery or within the first seven or so days afterwards?  Did the placenta come away spontaneously or did it need some obstetric assistance?

Common things occur commonly so this is the first place to ,look.  In particular, I would want to examine your hysterosalpingogram very closely because very frequently minor pointers to damage or scarring are often missed.  I would be prepared to look at the films if you send me digitised copies by email.  I would also say that high on the list of investigations should be a laparoscopy to check you do not have some evidence of infection or inflammation which has left its mark.  Endometriosis in general does not cause infertility – BTW you have no symptoms which suggest this diagnosis anyway.

2. Both your AMH and your FSH are abnormal, and together with the very poor results after ovarian stimulation strongly suggest a degree of ovarian failure.  IVF treatment either with hefty stimulation or with so-called natural stimulation doers not have great results in this situation.

3.  I don’t understand the sperm results.  Whilst it is likely the sperm are fine (one child; sev real eggs fertilised) what do you mean by a “morphology of 2%”.  2% abnormal which seems very low or 2% normal which seems very high.   What were your routine sperm count results?  The fragmentation is probably not significant.

Finally (for the time being) have your period changed since the birth of your child, or in the last two years or so?

Best wishes
Robert Winston