Dear Professor Winston,
I am 44 later this month, have already had two cycles of IVF (the first was at the end of 2014 – which ended in miscarriage in the 5th week and the second around April 2015 where I did not get a positive pregnancy test. Both treatments were carried out at the same clinic. Although I felt the second was not handled as well as it could have been – I was seeing different clinicians, advised against endometrial scratching (which I had first time), intralipid infusion was suggested but then not given. Also I was put on clexane to deal with suspected recurrent miscarriage, despite the clinic not thoroughly investigating the miscarriages. (when they found out I was weakly positive for anticardiolipin antibodies, they prescribed clexane and discouraged me from returning for blood tests 12 weeks later). The miscarriages I refer to were, first: after natural conception in April 2014, months before I began IVF and second after my first cycle of IVF. Both ended at 5 weeks.
Since the second cycle failed, I have had miscarriage investigations on the NHS and nothing abnormal has been found – other than a deficiency in vitamin D.
I am aware of the low chance of success and high rate of miscarriage but I would like to try IVF again. I am an only child, forever hearing about women I know, of a similar age, having successful pregnancies and think, with persistent and the correct treatment, it should work for me. IVF is my only option to get pregnant as I am single. I do not want to consider donor eggs or adoption at this stage due to personal reasons. Both previous IVF cycles reached blastocyst transfer and whilst the clinic have informed me of the success rates, they have said the quality of my eggs is very good for someone of my age. (They said women of Indian ethnicity tend to have good quality eggs at an older age) I don’t know how true this is.
I am planning to have treatment after my next period, at the same clinic, under a doctor who joined the clinic last year. She seems to be up-to-date on the current practices (told me that I should have had endometrial scratching last time as well) which is why I would like to be treated by her.
This is the treatment plan / drugs she has suggested, long protocol (as before), endometrial scratching, embryoscope, suprecur, merional, gonasi, cyclogest pessaries, voltarol, metronidazole, salbutalmol, prednisolone & lubion injections.
Lubion injections are the only drugs I haven’t been given before. Are you able to give me your opinion on the drugs she has suggested? Are both cyclogest pessaries and lubion injections necessary? Would intralipid infusion increase my chance of success? I want to follow all advice to ensure treatment is successful but at the same time not hand over money for drugs / treatment that are unnecessary. I want to be as sure as possible that they are doing their best for me, not using me as a means to make money.
Finally, do you treat patients for IVF? How do I find a reputable clinic?
Many thanks for your time.
Kind regards,
M

Reply…

Dear M,

Thank you for your letter. You have understood the basic problem only too well. The best success rate at your age group of 44 will be around 5% at best and over half of all pregnancies will end in miscarriage.. I do understand that you feel you have not been properly treated in some respects, but I am not inclined to accept this. The solid evidence shows that all the adjunctive treatments you have had, and the one that you have not had, are of highly dubious value and controlled trials do not show any benefit in women in your situation. I do not know of any evidence that vitamin D deficiency is relevant either.

Incidentally, as I have said before, the observation of “good quality eggs” is mostly based on microscopic inspection. Frankly light microscopy gives precisely no information of any molecular faults in your eggs, the kind of problems that may arise in ‘older’ women.

In your case I suspect it is simply a matter of statistical chance. The fact that you have had some kind of pregnancy – admittedly sadly lost – does mean you have been able to get pregnant and in the evaluation of other results we have found that women who have had a failed pregnancy have a slightly better chance than those that do not conceive after IVF at all.

Best wishes
Robert Winston

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