Dear Professor Winston,

my husband and I have been trying to conceive for over 2 years and as far as I am aware I have never been pregnant. We are both in our early thirties and have been told by the Reproductive Specialists we have been seeing that there is no apparent reason why we are not yet pregnant. We have undergone various blood tests, testing various hormone levels etc. and my FSH is roughly 9.01 and AMH is 3.8., from what can remember, and I have a small cyst close to my right ovary (but not attached to it and not affecting my right tube). Again, this was not considered to be an issue. I was told my FSH is slightly elevated but not a considerable cause for concern and my AMH is in the lower range for my age. My husband’s SA was fine, the number, shape and movement were all considered normal.

I am quite reluctant to undergo heavily invasive procedures however I obviously understand that I have to be realistic.

I have had a HyCoSy test; my tubes were clear and my uterus is slightly anteverted, however again no particular cause for concern. We have undergone an IUI using Fermera which was not successful. Earlier this year we reluctantly did one cycle of IVF. I did not respond to the fertility drugs as I was expected to and the dose was increased from 175 to 300ml Menopur. Of the 8 eggs retrieved only 4 were mature and 3 fertilized but only 1 fertilized normally and was considered best/suitable for transfer. We were told that the sperm and egg did not fertilize on their own and required ICSI. The IVF was unsuccessful. We were later told that there may be an egg quality issue, however results (number of eggs and number of embryos) vary from cycle to cycle and that may it may have just been a bad cycle.

I am very concerned about taking fertility drugs and continuing to pursue IVF, as we still don’t really understand what the issue is (apart from a possible egg quality issue) and whether IVF offers any significantly better chance of success versus continuing to try naturally, especially as the cause is not known and therefore any further talk of IVF seems to me to be a stab in the dark. I have heard the longer we try without getting pregnant means our chances of getting pregnant ourselves are reduced.

What are your thoughts. In cases of “unexplained infertility” would you suggest continuing with IVF or should we be trying something else?

Thank you.

K.

Dear K.,

Forgive me for most gently chiding you but – you seem to want it all, do you not?  You are reluctant to go through ‘heavily invasive procedures’, yet are prepared to go through the most invasive treatment before a proper effort at making a diagnosis.  Unless I’ve got it wrong, you do not seem to have had a hysterosalpingogram (believe me the HyCoSy test is no substitute for a properly done x-ray by a skilled radiologist), nor does it seem that you have had a laparoscopy, preferably around the mid cycle when your ovaries can be carefully examined and photographed, and your uterus and tubes carefully assessed by direct vision.  A laparoscopy also gives good access to other organs as well, including, for example, the liver where there are often tell-tale visual signs of why somebody is infertile.

Most importantly, you do not tell me whether the FSH level you record in your post to me (± 9.0 units) was repeated and whether anybody discussed in detail your lowered AMH?  What were the measured volumes of your ovaries at ultrasound examination, and how many follicles were observed a few days before ovulation was expected?  Has anybody checked to see if you have ovulatory mucus with sperm swimming in it in an unstimulated cycle, by the way?

I do agree with one thing though in your email. You yourself point out that you are quite likely to have as good a chance of conception without any treatment at all, as with using IVF.  That may well be true….. but it would be so sensible to try to make a diagnosis first before going through any treatment – or deciding to stop it completely.  In answer to your question, the so-called diagnosis of ‘unexplained infertility’ is effectively a failure of making diagnosis.  In most cases, it does not mean that nothing is wrong which cannot be found by careful systematic investigation.

I hope that this may give you something to think about very carefully.  I hope you do not feel I’ve been too blunt,

With best wishes

Robert Winston

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