Low ovarian reserve - go straight to natural IVF, or try normal IVF first?

[Kitekat81]

Hi everyone

I am 39 years old, TTC#1 for a year now (plus 6 months NTNP before that). We've had all the tests and investigations, and have found out that I have low ovarian reserve (everything else was fine). My FSH was borderline at 10.7, follicle count was 6 in January and 7 in February, and AMH was 2.2. My gut is telling me that we are unlikely to get pregnant naturally now, and I'd like to look into starting private IVF in about three months from now (the NHS waiting list is too long to be an option for us).

I am tempted by natural / natural-modified IVF, which looks to be a good option for people with low ovarian reserve. However, the nearest clinic which offers it is four hours from where we live, whereas we are an hour and a quarter from a clinic which offers normal IVF. This means that by going for natural IVF I would be reducing the stress from IVF drugs on my body, but potentially adding in a whole load of other stress trying to manage the logistics of travelling back and forth from the clinic.

I think what I need to do is book an initial consultation with both, and then go with the one that seems more confident about the possibility of success. However I was wondering if there is anyone on here who has any advice based on your experiences. Have you gone through IVF with low ovarian reserve? Or have you tried both normal IVF and natural / natural-modified IVF, and have some thoughts on how they compare and the order to try them? If so I would love to hear from you!xx

Hi there
Similar situation to you, we found out my AMH was 2.3 at the beginning of the year. We opted straight for private IVF as felt we didn’t want to wait any longer, i am currently on the injections for the short protocol ... I never looked into natural So don’t know much about that, we got told our chances to fall pregnant naturally were less than 1% xx

Hi @Kitekat81 I’ve a similarish position in that I have an AMH of 6.3 and AFC of 12 which indicates low reserves. I’m currently trying letrozole and progesterone (I also have a luteal phase defect).
I did a lot of research into the options c6months ago and spoke to 2 consultants. Both said to do maximum dose of stims and that the success rates of mild/natural are not very good at all.
On the other hand I have read that pushing your body too hard may compromise quality.
Where I got to in the end is that your first cycle is an expensive experiment! You can have someone with low AMH that responds pretty well (and so you could end up with an embryo to freeze) and vice versa. Equally, you may respond poorly and so feel there is no point in paying for excessive amounts of drugs. You just have to see how the first cycle goes...
I’m sorry that’s probably no help! If you find a definitive answer please do let me know

There is no way of knowing really until you've done a round of IVF to see how your body reacts and what the quality of your eggs/blastocysts end up being? You do really go in blind on the first cycle - some people are lucky and the protocol works for them first time but others need multiple rounds and different protocols to find the one that suits them?

I did 2 rounds of normal IVF age 36 and got rubbish results and then changed to
Natural modified IVF and had twins

You might find that you're suitable for mild IVF and it's at least a halfway point between full and natural modified if you're undecided. I'm doing mild with Create, i had 8 follicles last year when i was 41. Everything else on my baseline scan was normal for my age.

Create have quite a few clinics now across the country, so not sure if one will be close enough for you, have a look at their website if you haven't already. I think some procedures like collection and transfer do need to be done at their St Pauls clinic though depending on where you're based, so make sure you ask about that.

@Furmummy thanks for your reply! And sorry that you are also in the low AMH club 😔 Wow a 1% chance to fall pregnant naturally... was that just based on your AMH, or are there other factors as well? How long were you TTC before you decided to go for ivf?

@Kitte321 thanks for your reply! That's interesting that both consultants recommended normal ivf over mild/natural. I think you may be right that it's a case of trying one cycle to see how I respond, as everyone will have a different response. I hope the medication you are on works for you, and that you don't have to get to the IVF stage! 🤞

@ivfbeenbusy congratulations on your twins! 😊 That's a lovely ending to what I'm sure must have been a pretty hellish journey. It's interesting to hear from someone who has tried both. With the benefit of hindsight, are you still glad you tried normal ivf first, as it might have worked? Did you do natural modified with Create?

@IslandStars thanks for your reply! Yeh it's Create who I've been looking at for natural / natural modified ivf. I'm in Scotland so the nearest clinic is Manchester which is 4 hours away. Did they recommend mild ivf for you? I didn't think that I would be recommended that as on their website it said that mild ivf would work best for people with normal ovarian reserve, and natural for low ovarian reserve, so I just assumed they would recommend the latter for me. Have you been quite happy with Create so far? Is this the first time you've tried ivf, or have you already tried conventional ivf?

Hey @Kitekat81

I've got a lower AFC and AMH than yourself - AFC less than 4 on each ovary and AMH 2.1 when last checked. I'm 33 with MF too so have done ICSI with each cycle.

Cycle 1 and 2 was long protocol/high stims - got 3 eggs/3blasts from cycle one and 2 eggs/1 blast from cycle 2. - had one chemical from cycle 1 but none of my other embryos have stuck despite being top grade.

prior to cycle 3 I had a large fibroid removed.

Cycle 3 - short protocol/low stims with Ovaleap(new to the market) I got 8 eggs! 5 made it to blasts and I have gotten my BFP on OTD today! This cycle surprised everyone - my consultant couldn't believe how improved my number was.

I'm not sure if my 3rd cycle would have been classed as natural modified but my consultant swapped to low stim as he said that even on high stims my body produced really low numbers and we may as well not stress my body to produce lots when a low dose should get the same result.

All I can stay is I wish I researched a little more and didn't rush into my first cycle - it takes 3-months to make positive changes to your eggs and sperm - good luck!

@Kitekat81

My twins are Create twins via natural modified IVF . I don't have a low ovarian reserve but did it because normal IVF produced rubbish quality eggs for me - when I changed to natural modified my egg quality increased massively and that's when I had success x

@Kitekat81 Create recommended mild for me, although through prior research I felt at my age 41/42 it would be best. I believe in the quality over quantity approach. My baseline scan was quite positive for my age and didn’t show any other fertility issues, other than old eggs!

Create have been great for me so far, no issues with their treatment. I’ve done a 3 cycle package, this was advised as my best bet in order to bank embryos, although I did PGS so 3 cycles was more necessary to find PGS normal embryos. I’m doing FET this month.

@Kitekat81 I did both short protocol and natural modified. I actually responded better to natural modified but until you try one or the other you really don't know how you as an individual will respond! One thing I would say is that with Create you have to attend regularly for scans during stimulation - sometimes as often as every other day so being 4 hours away you might need to factor that into your decision

@Mrbay eek congratulations on your BFP!!! That's wonderful news!

Do you think it was the change of protocol which made all the difference, or did you do anything else to improve your egg quality? With hindsight would you have gone straight for the milder stims to start with, or would you still go with the higher stims first, because it might have worked?

@ivfbeenbusy that's fantastic, Create's approach putting quality over quantity is very convincing, and your experience shows that it does work!

@IslandStars yeh the quality over quantity approach definitely makes a lot of sense and is very appealing. I'm glad your experience with Create has been good so far. Do you mind if I ask how many embryos you got from three cycles? Did they recommend that you do PGS, or was that your choice?

@MabelG thanks for your reply! Have you done all your treatment with Create? Yeh the logistics of getting to the clinic for treatment is a lot to think about. I'm guessing it would probably mean lots of overnight stays away from home which would be expensive and disruptive, and potentially would mean time away from my partner as well, as I can work from home but he can't, so that's not ideal either. I would do it though if I thought it was the treatment that was most likely to be successful.

@Kitekat81 - well the result surprised the consultant but he felt that high stims didnt produce many eggs, whilst they were mature and decent ish quality there wasn't any point stressing my ovaries trying to produce lots of eggs when we know that they don't!

I made sure that I had lots of protein during stims, so lots of eggs, meat and protein shakes.

Diet wise, I didn't really change anything, if I wanted chocolate and sugar, I had it! I'm not a big caffeine drinker (one coffee per day) and I continued with this until ET.

Supplement wise, folate, pregnacare max, b12, vit d and ubiquinol (high dose) for 4/5 months before starting.
Cycle 2 I took dhea and that gave me mu worst cycle so I really wish I never listened to it starts with an egg!

Thank you, we are cautiously excited 😊 after 5 years it's nice to finally have something to look forward too.

@Mrbay oh no, I've just ordered some dhea! I went to bed sobbing on Sunday night (mother's day, so rubbish when you so desperately want to be a mummy) and I read the chapter on dhea in it starts with the egg, I immediately went online and ordered some as it sounded like the magic ingredient that would make all the difference for me. What side effects did you have from it? Did your consultant recommend that you take it, and if so did they do any tests before recommending it or was it just on the basis of your amh test?

@Mrbay sorry I've just re-read your message, so you were taking dhea before your 2nd cycle which had the least successful outcome. How long did you take it for?

@kitekat81 - I took it for 3 months before EC, but I didn't have levels tested beforehand, annoyingly my consultant said yes you can take it but didnt do any bloods.

@Mrbay argh that's frustrating. In the book it does really stress the importance of testing levels first. I ordered some as I've heard some people saying it takes a while to arrive from the USA, so I thought I would be proactive. It wasn't expensive so not disastrous if I end up not using it.

Just to throw it out there - studies have shown that low amh makes no difference to natural conception if there are no other factors at play.

My amh was 2.8 age 34. AFC was 6. Since then I’ve been pregnant 3 times- including once via ivf and one natural conception which was achieved (unbelievably perhaps) in one month of trying. This may have just been random luck but i don’t think it can be ruled out unless there are other factors. Good luck x

@Kitekat81 I moved to Create from elsewhere specifically to do natural modified IVF - it worked for me and I am pregnant. They were against me taking DHEA though as it isn't just a supplement - it does actually affect your hormones

@Kitekat81 Thanks, had my transfer yesterday, so can't say how successful all this will be yet, but i had a good response from mild.

Cycle 1: 11 eggs, 3 blasts (no PGS normal)
Cycle 2: 11 eggs, 6 blasts (2 PGS normal)
Cycle 3: 7 eggs, 4 blasts (no PGS normal)

I had some high level mosaics, but doubt i will be able to transfer them. I did PGS because they said it would increase my chances from 25% to 65%. Disappointed to only get 2 normal, the odds would have suggested 3 for my age, but it has saved me a lot of time and money in wasted FETs.

I'm wary of recommending PGS, as it doesn't improve pregnancy/live birth rates, it's just a selection tool to choose the most likely embryo to implant and i was worried about miscarriage and the time which would be lost through that if i needed to cycle again at 42. If you have less than 5 blasts, it may not be worthwhile.

@Ilikeviognier thanks for your reply! That's really encouraging to hear about your success conceiving with low amh 😊 Do you mind if I ask your age when you conceived your three pregnancies? Yeh I know that a low amh doesn't necessarily affect natural conception, that's why it's been really hard to know how long to try naturally before resorting to ivf. We've been trying for over a year though with nothing happening at all in that time, and that combined with my age makes me think that we can't wait much longer.