Low AMH - Natural Modified or Mild IVF?

[Sunflower360]

Hi 👋 I was hoping for some advice. I am about to recommence IVF soon after a failed high stimulation short protocol.

My circumstances are:

• Age 37 (38 not too far off....)
• AMH 6
• AFC 4-6
• 1 x failed high stimulation IVF cycle (which led to 4 eggs, only 2 were mature, 1 failed to fertilise at all and the other abnormally fertilised with 3PN due to 2 sperm entering, so ICSI advised for next time)
• OH has lower morphology (but not worryingly low. Hence, IVF and no ICSI suggested the first time around), otherwise, all other parameters are good

Question is what have people's experiences been with natural modified and/or mild IVF?

I am reading a lot about natural modified being better for those with low AMH, if I only got 2 mature eggs in a high stimulation cycle, is it better to just go with natural modified? Would mild be that much different from the high stimulation cycle?

I am gauging with IVF consultants each have their own approach/ideas, so I would like to go into my next consultation with questions and to ensure we ourself make the best decision for us following the advice given.

Be good to hear different experiences. Natural modified is also a more cost-effective option, I am trying to gauge whether mild IVF would even be worth the extra cost in my circumstances. That cost difference could perhaps be used for more natural modified cycles and focus on quality with lower numbers (I would never get double digit eggs anyway)?

Shared experiences would be appreciated.

Thank you in advance! 🙂

@Sunflower360 Hello! Still pregnant as of last Friday 😁 I had my 7 week scan then and all was well. I've also been feeling horribly pukey. Morning sickness is no joke. No actual vom yet but I wish I could because maybe that would be some relief! Healthy diet has also gone out the window. All I want to eat is McDonalds and salt and vinegar crisps!

Not that I'm complaining... I feel very very lucky to have got to this stage.

How are you doing?

That's good to hear @countrypunk ! I'm good thanks, due to start 3 x natural modified IVF cycles end of this month. I was wondering did you do anything specific diet/supplement wise? I have added supplements and made changes to diet but any suggestions are welcomed! Trying to hone in on quality as my numbers will always be low

@Sunflower360 Yes - see my post below on 25 July. I really don't know if any of it made a difference. This IVF stuff so often feels completely random.

Good luck, keep us posted!

Hi @Sunflower360 , hope you are well. Just wondering how you been getting on? Looking at alternative options after a failed cycle - thanks x

Sorry to hear that @bloss0mx I ended up going with a 3 cycle ICSI natural modified package with Create. From the 1st cycle I got 5 eggs collected, 4 were mature, 3 fertilised with ICSI (4th degenerated through ICSI which is a risk with the procedure) and that gave us 2 embryos in the freezer (one day 3 which is standard for Create on the first cycle and a good grade day 5). I'm due my 2nd egg collection this week so will see what that holds. So far have been able to do back to back egg collections, which is one of the benefits of natural modified.

So far I have found natural modfied to have worked ok in comparison to the max stims cycle I did earlier this year but of course will see what happens when it comes to transfer stage.

Are you considering mild or natural modified?

Thanks for sharing @Sunflower360 and good luck with EC this week 🤞

I am also your age with same AFC but AMH is only 1.4... just completed 12 days stims of Gonal F 300 and Menopur 150 (not sure if this is high) - collected 3 eggs on Monday, 2 mature but 0 fertilised. Still waiting to speak to a doctor about the results but planning ahead due to my stats!

I am considering both as ideally I would like to do back to back too. Do you mind sharing what made you go with Create and how much is your 3 cycles plus meds is please?

Thanks again x

@bloss0mx your situation sounds quite similar to mine earlier this year as I was on 450 Gonal-F and only got 2 mature eggs of which both failed to fertilise properly despite my OH having a good sample on the day. I've never used Menopur but I think it's does the same thing, so I suppose it would amount to the same amount of stims in total (you may want to ask why they decided to have 2 different types of stimulation rather than just increasing the one in your follow up, just to understand that more, I'm forever asking questions so I can understand why their advising what they are!)

I was previously with a different NHS clinic for my 1st round and although they were cheaper to have the private cycles with them for the subsequent rounds, I felt they were probably not best placed to tailor their approaches to someone with low AMH. Hence me then looking into Create as they are the leaders in the whole milder form of IVF and those with low ovarian reserves.

What I will say about Create is that if you have doubts about the whole mild produces better quality then they probably won't be the best clinic as that is fundamentally their business model/approach.

After a fair bit of reading I am quite sold on the mild=better quality but that may just be because I had a bad result with a max stimulation cycle! Everyone is so different and I have read of people having success with high stims, it just wasn't for me. And as it happens, based on my last cycle with Create, I had a better result with a shorter duration and smaller dose of stims....could it be the much milder form of IVF or was it the change in diet/supplements/supplementary therapies such as acupuncture etc that I've been doing since that NHS cycle or was it just luck, I can't be sure to be honest! But either way I have been really happy with the level of care and the tailored approach that Create have provided, which in itself I feel makes a difference to the journey.

Then there is the cost side. It is 'cheaper' than other private clinics (albeit not cheaper than our previous NHS clinic), which is mainly attributed to the lower cost in medication as you are on lower doses for a shorter period of time (meds themselves were 2.7k for all 3 cycles). So in total our 3 cycle natural modified cycle was 16.3k including medication for all 3 egg collections and all scans, blood tests etc. It's as all inclusive as it can get but you do need to factor in that perhaps on some occasions you may need more meds/tests but they do try and estimate roughly what you need in the package at the offset. Also to note that only includes 1 transfer after all the egg collections...so if you have more than 1 embryo you'll be looking at an additonal cost for each subsequent transfer. Mild IVF was coming out to around 19.5k if I remember correctly. Also, those prices all include ICSI (which was 3.2k for all 3 cycles).

Hope that helps. You may also find this useful which is a study into natural modfied IVF and picking the best embryo to transfer over 3 and going from there:

www.ncbi.nlm.nih.gov/pmc/articles/PMC6822952/

@Sunflower360 OH - we do sound very similar, which gives me hope seeing you have gone on to having embroyos since!

We have since spoken to the doctor - she basically gave us a 5% chance if we were to continue, made it like we would be throwing money down the drain and suggested using donor eggs instead. I will definitely be going elsewhere... 😌

Appreciate your insight - super informative and useful, which I will factor in to my next steps!

May I ask how many follicles you had in your first cycle? 5 eggs sounds very good for a natural modified. Also, what supplements are you taking?

Thank you x 😊

We were given 10% chance after our NHS cycle by the consultatant and they said they did not really do mild IVF...would take it all with a pinch of salt and try and make an informed decision that works for you as the advice will vary dependent on the consultant you speak to.

Just before starting our Create cycle, in between the cycles, I got pregnant naturally and unfortunately had a chemical pregnancy so very early miscarriage but I decided to proceed with that IVF cycle with Create (Dr allowed it only because it was a chemical, if it was further down the pregnancy I miscarried I would have had to wait a cycle). I had 8 follicles in that 1st Create cycle of which 5 they were able to collect eggs from (the others were tiny), and of which 4 of those eggs were mature.

The aim of natural modfied is 1, maybe 2 eggs and anything else is a bonus but so far my body seems to be responding well to it.

Basically the protocol lets your body naturally recruit the follicles for the month, and you start stims around day 5 of your cycle. This month I started on day 8 as it was all a bit slow but appears to have caught up (well I'll find out for sure in this egg collection how it goes), so Create do tailor the treatment to you- think I have had around 6 scans for this cycle and it's all included in the package (last month I only needed 3 I think).

If you did decide with natural modfied go into it expecting 1, maybe 2 eggs. The aim is to extract the dominant follicle as that has been naturally selected as the strongest for the month, if you go in with that frame of mind then anything else collected really is an added bonus.

Supplement wise and after reading I decided the following for me:

• 3800 IU vitamin D in Proceive and additonal tablets
• 620mg CoQ10 in Proceive and additonal tablets
• 400ug Folic Acid in Proceive
• 650g Vitamin C in Proceive and tablets
• Others in Proceive
• 1000 IU Omega-3

Also OH is on 400 CoQ10, 1000 IU Omega 3 and 1000 IU vitamin D.

Also I have adopted a more high protein low carb diet, don't get me wrong I still allow myself to eat takeaways but it's all in moderation.

@bloss0mx I ought to add Create tested my AMH again and it dropped from 6 to 4.3 pmol in 6 months, but it is really about the follicle count with IVF so I gather

Also with supplements try and take them for around 2 months before starting a cycle to get the most benefits, takes around 2-3 months for eggs to develop before they get recruited... that's what I understand of it anyway

@Sunflower360 Sorry to hear of your chemical pregnancy - great that they allowed you to proceed with positive results too x

It is interesting to hear of others experience as I was also similar with 7 follicles, 5 ready but only 3 eggs collected. I am attending Create's virtual evening soon so looking forward to hearing more about their treatments.

Thanks for your list of supplements. I have since read into them more and gone on a crazy shopping spree lol guess this is also my way of coping with the failed cycle. We will look to start early next year so want to throw everything I can at it.

I hope your EC goes / went well. 😊 x

Thanks @bloss0mx EC went ok, got 2 this time which so far both fertilised. It was a slow start this month so wasn't expecting much tbh, but will see how these 2 progress and if any are suitable for freezing

Fingers crossed @Sunflower360 - quality over quantity 🤞 x

hello @Sunflower360 , I hope you're well and that the last 1.5 years went your way. I just read through this entire thread becuase I've just had EC on my 2nd max dose ivf round and only had one egg collected (despite 5 ready follicles). The last round I had three eggs, all of which fertilised, one transferred but failed. One spontaneous pregnancy and mc in subsequent cycle. Then right on ivf again.

Scouring mumsnet while I wait for the initial call from the embryologist to see if our one egg turned into an embryo and survived the night.

Looking to plan next steps so I've something to fall on later this morning (if indeed I'm to fall). I've heard good things about create. And I had a vague understanding that mild/modified was a thing for low amh. (I'm somewhere around 3 or 4). Reading this thread has helped a lot and I've screen shotted /tabbed linked articles to read later today.

I'd love to know how you got on with that create round. It's basically what I think I'll do next, especially after reading this thread. I just turned 39, so probably at the same age as you by now? I really hope all went well for you.

Hi @Nosejug

Can completely appreciate how you're feeling, it can be an emotional journey. For me it has been ok, breakdown is below, from my personal experience I would suggest Create as they specialise in older women with lower AMH to get the best results. My AMH when starting with Create was around 4pmol and I was 37/38 through the egg collections.

1st NHS Cycle (different clinic) High Stimulation short protocol (450 Gonal F): 2 mature eggs collected; no embryos

2nd Create Cycle Nat Mod ICSI: 5 mature eggs collected; 2 embryos frozen

3rd Create Cycle Nat Mod ICSI: 2 mature eggs collected; 1 embryo frozen

4th Create Cycle Mild ICSI: 7 mature eggs collected; 5 embryos frozen

Currently pregnant following 3 FETs (4 embryos transferred over the 3 FETs as the last one was double that is a singleton pregnancy).

Hope this helps and good luck!

You may also find this thread useful to read/share about others experiences at Create

Create Fertility - Experiences (Part 3) - www.mumsnet.com/talk/infertility/5023979-create-fertility-experiences-part-3

I would highly recommend multiple eggs collections and batch freezing if you can before transfer and PGTA before freezing. We didn't test and if we had it may have saved time with the multiple FETs. As it happened it was ok in the end (in tail end of 3rd trimester now). I did back to back FETs as they were natural and non medicated due to me ovulating which saved some time, but being 39 (which I am now too) I would say time is of the essence when it comes to egg collections. If this 3rd FET had now had worked I was considering 2 more egg collections with PGTA before doing any more transfers (including those that were already frozen). Just thought I'd share what my thought process was at that point. Hope that helps!

Aw that’s brilliant to hear you’re well into your pregnancy @Sunflower360 !

And thanks so much. all of that information is really useful, and a really helpful summary of the thread. I showed the create website to my fella this morning and we’ll take it from there. I like the idea of back to back collections. We don’t live near a create but I’m sure I can make it work.

happily our one little egg did fertilise, so if the embryo is still going by day 3 they want to transfer it then. I’m so glad we’re still in with a chance, but yeah, I’ll be looking at create if AF arrives in two weeks. Many thanks again for the info, and big congratulations on your pregnancy :)