Causes & Treatment

High Hopes and Low Ovarian Reserve

Eloise Edington | 11 Aug 2021

When you’re struggling with infertility, doctors often suggest IVF or ICSI without exploring other avenues of treatment. This was especially true for Mrs. A who has kindly shared her story with Fertility Help Hub reader hopefully to shed light on the process of ICSI and the thoughts and feelings that she faced along the way.

Read on for a step-by-step guide through the ICSI process and ways that Mrs. A dealt with administering injections, medical negligence and waiting for results.

Words by Mrs. A

My Mum had always told me I would be “extremely fertile”, as all the women in our family are. She often said it to me over the years, so I took it as gospel, but from the age of 30 I still asked at every GP appointment: “Is there anything I should be looking out for fertility-wise?” Only to have the same old tired questions trotted out:

Are your periods regular? As clockwork
Do you, or have you ever, smoked? No, never
Is your BMI and diet healthy? Yes

To which the GP’s response was always along the lines of: “I have no concerns and foresee no issues with your fertility; you are perfectly healthy”. I had never been offered further testing of things like my AMH levels or even had a red flag raised, so at 34 years of age, feeling calm and optimistic, I went into ‘trying’.

When six months of high frequency, high quality sex (only made possible when honeymooning under a global lockdown) didn’t result in Olympic qualifying triplets, Mr. A started worrying about his sperm. Our GP told us we had to give it a full year of TTC before they would explore any potential fertility issues. Mr. A ignored that and ordered a next-day home sperm analysis kit. The result came back saying he had a low sperm count, showing as an alarming angry red line that left very little doubt as to the cause of our difficulty conceiving. The next day (after discovering we hadn’t been trying long enough to qualify for NHS testing), I booked us a couple’s fertility MOT at a fertility clinic near home.

When the fertility specialist called, he coldly and flatly told us that Mr. A had as low a sperm count as 0.2m (he couldn’t even tell us if any were moving), and that this wasn’t the only cause of our infertility. And the hits kept coming. He told us that, despite my age, my AMH level (5.4) and follicle count (10) meant I was going to run out of eggs in a year or so and that I should prepare to go into early menopause at any moment.

My main take-outs from that call were the fertility specialist putting our chances of conceiving naturally at less than 1% and that we would struggle even with IVF and ICSI (not that I knew what most of these abbreviations meant). The doctor was extremely defensive when we asked questions and he made out that he didn’t have time to explain these new terms to us.

When asked if lifestyle changes could help with our sperm count, he borderline laughed and told us “No”. The call lasted around twenty minutes and it was quite frankly terrifying. As a follow-up they simply sent us the bill for a round of IVF. I felt we were being scare-mongered into a sales pitch, so I asked for our test results to be sent to us and told them aggressively where to stick their invoice.

The next day, I shared our fertility test results with our local GP, who tried hard to be helpful. She knocked the suggestion that I was imminently entering early menopause on the head: “we’ll keep an eye on your AMH levels every 6 months and plan as we go — for it to drop that quickly is unlikely — let’s not catastrophise!” In that moment I loved her for it. But then she calmly advised us that, in our area, my low AMH level would very likely mean the NHS wouldn’t cover IVF and recommended that we look privately if that was the route we wanted to go.

We picked a clinic and it took almost two months for our first call with the consultant due to COVID. Neither of us believed the first doctor when he’d said lifestyle changes weren’t worth it so we both stopped drinking, made healthier food decisions and upped our exercise. The most complicated decision was which supplements to go for. After a level of scientific desk research we ended up with the following and they have served us well:

Mrs.A

200g conemzine Q10 (three times a day)
Alpha lipoil acid 600mg (daily)
Pregnacare (daily)

Mr.A

Wellman conception (daily)
200g coemzine Q10 (daily)
Alpha lipoil acid 600mg (daily)
Symprove for gut health (daily)

I will say that it felt alarmingly easy to burn-out on IVF research before we’d even taken the first step, so we played it by ear. When things felt too much, we took nights off being good, got drunk together and ate ‘all the things’. The stress relief achieved felt way healthier than any diet, and I highly recommend occasionally falling off the waggon if needed -– just get back on again the next day.

As a final bit of preparation I booked Mr.A in for a new semen analysis a couple of days before our first call with the new consultant. I was frustrated that he hadn’t already been offered an ultrasound, a urology appointment or frankly any exploratory work to find out the root cause of his count and was completely stunned that he hadn’t originally been encouraged to make lifestyle changes. ICSI was hailed as ‘The All-Encompassing Answer’ and no deeper understanding was required for it to work. I felt then, and still feel today, that this is wildly unfair on the women who may be undergoing the physical rigours of IVF unnecessarily simply because ICSI is an easier, more comfortable, solution for the man than finding and, potentially, curing any issue on his side. If I could change anything after this experience it would be for greater equality of exploration and treatment options between the sexes.

When we finally had our call with the new consultant, Dr.R, it couldn’t have been more different. He took the time to explain every detail of our test results and every step of the process. He was optimistic about our odds with IVF Select and ICSI. He drove home that my AMH was merely a signal of quantity not quality, and my age implied that my quality should be good — so he was hopeful. He also shared that Mr.A’s lifestyle changes had upped his sperm count to 3.4m showing strong motility and so making him viable for ICSI. With all this information, he put our chances of getting pregnant with IVF Select at 65 – 70%. We were both beyond relieved and suddenly hopeful for the first time since our results came back. Dr.R created a plan for us that aimed to secure six genetically balanced embryos (enough for a good shot at two, maybe even three, successful pregnancies) before we went ahead with our first embryo transfer.

Once bought into the plan we wanted to understand how challenging getting six genetical balanced embryos would be for us. To help set expectations, Dr.R, explained that a woman’s AMH number was a good indicator of the number of eggs he’d expect to collect each cycle. In my case, this meant a predicted five to six eggs, but I could get as many as ten given my follicle count. This is low.

The other kicker with low AMH is that we typically don’t respond well to IVF stimulation drugs. Given that the more eggs collected characteristically means more chances at genetically balanced embryos, Dr.R wanted to inspire all ten of my follicles into action. To do so he recommended we add the hormone DHEA to my supplements list (25mg, three times a day) ordered only from his approved supplier. I’d already come across DHEA in my research. It showed very promising results but had yet to be tested to a safety level that would make it mainstream approved and, as a result, wasn’t available in the UK. It has some pretty bad sounding side-effects too –- facial hair growth, a deeper voice, oily skin, shrinking breasts… I mean at a time where you’re arguably trying to be your most womanly to be told to take a hormone that ultimately seemed to turn you into a man was something to get your head around. However, what results there are have been really promising in women with low AMH and Dr.R suggested that we at least try it. The plan was all set.

A few days after our first call with Dr.R, my period came. Suddenly, after weeks and weeks and weeks of waiting, everything started happening very fast. I started on Friday so, rather than wait the weekend, they booked my baseline scan that same day. It confirmed ten follicles and they cleared me to start stimulation. I was told to begin my evening injections of Menopur (450 IU) the next day.

The plan was that I would be on Menopur (a follicle growth stimulator) for around 10 – 14 days. Then, once any follicles got to a decent size, Fyremadel (an ovulation blocker) was added to stop the larger follicles releasing eggs whilst the smaller ones caught up. Then finally a trigger injection once enough eggs had reached the full-size threshold. The whole stimulation cycle, from first injection to egg collection, would likely take around 17 days.

Most of the time with IVF I’d turned to women: women authors, women who’d done it, women who were in it… but with the fear of injections, my Dad surprisingly stepped up. A few years ago, he’d had a sporting injury and torn his Achilles. He’d been in a wheelchair for months and had to inject himself with blood thinners every morning. He’d hated it but worked out how to do it well. He gave me tips and tricks (pinch the fat, look away, count down, do it FAST). It was great to have someone close to me who’d done it, and it was great for him to feel like he could actually be helpful and surprisingly, given the situation, offer some relevant experience.

I decided on injecting myself the first time. Mr.A sat with me and I think a partner, parent or friend being with you for the first one is very helpful. Someone watching you makes you want to be strong. I decided to try it standing up, took a deep breath, counted to 3 and then did it like I was quickly and calmly popping a balloon.

The Menopur stings a bit but never gets too painful. Afterwards it took some time for my adrenalin to come down but I felt a lot of relief that it had been way nicer than anticipated. Totally manageable! (If you’re about to start IVF please don’t worry too much about this, it will be fine).

I did my own injections for the first few days, to make sure I got confident with them, but wanted Mr.A to be involved. He didn’t need much encouragement. As it turns out Mr.A is an excellent back-seat-driver when it comes to self-administered subcutaneous injections. He presented a method involving Haagen-Dazs ice cream. His approach was simple – he would handle everything, the mixing and the jabbing. All I had to do was look away and eat a huge spoonful of ice cream when he shouted “now!”. It worked like a charm. We still use this ‘technique’ for every injection, and it comes highly recommended. You’re welcome.

I had very few side-effects to the stimulation drugs, only very small bruising on my stomach and that slightly swollen sensation you can get before your period. But after the third day I also started getting spaced-out. I was forgetting the names of people I knew well, I accidentally poured milk into our kettle trying to make a cup of tea! This wasn’t listed as a side-effect on my instructions or the drug packets so I asked one of the nurses. Apparently, it’s a natural reaction to a hormone your follicles release when they’re growing. When more than one follicle grows the spaced-out sensation gets stronger, but some women feel it a lot and others never notice. Other than that, things were going fine.

On Day 4 I headed to the clinic for my first progress scan — an internal ultrasound to check how many of my follicles were responding to the stimulation. Mr.A and I wanted to be together for the scan but due to COVID we weren’t allowed. Dr.R had said he would expect five or more to be active so that was my hope. When the scan revealed only two were responding well and one only just starting to grow, my first reaction was to stay positive. “It’s only Day 4 though, others will grow over the next few days, right?” But the nurse explained that wasn’t the case. I was told that if they didn’t see any signs of stimulation around this time it was unlikely that inactive follicles would start responding later on.

The two follicles that were responding had responded surprisingly fast. They were already big enough to be collected. The third one was very small but had a chance so they would give me two more days of stimulation. I was asked to go home straight from the scan and start my Fyremadel injections immediately to stop my two bigger follicles from releasing too early. I left feeling like nothing was going to plan.

I remember being quiet for my second progress scan. I didn’t pry for an answer before the nurse was ready and it felt like ages for her to find and measure the follicles. When she finally tilted the screen for me to see I was sure it would be bad news, but instead the screen showed my third follicle had unbelievably caught up! All three were a great size and two new smaller ones had also started to respond! I was surprised, happy and also strangely proud that 5 follicles had at least tried in the end. The relief of feeling like we might have a shot, however small, at an embryo this cycle was huge.

I was about to ask how much time it might take for the two new smaller follicles to catch up but was caught off guard (yet again) when I was told I would be going in for egg collection as soon as possible. The three that had responded were getting too large and we needed to move fast, or we might lose them. I was to take my last injections today and my trigger tomorrow. After only 6 days of stimulation my egg collection was being moved up a whole week earlier than originally planned.

I left the clinic with a mix of emotions: glad that we’d got to three follicles, that I could come off the drugs and that we would at least know the result of this round soon. But also concerned that my cycle was not going to plan and annoyed that my responses were all over the place.

To celebrate our third follicle putting in a shift, my husband booked us into our favourite restaurant. I was so excited that I managed to leave for dinner completely forgetting to take my last Menopure injection. But it was only an hour outside our window… that was ok right?

After the timings scare, the trigger injection took on a whole new level of stress. We’d had it drilled into us that we had to take it at exactly 10pm. It turns out the trigger injection isn’t quite as simple as the others, an issue not helped by the step-by-step instructional video being for a different kit from ours. Some of the key items didn’t match our set and we had double the vials! At this point I started to crack but Mr.A kept us collected. We stumbled through, mixed everything we could and just blindly hoped we’d done it right. With, literally, seconds to go Mr.A jabbed me and it was done.

We enjoyed 24hrs without any injections and then it was time for our egg collection. The whole thing is normally only around 20 minutes and is minimally invasive. You’re only heavily sedated rather than under full-on general anaesthetic and the typical side effects are slight bleeding with cramps and bloating for a few days after. What I found comforting was the fact that a given egg collection team perform, on average, 15 of these procedures a day so are pretty slick at getting it right.

After a while, my doctor arrived and explained the surgery to me. I was then fitted with a cannular (which was honestly the only uncomfortable bit of the whole procedure) and guided into the OR. Afterwards, they kept monitoring me until they were happy that I was ok and fully awake. I was told Mr.A’s sample went smoothly and all three of my follicles had eggs in them and all were safely collected.

The call from the embryologist the next morning brought good news. All three of our eggs were mature and two of them had fertilised overnight. Mr.A was relieved that his sample had meant ICSI could work and I was relieved that all our eggs were mature. We were given some colour: “They’re already splitting into two cells and looking great”. I was aware that this was bang on statistically average (apparently 70% of eggs fertilise — they don’t know why some do and some don’t). We were so pleased to have two in the running but were brought back to earth when we were told only 40% typically make it to Day 5. We strapped in for the wait and tried to remain positive about our chances.

The next day, we had an unplanned call with Dr.R who wanted to book us in for our second stimulation cycle. He made it clear he was hoping the DHEA would make a difference next time but didn’t suggest changing anything in our protocol. Talk of another cycle threw me a bit, I was reminded what a huge task it was going to be to get to six embryos and seriously hoped the DHEA was doing something.

I was still feeling overwhelmed with how much further we had to go when Dr.R threw us a ray of light. He told us he’d called the embryology team to check how our two were doing and they were very impressed! Both eggs were showing strong cell division way ahead of time and were nice and symmetrical so far. Based on this information he upped our percentage chance of both eggs making it to day 5 to 70%. And, just like that, hope took over again.

It was around this time that I started to feel slightly worse from the egg collection. I looked, and felt, like I was a dress size larger than normal and emotionally I was much less steady than usual. I felt full, nauseous and very tired all the time. I chatted to the nurses about it and they told me I would only start feeling back to normal once my period comes.

I woke up the next morning at 5.50am and stayed that way, so much for keeping relaxed. Mr.A slept like log. By the time the call did come I was exhausted. The embryologist cut right to the chase and happily announced that both our eggs had made it to Day 5. “One is about to transition so we can biopsy in an hour or so! The other is a little sleepy but we anticipate that one transitioning by this afternoon. Congratulations!”. We were beyond shocked and completely overcome with happiness. Despite all the odds we felt like we’d been given a chance at a success this round.

I remember calling family and friends, telling them the good news and smiling constantly all day. I couldn’t believe the situation we were in, given how few eggs we’d collected. All my cool composure melted and I was just beaming happiness.

I was woken up the next day by the same embryologist. She’d called to tell us that we’d lost one overnight. Just like that the round went from a likely success to a likely failure. In all the confusion of this unexpected news our embryologist suddenly started insisting that we run genetic testing on our one embryo right away, breaking with our plan to batch test and get results later. She was pushing because she felt Dr.R should know and it might change the drug protocol we’d be put on next round. She also explained that it would help us to know how many more rounds we might need. I was too thrown by the news that we’d lost one and just wanted to get off the phone so agreed and hung up.

To this day I wish our embryologist had never called early. I strongly believe that if she’d only waited and we’d only gotten the call saying we had one Day 5 embryo our reaction would have been so different.

It was ten days until we could speak with Dr.R again. During that time, my period finally came and it was heavy and cathartic as advertised. I felt my mind clear and my emotions level out. It felt like a fresh start and my body went from strength to strength.

When Dr.R finally called, he was apologising profusely that the results on our embryos had been shared too early and assured me that he was putting notes all over our files to not call us before a biopsy had been successfully performed in future rounds. I told him that I’d felt pushed into early genetic testing and whilst I understood that we couldn’t go back on it now, I wanted him to put another note on our file so no one would ever actually call us with the results. I didn’t want to know for sure the round hadn’t worked, I wanted to hold onto hope for a little while longer. He understood.

Dr.R went on to share some good news. My embryo had been rated 3BB which was very solid and promising for future rounds. Given the rating of our embryo he upped its chances of getting through genetic testing to a very precise 52%. I remember finding it very hard to give into that good news as I felt, and still feel, like both good and bad news in IVF seem to change at any moment.

Case in point – Dr.R then gave me an update on Mr.A’s low sperm count which caused some shock. The sample that he gave during the egg collection had revealed a huge jump! He was now showing a count of 25 million, from his original count of 0.2. I think the lifestyle changes must have been the reason.

Then, Dr. R said that given Mr.A’s current sperm count, we would have to be very careful not to get pregnant naturally on our month off between cycles. Dr.R reminded me that if we wanted to ensure we could have a chance at more than one child we had to keep going and collect as many embryos as possible before trying, either naturally or through a FET.

I still feel deeply happy that we might have a chance at conceiving naturally but it’s strange to unexpectedly find yourself in a situation where you surprisingly could have what you want but actively mustn’t have it, simply to ensure you can have more of it later.

The call ended, and with it so did our first round. Despite all the ups and downs we’d walked away with one potential embryo and a stellar sperm count. We were in for a four and a half week wait before we could start stimulation again and our hopes were pinned on DHEA making Round 2 easier, physically and mentally, before jumping back on the roller-coaster again.

And finally, to everyone whose already on their roller-coaster, or about to jump on, I send you love and hope you get everything you wish for. I also hope that in sharing some of our story we’ve been able to help in some small way.

Hopefully, this blog has helped you to get an idea of the ICSI process, step-by-step and, although of course this process is never an easy one, we hope it has been useful to hear Mrs. A’s experiences.