Dear Dr Sher,

I’d like some advice regarding protocol choice for what will be my 4th IVF-ICSI cycle.

I am in the UK. I have no medical problems, but I do have a BMI of 33 (prev 43), I have just recently turned 40 and work as a hospital doctor so can be under stress. No FH of fertility issues, in fact my mother had a surprise pregnancy at 45 with normal outcomes.

Initial investigations demonstrated a normal age adjusted AMH (12 in UK measurements), AFC of 31 on TVUSS but polyp was seen. Had resultant hysteroscopy for polypectomy which was otherwise normal.

Husband has teratozoospermia with 1.3 % morphology, otherwise counts well above average (116m/ml concentration) hence ICSI.

I started treatment age 39.5. All done privately rather than NHS given BMI.

Cycle 1 – Norethisterone 5mg. Then stimulated with Folliotropin Alfa 225 (ovaleap)/ Ganirilex. 36 hour trigger – 250mg Ovitrelle
Outcome – 6 eggs, 2 mature, 0 blasts.

Cycle 2 – Leuprorelin (Prostap). Ovaleap 300mg for stimulation. 37 hour Ovitrelle 250mg trigger.
Retrieved 10, Mature 9, Blasts 1 – slow to progress, transferred at day 6. Failed.

Cycle 3 (now 40yo) – as above with only change was increasing Ovaleap to 375mg during stimulation.
Retrieved 8, Mature 4, Blasts 0

Their opinion is that this is now clearly an egg problem despite promising AMH and relate it to my age. They are suggesting the next cycle is my last with my own eggs.

As such, I just wanted an opinion on their suggested protocol – which is to do exactly the same as cycle 3, but with potentially a double dose Ovitrelle to trigger and ICSI-AOA with calcium ionophore.

My questions are:

1. Is this planned protocol right given my previous outcomes or should I be asking for consideration of an alternative to planned medications? Could the higher dose of Ovaleap have been detrimental given the worse results?
2. Would getting my bmi below 30 before the next stimulation be of proven benefit? (I am continuing lose weight, but could defer by a month or two to lose that 11kg)
3. Beyond 5mg folate, vit D, coQ10, avoiding caffeine/alcohol and eating a colourful diet – am I missing any key supplementation?
4. How many cycles should I undertake before calling it quits? Is there a ‘magic’ number? (4 feels too early)

Thank you so much in advance for any advice. If there are some specific papers I should read to help inform any discussion with my team/or someone in the UK you would suggest I contact for a second opinion, please do let me know.

Best Wishes,