Pregnancy After Failed IVF, Low Ovarian Reserve and Advanced Maternal Age: Patient Success Story
This case describes a 40-year-old patient with diminished ovarian reserve, endometriosis, hypothyroidism, and a history of previous unsuccessful fertility treatments. After seeking a second opinion abroad, the couple wished to attempt another IVF cycle using the patient’s own oocytes before considering oocyte donation. The treatment plan was individualized, taking into account the patient’s previous poor tolerance to high-dose stimulation, her ovarian reserve, and her desire to feel more actively involved in the decision-making process.
Key Clinical Points
- Female patient aged 40 at initial consultation
- Male partner aged 33 with optimal sperm parameters
- Medical history significant for hypothyroidism and endometriosis
- Previous unsuccessful assisted reproductive treatments in the United Kingdom
- Diagnosis of diminished ovarian reserve and advanced maternal age–related infertility
- Previous IVF failure despite apparently adequate follicular and endometrial development
- Oocyte donation discussed as the medically recommended option with the highest probability of pregnancy
- Patient elected to attempt another IVF cycle using her own oocytes
- Mild stimulation protocol used due to poor tolerance of previous high-dose protocols
- Four mature oocytes retrieved and four normally fertilized after ICSI
- Four blastocysts obtained
- First fresh embryo transfer resulted in clinical pregnancy followed by missed miscarriage
- Subsequent frozen embryo transfer resulted in the birth of a healthy baby girl at term
The female patient was 40 years old at the time of the initial consultation, while her partner was 33 years old. The woman’s medical history was significant for hypothyroidism, diagnosed at the age of 23, and endometriosis. Her surgical history included tonsillectomy. Regarding family history, her mother had Parkinson’s disease. From a gynecological perspective, she reported regular menstrual cycles ranging between 25 and 29 days and an obstetric history of G1P0010, corresponding to one prior surgical termination of pregnancy. She denied toxic habits, allergies, or other relevant medical conditions. Her regular medication consisted of levothyroxine at doses ranging between 100 and 125 mcg daily.
Her partner reported no significant personal medical history. Family history was notable for paternal myocardial infarction and possible ischemic heart disease. He also denied toxic habits or other relevant health conditions. Male patient has optimal sperm parameters and overall good health.
The couple had undergone several unsuccessful assisted reproductive treatments in the United Kingdom prior to seeking care in Spain. Their reproductive history included one IVF cycle converted to intrauterine insemination (IUI) due to low response, one conventional IVF cycle resulting in three blastocysts. She underwent fresh single embryo transfer resulting in a negative test, and one frozen embryo transfer cycle with double embryo transfer under stimulated cycle with rFSH 50UI/24h, also unsuccessful. Despite apparently appropriate follicular development and adequate endometrial progression during previous treatments, implantation had not been achieved. The patient expressed dissatisfaction with the level of care received in her previous clinic and sought a second opinion and further treatment abroad.
The potential role of preimplantation genetic testing for aneuploidy (PGT-A) was also discussed in the context of advanced maternal age. However, it was explained that its usefulness might be limited due to the low probability of obtaining more than one blastocyst for biopsy. Situations in which fresh embryo transfer may not be advisable were also reviewed with the couple.
At the patient’s request, the oocyte donation process (OVODON-SP) was explained in detail, including both medical and procedural aspects. Counseling was additionally provided regarding the legal and regulatory framework governing gamete donation in Spain.
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Diagnostics – what was diagnosed with the woman and the man?
The female patient was diagnosed with diminished ovarian reserve, advanced maternal age–related infertility, and repeated IVF failure. Given her age, ovarian reserve parameters (follicle count of 2+3 and AMH 0.4ng/ml), and previous unsuccessful treatments, oocyte donation was discussed as the medically recommended option with the highest probability of achieving pregnancy.
However, the patient expressed a strong desire to attempt another IVF cycle using her own oocytes, partly because she did not feel adequately cared for in her previous clinic and wished to pursue treatment within a different clinical setting before considering donor oocytes. She demonstrated good understanding of the low expected success rates associated with autologous IVF in her particular case.
The patient also reported poor tolerance to previous high-dose hormonal stimulation protocols. Therefore, in the event of a new IVF attempt, a mild stimulation approach was proposed in order to reduce treatment burden while still attempting follicular recruitment. Suggested strategies included combinations such as clomiphene citrate (Omifin) with FSH/LH supplementation or Letrozole-based stimulation protocols.
Dr Alicia Saborit
What protocols and procedures were used? What was done differently?
Possibilities were discussed with patients and treatment alternatives were recommended. the patient elected to proceed with another IVF attempt using her own oocytes. The stimulation protocol consisted of clomiphene citrate 100 mg daily for 6 days in combination with Menopur 225 IU. A GnRH antagonist was introduced according to follicular development during monitoring.
Follicular development during stimulation was notably synchronous, with a total of five developing follicles observed. The patient completed a total of 11 days of ovarian stimulation. Final oocyte maturation was induced using a dual trigger protocol (hCG and GnRHa). At the time of oocyte retrieval, estradiol levels were approximately 1100 pg/mL and progesterone remained low at 0.2 ng/mL, supporting favorable endometrial and hormonal conditions for fresh embryo transfer.
A total of four cumulus–oocyte complexes were retrieved, all corresponding to mature metaphase II (MII) oocytes. Intracytoplasmic sperm injection (ICSI) was performed, resulting in normal fertilization of all four oocytes (4/4 fertilized).
What were the results before an embryo transfer?
Embryo development was unexpectedly favorable considering the patient’s age and ovarian reserve. By day 5 of culture, four blastocysts had developed, graded as 5AA, 5AB, 3BA, and 3AB. Given the excellent embryological outcome, adequate hormonal profile, and appropriate endometrial conditions, a fresh double blastocyst transfer was performed
The Embryo Transfer
A fresh double blastocyst transfer was performed using two high-quality embryos. The transfer resulted in a clinical pregnancy.
Unfortunately, the patient later experienced a missed miscarriage at 9 weeks of gestation. Surgical management with uterine aspiration was required. No genetic analysis or pathological study of the products of conception was performed.
Following the pregnancy loss, the couple required time for both physical and emotional recovery before resuming fertility treatment. During this period, optimization of the patient’s hypothyroidism management was also undertaken in order to improve endocrine conditions prior to planning a subsequent frozen embryo transfer cycle.
After the embryo transfet, pregnancy – details, result
Following recovery, the patient underwent a frozen embryo transfer (FET) cycle using a hormonally substituted endometrial preparation protocol with oral estrogen and progesterone supplementation. A single blastocyst transfer was performed.
This frozen embryo transfer resulted in a successful clinical pregnancy. The pregnancy progressed without major reported complications, ultimately resulting in the delivery of a healthy baby girl at term.
How many couple in similar situation are treated in the clinic? How common such medical background/situation is among the patients?
Patients with a similar clinical profile, advanced maternal age, diminished ovarian reserve, and previous failed IVF attempts, are very commonly seen in our practice. Many couples seek a second opinion after undergoing unsuccessful fertility treatments elsewhere, often feeling emotionally exhausted, discouraged, or insufficiently involved in prior decision-making processes.
In this particular case, the partner’s young age and absence of significant medical or fertility-related factors may also have contributed positively to the final reproductive outcome.
This case represents a particularly resilient journey for a couple who felt that they had not been adequately listened to or actively involved in treatment decisions during previous fertility care nor that it was tailored to their specific case. Importantly, the take-home message from this story is not that patients should always continue attempting treatment with autologous oocytes against all odds. Rather, it highlights the importance of providing patients with complete and transparent information, openly discussing all available treatment alternatives, and ensuring that couples feel empowered to ask questions and participate actively in the decision-making process.
Ultimately, fertility treatment should aim to balance medical evidence aligned with patient values and preferences and health state. Cases such as this one also serve as an important reminder of the need to respect patient autonomy while continuing to provide honest medical guidance and realistic counseling regarding prognosis and success probabilities.
About the Author:
Dr Alicia Saborit graduated in Medicine and Surgery from the University of Elche in 2013. She later specialized in the field of reproductive health by completing a Master’s Degree in Reproductive Medicine at IVI Global Education in 2019, followed by a Master’s Degree in Reproductive Medicine, Gynecology and Endometriosis at the University of Navarra in 2021/2022.
Since 2017, Dr Saborit has been practicing medicine, building extensive experience in reproductive medicine and gynecology. She currently serves as the Medical Director of Reproclinic, where she is committed to providing personalized and high-quality patient care.
Dr Saborit speaks Spanish, Catalan, French, and English, allowing her to support and communicate effectively with international patients.
