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Many older infertile women are very unsure as to whether they need to do IVF; and if they do need IVF, if they should use their own eggs or to use donor eggs. While they understand with their heads that using donor eggs would maximise their chances of getting pregnant, it's hard for their heart to accept this decision, because most of us want a genetic link with our child !

This is especially true for older women who have regular cycles; grow follicles on ultrasound scans ; or have had a miscarriage in the last 2-3 years. If my cycles are regular and I can get pregnant in my own bedroom, doesn't this prove my eggs are fine ?

Gynecologists ( who do not specialise in infertility treatment) will often add to this confusion. Because they see 42 year old women who get pregnant in their own bedroom, they fail to understand there is a big difference in the biology of a fertile 42 year old and an infertile 42 year old. They will often "treat" these older women with clomiphene and follicular monitoring - causing them to waste valuable time !

The more sophisticated doctors will get their patient's FSH levels tested - and if these are normal, this will lull them into a false sense of security ! Not only are FSH levels very poor markers of ovarian reserve, they also vary from month to month; and if they are checked without also testing the estradiol ( E2) level at the same time, you may get an apparently normal FSH level, even if the ovarian reserve is very poor. ( A high E2 level can suppress a high FSH level into the normal range, and fool both doctor and patient !)

Unfortunately, most older women do not want to hear bad news. They are often in a state of denial and are not happy to listen to an IVF specialist who tells them that their "eggs are bad" ! They confuse calendar age with ovarian age - and are even more perplexed when they go online and read success stories of older women with high FSH levels who have got pregnant in their own bedroom !

Who should they trust ? Is the IVF doctor pushing IVF because he wants to make more money ?
Or is he providing medically sound advise ? Will you regret not doing IVF ? Or do you have an equally good chance of making a baby in your own bedroom ? And what if the IVF cycle fails ? Then what ?

While it's true that we do have better tests today for checking ovarian reserve, such as the AMH level and the antral follicle count , it's hard to make such an emotionally charged decision based purely on the results of medical tests. How reliable are these tests ? Can the results improve with alternative medicine ? herbal supplements ? acupuncture ?

If you are unsure what to do , and are emotionally detached enough to make a decision based purely on medical testing, then please ask your doctor to do a clomiphene citrate challenge test ( CCT) for you. This is a simple , inexpensive test, which provides very valuable information; and has stood the test of time. When it's hard to make a decision and you are confused, sometimes basing your decision on an objective test result can help you overcome your paralysis and move on with your life !

How does one do this test ?

Day 1 = day the bleeding of the period starts

On Day 3 , you need to do a blood test to measure your levels of FSH,LH,PRL and TSH; and AMH ( anti-mullerian hormone). Do this from a reliable lab please !

Take 100 mg clomiphene citrate from Day 5 - Day 9.

Repeat the blood test for FSH again on Day 10.

If the Day 3 plus Day 10 FSH levels are less than 25, then we can try to do IVF with your own eggs.

If the Day 3 plus Day 10 FSH levels are more than 25, this suggests you have ovarian failure,
and that donor egg IVF would be your best treatment option, if you are willing to consider this. A low AMH level will help to confirm this diagnosis.

If you are not sure how to interpret your results , you can ask me for a free second opinion !

For the older woman, time is now at a premium for you - please don't waste it ! When you are 60 years old and looking back at your life, you should never have any regrets that you left any stone unturned and didn't give yourself the best shot at fertility treatment. Treatment can be expensive, but a baby is priceless !

Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !

Infertile couples are often confused whom they should visit when they need medical assistance. Even though infertility always affects a couple , it's usually the woman who takes the initiative in seeking medical care . Most will bypass their family physician , but are unsure whether to go to a gynecologist or an infertility specialist. Both options have advantages and disadvantages , and it's worth examining these.

The gynecologist is a logical first choice. Most women have a long-standing relationship with their gynecologist , and are comfortable with him. Since gynecologists are specialists in tackling women's health problems , most can competently diagnose the cause of infertility ; and provide basic medical treatment. They are usually quite conservative; and would be the first choice for simple problems . However , they are often poorly equipped to deal with complex infertility problems.

Since a man with a hammer only sees nails, they will often subject the patient to unnecessary surgical procedures , such as a laparoscopy; or perform intrauterine inseminations for men with low sperm counts , simply because they do not have anything else to offer. They are often extremely poor at handling male infertility problems , and will usually refer these to their friendly urologist. This often means that care gets fragmented; and ends up of being poor quality.

Most gynecologists are also not aggressive enough when dealing with older women. Since most of their women are fertile, they often forget to remember the impact which aging has on the ovarian reserve of infertile women.

Also since they rarely have a special interest in treating infertility , waiting rooms are often quite infertile-patient unfriendly. There are often full of expectant mothers , and this can cause unnecessary emotional distress. Also some of them are not compassionate or empathetic enough when dealing with the impact which infertility has on the woman's psyche.

Infertility specialists would be the first choice, if you have a complex problem. Not only are they experts at dealing with infertility they have a lot of experience; and are armed with the advanced reproductive technology to solve most problems. However they are often quite expensive ; and some of them will often resort to unnecessary , complex costly treatment, even to tackle simple problems.

This means the patient has to choose between the risk of wasted time with the gynecologist, versus overtreatment with the infertility specialist. Since the infertile couple doesn't know how simple or complex their medical problem is , this often leaves them in a quandary.

What we do in our clinic ? If I am the first doctor the infertile couple is seeing, I will complete the workup for them , so we have an idea as to what the reason for the infertility is. This takes about 7 days and costs about US $ 200 only. If it's a simple problem , we will suggest that they find a gynecologist for their treatment. This allows us to concentrate on infertile couples who have complex problems , so that we can provide them with a higher quality of service, without diluting our focus.

In the best of all possible worlds , gynecologists with take care of the simple problems ; and if they have failed to achieve a pregnancy within 6 months , they would refer these patients onto an infertility specialist. Unfortunately, since most doctors have a proprietary attitude towards their patients , they are often reluctant to refer these patients to infertility specialists , because they do not want to lose them. This often means that they waste the patient's time , money and energy in pursuing ineffective treatments.

One useful tip is to create a clear plan of action with a well defined timeframe in partnership with your doctor , so you have a clear sense of what your treatment options are. This way, you retain control of your medical treatments as well as your life so you have peace of mind you did your best.

Want to make sure you are on the right track ? Please send me your medical details by filling in the Free Second Opinion Form and I'll be happy to help !

Most patients will vouch for the fact that the care provided in many IVF clinics leaves a lot to be desired. The clinic does not seem to have a treatment plan or protocol - and even if it does, this is not shared with the patient, who is often clueless about what is going to happen next ! There is very little communication amongst the staff, and often it seems that the right hand does not know what the left hand is doing. It seems that all the treatment is done on a daily, ad-hoc basis, and this lack of transparency create a lot of unease and distress. Also, because the senior" doctor is never available , it seems that all the decisions are made by assistants or nurses !

There is often poor communication between the clinic's staff members , who may end up providing contradictory information. The patient's expertise and intelligence is never respected; and most patients end up feeling patronised.

This seems to be true in very large clinics - and in small ones as well.

Thus, in some places, the gynecologist ( who is not an infertilty specialist) will do the superovulation and ultrasound scan monitoring; and then refer the patient to an IVF specialist for the egg collection. While satellite IVF clinics do work well , this is true only when they are tightly controlled and have strict protocols which are closely followed. Unfortunately, when gynecologists do an "occasional" IVF treatment every week or so, they often end up doing a major disservice to their patients , because they do not have the skill or expertise to treat them properly !

This is also true for centers which depend upon a "travelling embryologist" to do the ICSI treatment procedures. While these embryologists are very skilled and in great demand , it's hard for them to be in two places at one time. This means that they are often travelling from center to center, all across the country, and can only be in one center for about 48 hours. This means that the egg collections have to be done in this 48 hour window - and while about 80% of patients will grow eggs at the expected rate, this is not a good idea for older women or women who are poor ovarian responders, who need much more individualised treatment protocols , tailored to their body's needs.

The same criticism is true for the clinics which are run by "big-name" IVF specialists, who fly down from out of town to do the egg collections or embryo transfers once every month. The treatment protocols are monitored by remote control - but as any honest IVF specialist will tell you, this is suboptimal, and not in the patient's best interests !

Similarly, even in some very large IVF centers, the andrologist is available only once a week . This means all the TESE and PESA procedures have to be done on this one day - and the sperm are then frozen and used later for the ICSI procedure . This is not something which is in the patient's best interests, because the survival after freezing testicular sperm in men with partial testicular failure can be very poor !

The truth is that many IVF clinics today are run as commercial enterprises, to maximise profitability, rather to to maximise success rates. Ideally, you should look for an established clinic, which provides comprehensive care facilities under one roof, 24/7 !

Taking treatment at a world-class clinic will maximise your chances of success and give you peace of mind you did your best !