Clinical case: when strategy is more important than speed

Low ovarian reserve, large uterine fibroids, and hydrosalpinx — how step-by-step treatment led to the birth of a child.

In the practice of a fertility specialist, there are cases where pregnancy does not occur for years not because of a single factor, but due to a combination of them. In such instances, the decisive factor is not an individual protocol, but a correctly constructed sequence of treatment.

This story is an example of how an individual strategy can change the prognosis even in a complex clinical situation.

The patient, 37 years old, visited the clinic with complaints of the absence of pregnancy for over 4 years.
In her history — no previous pregnancies.
The husband is 40 years old, also has no children. Semen analysis results are within normal limits. During the primary examination, several factors were identified that simultaneously influenced the inability to conceive: AMH — 0.1 ng/ml (severely diminished ovarian reserve)
FSH — 10.9 IU/L (on the 3rd day of the menstrual cycle)
According to ultrasound: 3 uterine fibroids, one of which deformed the cavity (≈60 mm)
Hydrosalpinx (inflammatory fluid in the fallopian tube) — according to the patient, it had been periodically detected on ultrasound previously
In the ovaries — only 1–2 antral follicles
Concomitant conditions: autoimmune thyroiditis and hypothyroidism.Thus, the patient had a combination of:

• severely diminished egg reserve
• uterine factor
• tubal factor
• endocrine disorders.

In such situations, it is crucial to determine the main question: what should be done first on the path to achieving pregnancy?

When the ovarian reserve is this low, the key constraints are time and reproductive age. Any surgery, prolonged treatment, or delay can further reduce/deplete the number of available follicles. That is why in modern reproductive medicine, the following principle is often applied in such cases: first — obtain and preserve genetic material, then — prepare the body and the uterine cavity for carrying a pregnancy.

This is explained by several factors:

Loss of time = loss of oocytes
After uterine surgery, removal of a fallopian tube, or long-term treatment, ovarian function may decrease even further.

The presence of a euploid (chromosomally healthy) embryo changes the prognosis
When genetically healthy embryos are already obtained, surgical treatment can be carried out with more confidence.

Reduction of psychological burden
The couple knows that embryos have been obtained, and now everything must be done for successful implantation and gestation.

Given this, the decision was made to start with embryo accumulation.

Before stimulation, thyroid function was stabilized. Hypothyroidism reduces the chances of implantation and increases the risk of pregnancy loss, so normalizing hormones is a mandatory step. Also, thyroid dysfunction is a very common cause of the appearance and growth of hormone-dependent formations — including uterine fibroids.

Double stimulation (DuoStim) was chosen — an approach that allows obtaining more oocytes and embryos in a short period of time.

Results:

• 1st cycle:

2 MII oocytes → 1 embryo → aneuploid

• 2nd cycle:

2 MII oocytes → 2 embryos → 1 euploid

• 3rd cycle:

4 oocytes → 3 embryos → 2 euploids

As a result, 3 euploid embryos were obtained.

Only after this was it possible to move to the next stage — uterine preparation.

Large uterine fibroids that deform the cavity can:

• disrupt embryo implantation
• alter the blood supply to the endometrium
• increase the risk of miscarriage due to increased pressure on the uterine cavity and the fetus
• cause inflammatory processes

Nodes larger than 4–5 cm that come into contact with the uterine cavity are particularly critical.

Hydrosalpinx is a fallopian tube filled with fluid.
Its impact on implantation is well-known in reproductive medicine:

• the fluid can flow back into the uterine cavity from the fallopian tube
• it is toxic to the embryo
• it reduces and practically eliminates the chances of embryo implantation

Therefore, it is recommended to remove the hydrosalpinx before embryo transfer.

After obtaining the embryos, GnRH agonist therapy was conducted to:

• reduce the blood supply to the myomas
• stabilize their size
• reduce the risk of blood loss

To avoid symptoms of estrogen deficiency, micro-doses of estrogen were used.

1.5 months after the start of the GnRH agonist effect, laparoscopic removal of the uterine fibroids and the fallopian tube with hydrosalpinx was performed.

This eliminated the mechanical and inflammatory factors.

After surgery, the uterus needs time to recover. Early transfer increases the risk of: scar insufficiency during pregnancy and poor implantation.

9 months later, a hysteroscopy was performed to rule out chronic endometritis and assess the state of the endometrium.

Only after full recovery — one year after the operation — was the embryo transfer performed.

One euploid embryo was transferred.
Clinical pregnancy occurred.
A healthy baby boy was born.

Two more euploid embryos remain preserved for future pregnancies.

1. First, embryos were obtained — the reproductive potential was preserved.
2. Then, factors interfering with implantation and gestation were eliminated.
3. The uterus was given time to recover after surgery.
4. The transfer was performed under optimal conditions with a verified endometrium. After all, the very fact of inflammatory content in the fallopian tube was already a risk for chronic endometritis. This specific logic allows for increased chances in complex cases. Clinical conclusions:

• With low ovarian reserve, it is important to first preserve eggs or embryos.
• Normalizing hormone levels is crucial for improving the response to follicle stimulation and protecting against the growth and recurrence of hormone-dependent formations.
• Large fibroids deforming the uterine cavity can significantly reduce the chances of pregnancy.
• Hydrosalpinx negatively affects implantation and often requires surgical treatment.
• A step-by-step strategy is more effective than rushed transfer attempts.

Romanova Olga Olegivna — fertility specialist, gynecologist-endocrinologist, Chief Physician of the Reprolife Medical Center. Specializes in managing complex cases of infertility, working with low ovarian reserve, and personalized stimulation protocols.