The 38-year-old patient was offered a natural cycle IVF attempt due to critically low ovarian reserve. Her menstrual cycle was regular every 26-28 days and a general examination revealed no abnormalities. Tests prior to treatment were: day 2 FSH 16.4 IU/L, anti-mullerian hormone (AMH) 0.78 pmol/L and antral follicle count (AFC) 3. Her pre-IVF scan showed normal uterine cavity with good uterine artery blood flow (Pulsatility Index = 1.45).
Her partner had a history of bilateral undescended testes resulting in an orchidopexy at the age of 3 years. This resulted in his semen analysis showing severe oligoasthenozoospermia. Her first stimulated IVF cycle with ICSI was performed in another clinic in 2007 and resulted in the term birth of healthy female. The second stimulated cycle in January 2010 yielded only one egg which produced a 5 cell embryo on day 2 which was transferred but resulted in a negative pregnancy test. Following this attempt and with results showing rising FSH levels (12.3 and 16.4 IU/L) the patient was advised to consider oocyte donation which she did not accept.
In 2011 she attended our clinic for treatment and had 2 unsuccessful Modified Natural IVF cycles. The first produced 2 follicles but no oocyte was retrieved and the second produced 1 oocyte and a 5-cell embryo for transfer but no pregnancy resulted.
In the current cycle the first scan scheduled at day 3 of her cycle showed menstrual endometrium, 2 follicles measuring 7 mm mean diameter on each ovary, FSH 16.4 IU/l, LH 6.8 IU/l, and oestradiol 120 pmol/L. A repeat scan on day 6 of the cycle showed early triple layer endometrium (Endometrial thickness (ET) 4.7 mm), one 10 mm follicle on the right ovary, and a 10.5 mm on the left ovary. The following scan on day 9 showed triple layer endometrium (ET 7.4 mm), a 12.4 mm follicle on the right ovary and 11.9 mm follicle on the left. The oestradiol level was 613 pmol/l and LH 7.5 IU/l. On the morning of day 11of the cycle the patient reported a strongly positive urinary LH test and felt that she might have surged the previous evening although the test was equivocal. A scan showed a triple layer endometrium 9.10 mm and a dominant follicle on the right side measuring 16.3 mm with very good peri-follicular blood flow with peak systolic velocity 19.6 cm/s. In view of this, oocyte retrieval was scheduled for later in the same day. 
Transvaginal oocyte collection was attempted using a double lumen Vitrolife  follicle aspiration set 1.6 x 350 mm with 4 flushings of the follicle. Granulosa cells were observed in both the aspirates and flush but unfortunately no oocyte was identified. The patient gave agreement to another attempt the following morning and was given hCG 10000 IU subcutaneously. The following morning the ultrasound scan showed a regular round follicle in the right ovary with clear contents measuring 11.3 mm (Fig. 1) which had very good peri-follicular blood flow with a peak systolic velocity of 27 cm/s (Fig. 2). 24 hours after hCG injection a further attempt at oocyte collection yielded an oocyte cumulus complex. Four hours post oocyte collection the cumulus cells were denuded using hyaluronidase (Sage, Cooper Surgical) and EZ Strip pipettes (RI UK ltd) a metaphase-I oocyte was observed. This metaphase-I oocyte was transferred into Oocyte Maturation Media (Sage, Cooper Surgical, USA) for maturation in culture and checked after 4 hours. The oocyte had extruded the polar body and ICSI was performed on the resulting Metaphase-II oocyte 3/4 hours post PB observation. Fertilisation was confirmed by the presence of 2 pronuclei (Fig. 3). A 2-cell grade one embryo was transferred uneventfully on Day 2 under ultrasound guidance using Wallace SureView 23 cm (Smiths Medical International ltd). A positive betaHCG of 108 was detected 2 weeks after the ET and a viable clinical pregnancy with clear foetal heartbeat was seen on ultrasound 2 weeks later.