When to move on to IVF

November 27, 2010Carole 7 Comments »

When should a patient move past intrauterine inseminations (IUI) to IVF? The short answer is that every patient’s circumstances are different and the key is finding a good physician to guide you. But here are a few checkpoints at which you might want to stop and consider next steps with your doctor. If your obstetrician or family doctor is performing the inseminations, proceeding to IVF will likely require a change to a reproductive endocrinologist who performs IVF procedures. In some cases, loyalty to your existing doctor may keep you in his care too long.

According to one large IVF center (which obviously has an incentive to perform IVF), there is a trend toward using IVF sooner rather than later. They say “Whereas most couples would do 3-6 IUI cycles before IVF treatment in the early 1990’s, today most couples choose to move on to IVF after 2 or 3 failed artificial insemination cycles.” The experts can recommend but every couple needs to pursue treatment on a time table that is right for them. Don’t be afraid to ask questions.  It is perfectly alright to ask your doctor to speed up (or slow down) the treatment time table.

If both tubes are blocked, tied or missing. This is a no-brainer. Do not stop at IUI, proceed directly to IVF. Because natural fertilization happens in the tubes, tubes are absolutely a must-have for inseminations to work. Sometimes you don’t know that your tubes are blocked. If you have had a couple of inseminations without success, your doctor may suggest that you undergo a hysterosalpingogram (HSG) to check the condition of your tubes. You should have visible “free spill” of dye from at least one tube (preferably both) to proceed with IUI. In a perfect world, it would be best to have a HSG before the first IUI to rule out blocked tubes.

The rule of threes. Although clinical advice varies, some doctors abide by a rule of threes in which they attempt three interventions of a type before advancing to a more aggressive intervention. For instance, a physician may suggest tracking ovulation using LH test kits at home in combination with timed intercourse or timed insemination as a minimal intervention. If that doesn’t work, he may suggest minimal ovarian stimulation using Clomid combined with IUI or timed intercourse. If Clomid doesn’t work, then stronger injectable medications may be prescribed with IUI. Based on your initial diagnostic assessment, where you start on this path will vary. Having said that, the couple who goes to IVF only after enduring twelve failed IUI’s have almost certainly waited too long, unless their financial and emotional resources are unlimited and they are under age 35.

Severe male factor. If your partner’s sperm quality and number are low, your physician will likely recommend IVF sooner rather than later. In an earlier post, I used sperm bank minimal quality guarantees as a guideline for deciding when IVF rather than IUI should be used. Based on these criteria, ten million motile sperm should be available in the insemination catheter post-processing for an IUI to have the best chances to work. That doesn’t mean 5 million motile can’t work but it is less likely to be successful. Ten million motile concentration may be minimal for an IUI but is more than sufficient for IVF. Men with below normal counts usually have enough sperm for IVF since thousands per ml, not millions per ml are enough. For IVF, good progressive motility is extremely important because the sperm have to find, bind and penetrate the egg on their own.

If intracytoplasmic sperm injection (ICSI) is used than a specimen need only provide as many sperm as eggs to be injected and progressive motility is not essential. Embryologists are thrilled to have more sperm to select from even if they only need a handful but we don’t always have that luxury in cases with severe male factor. Still,  successful pregnancies from ICSI have been fathered by men from whom barely enough sperm could be obtained to inject all the available eggs.

Advanced Maternal Age. If you are over 35 years of age, you are no longer in the youngest age group and may be classified as being of advanced maternal age. As difficult as it is to hear, every intervention is statistically less likely to work for women in older age groups. And since IUI’s tend to be less successful than IVF, older women can expect even worse outcomes with IUIs than younger women, on average.

ASRM recommends that women older than 35 years of age may want to shorten their time of trying to conceive with intercourse to six months because fertility is reduced with advancing age. Likewise, older women may want to shorten their time with less effective IUIs. Both IUI and IVF pregnancy rates decline with advancing age. However, unlike IVF, there is no national database on IUI success rates to enable you to find the best doctor. You will need to rely on your doctor’s quoted IUI rates, if he tracks them. By carefully reviewing CDC stats you can identify IVF clinics with pregnancy rates at 50% or higher.

Cost Effectiveness. At some point, you may want to consider whether you are no longer saving money by using IUIs instead of IVF. A typical IUI with injectable ovarian stimulation medications may cost $3000. If you have undergone four IUI cycles without success, you have spent the equivalent of one IVF, since the typical IVF cycle costs $12,000 in the US.  If IUI’s were a long shot anyway because your partner’s sperm count and quality are low or you are older, it may be time to move on before you reach the point where you no longer have enough funds remaining for at least one IVF attempt.

IVF insurance. If you have insurance that covers the cost of IVF, it might be to your benefit to access IVF treatments sooner rather than later if one or two IUI’s don’t work. Look at your coverage carefully and determine whether you have a lifetime cap or not. In some cases, your doctor may still want to do a preliminary ovarian stimulation with IUI to assess how well  your ovaries respond to ovarian stimulation medications.

To reduce the risk of multiples. Contrary to popular opinion, IVF is an excellent method to reduce the risk of multiple gestation because you get to choose how many embryos to put back. If you only transfer one embryo, your risk of twins is extremely low because the only way to get twins is if the single embryo splits into identical twins after transfer. If you have a medical condition in which twins or more would be unhealthy or especially difficult for you to carry, IVF gives you more control over the outcome. IUIs can be extremely risky because there is no way to control the number of eggs that will ovulate and be fertilized. Most cases of triplets or quads or more can be attributed to IUIs, not IVF.

Emotional exhaustion. IVF is the ultimate medical intervention using your own eggs. If you are emotionally exhausted with the whole infertility ride, getting to the end sooner rather than later may be a good thing. Of course, even a failed IVF isn’t the end of the road if you want to continue. Your doctor can modify the stimulation protocol or add ICSI  or hatching to the protocol. In some cases, IVF may identify that ICSI is necessary or that problems with the uterus may exist which might require surrogacy. Recurrent losses may indicate that aneuploidy testing may be helpful. The point is that if you want to do more, there is always more that can be done, especially if you are willing to move on to egg donation or gestational surrogacy. Unfortunately, most people have limited financial and emotional reserves, and at some point are faced with difficult decisions about when to move on, when to continue and when to stop medical treatments.

© 2010, Carole. All rights reserved.

7 Responses to this entry

  • Kevin H - Infertility Insurance Mandates Says:

    Check how your insurance covers infertility if at all. Most policies don’t, but some do. Four states mandate coverage for IVF but no other infertility treatments: Arkansas, Hawaii, Maryland, and Texas. IVF may be most cost effective in these states, while not so in the five states the mandate IVF along with other infertility services.

  • Egg Freeze Expert Says:

    Very insightful article! Thank you so much for sharing all of this information. I especially agree with the final point – there’s not way to take back all the emotional distress associated with infertility. Hope that this article helps out many people going though the journey of becoming parents.

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