RECAP: Aimee and Boyd have been infertile for three years. After completing some basic testing, we are ready to discuss treatment options.
When considering what treatments to do, what are some of the things that patients consider?
In my experience, patients care primarily about cost and effectiveness. Some other concerns include how much time is consumed, how much risk is involved and how much inconvenience, or even outright suffering is involved?
What choices do Aimee and Boyd have?
- NO TREATMENT: Starting with the simplest, let’s not forget that one choice is to do nothing, and just continue trying on their own. Given the facts of the case that we know so far, I would estimate that their chance of getting pregnant on their own is about 2% per month. It’s not entirely insignificant. If only we knew for sure that their monthly odds were truly 2% and would remain at 2%, then we could confidently tell them that they have about a 38% chance of getting pregnant naturally in the next 2 years. One problem is that if we guess wrong and they really have a zero % chance, then those two precious reproductive years are completely wasted. For many couples who choose not to see a doctor, this is what they choose to do. Some of them just keep trying, month after month (as long as they have the patience) and in two years, about a third of them will finally get pregnant. The other two thirds will then find themselves in a worse situation than they were in two years ago, because they will have aged.
- CLOMID ONLY: If a woman is clearly not ovulating on her own, and if Clomid works to get her to ovulate, then this becomes a great strategy with little cost. Clomid is very helpful in this setting. However, if someone is already ovulating, then Clomid is LESS helpful and in some cases, not helpful at all. There are certain scenarios in which one could argue that Clomid is harmful to ones fertility by its adverse effects on the cervical mucus and on the lining. So, two factors make this an unwise choice for Aimee and Boyd. First of all, we believe that she already ovulates on her own. She has regular periods and positive ovulation testing, so she is far from the ideal candidate for just purely taking Clomid. The second reason this would be a poor choice is that they have already tried it. I’m more enthusiastic about something that has not been tried before than I am about something that has been tried before and that has failed, especially six times.
- INJECTABLES ONLY: Taking injectable ovulation medications instead of Clomid is certainly an option, but I would suggest that they do it in conjunction with intrauterine insemination (IUI)
- INJECTABLES + IUI: This is my recommendation for this couple. We would give Aimee medications to make a greater number of eggs and she would have a higher quality chance of conceiving with each egg because of the overall better hormonal environment. On the perfect day, or sometimes at the perfect HOUR, we would introduce the sperm deep into the uterus with a relatively painless procedure. This greatly increases the number of sperm that have access to where the eggs should be
- IN-VITRO FERTILIZATION: There are definitely some aggressive RE’s who would push IVF on this couple. I have been the second-opinion consultant on many such cases. I will concede the fact that IVF stands to produce a higher chance of instant conception as compared to three cycles of IUI, but in general, it’s important to let the patients make the choice, after properly counseling them of course.
After listing the different options, I asked them if they had any questions. They had several, so we broke it down to a comparison of the two best choices, Injectables+IUI vs IVF.
- COST:
An IVF cycle runs about $11K to $15K for everything. This include the medications, the anesthesia, the doctor’s fees, the blood tests, the embryology fees. That fee usually includes features such as ICSI and assisted hatching.
An IUI cycle runs about $1K to $3K.
Both of these can be less expensive or even free if a patient has insurance coverage for them, but most of my patients here in California don’t have any coverage. - EFFICACY:
I estimated, given our past track record, that they would have a 40-60% chance of pregnancy with a single cycle of IVF plus all the subsequent frozen embryo transfers that we could do until we ran out of embryos.
A single IUI cycle has a 5-25% chance of success, but in general, they would have about a 40-50% cumulative chance of success with three cycles. Now, of course, we never have to commit to three cycles. We can just make the decision to do one cycle and hopefully, it will be the only cycle we need to do. However, if it fails, we still have the choice at that time to decide to move on to IVF rather than to do another 1-2 IUI cycles. Because they have never failed (or even tried) an IUI cycle before, their odds are at their best. Each time someone fails at something the predicted odds of success of the exact same treatment end up less.
For example, imagine you know 100 people who are about to take their driver’s license exam. And you know that the passing rate is 90%. So if your friend is about to take the test and asks you what you think the odds are that he will pass, you might guess 90%. But if he fails the test and goes back to take it again, you might think his odds to be less than 90%. But what if he is allowed to take the test 15 times and he fails it every time. Then when he is contemplating taking attempt #16, you would certainly not estimate his odds of success at 90%. This is an important principle to consider in infertiltiy treatment. Had Aimee not done Clomid with her OB and had she wanted to do Clomid for the first time, I would have been fine with trying it at least once. But since she had already tried and failed six times, I told them that trying a 7th cycle of Clomid was a bad idea. - RISK:
The two biggest risks to consider are hyperstimulation and multiple gestation (twins or more). With IVF, we have much more control, because we take out all the eggs, make them into embryos and then CHOOSE how many to put back. With IUI, it’s totally uncontrolled. If a woman ovulates 20 eggs, we have to either cancel the cycle entirely (which is what we would do) or risk exposing all 20 eggs to a chance of conceiving. So in general, the risk of triplets would be higher with IUI. With regards to hyperstimulation, in an IUI, I would give a lower dose of medicine and that would minimize the risk. With IVF, we want to be more aggressive with the stimulation, so with higher doses, there comes a higher risk of Hyperstimulation Syndrome, a condition where the ovaries swell up with fluid leading to a lot of pain and potential serious medical issues. The overall chance of serious hyperstimulation is below 1%, but many patients may have a milder form. - TIME COMMITMENT
With an IUI cycle, Aimee could expect to come for about 4-6 office visits for ultrasound monitoring and for the actual insemination. This would be over a course of two weeks.
IVF, was a little more extensive, but not much more. Over the course of 4-6 weeks, there would still be about 5-8 office visits, but there would also be the big day of the egg retrieval followed a few days later by the transfer and a day of bedrest.
Armed with all this information, Aimee and Boyd confidently left the office with the firm decision to do a cycle of IUI with injectable medications. Her instructions were to call us with the first day of her period. Aimee shared that she was going to be in a great mood at work this week, because she would be filled with excitement about her upcoming treatment. I told her that a good attitude was definitely helpful in all this.
