Hi there Dr!

VIRA
Chicago, IL

Dear VIRA,

The situation you describe is a common one. We have somebody with over a year of infertility, despite regular periods. A workup has been done. Treatment has been tried. But still, there is no pregnancy yet. What are the options at this point. Let’s break it down logically.

Should we do more testing?
What do we know with respect to the three factors that contribute to infertility? SPERM problems. EGG problems. ANATOMICAL problems.
You share that your RE has evaluated your husband’s sperm and has told you that he has "perfect counts".
Because you are doing monitored cycles, we are getting a good idea of your ovulation.
You also share that you have had an HSG and that it came out great.
With this limited information, I agree with your RE’s decision not to pursue any further advanced testing at this point.

Another IUI vs IVF?
This is always a tough decision. There are many factors to consider.
COST DIFFERENCE: Some people have full insurance coverage for IVF. So for them, the cost of IVF and IUI are the same — zero. Many of these people choose to go straight to IVF because they can pregnant faster at no cost. On the other extreme, some have full coverage for IUI, but no coverage for IVF. These patient usually ask me to keep trying as many IUI’s as possible. There are also many people who have worked hard for many years and therefore have great financial resources. Most of these will choose to do IVF fairly early.
PAST TREATMENT FAILURE: All other things being equal, someone who has never tried either IUI nor IVF would be better off with IUI as compared to someone who has already failed IUI eight times, for example.
TUBAL DIAGNOSIS: All other things being equal, someone with known tubal problems or with endometriosis would be better off trying fewer IUI cycles than someone with no tubal problems.
SPERM DIAGNOSIS: All other things being equal, someone with low counts or unproven fertility would be better off trying fewer IUI cycles than someone with great sperm and proven fertility.
PERSONAL SENSE OF URGENCY: Those who have more patience and are not desperate to get pregnant "this very month" can try more IUI cycles than someone who is insistent on absolutely getting pregnant right away. A lot of this has to do with age also. Someone younger has more time to play with, so may try more IUI cycles before going to IVF. Someone older would be wise to consider IVF sooner than later.

Conservative stimulation vs Aggressive stimulation?
You bring up a very good question. How many eggs should you be trying to get? The answer to this also depends on many factors.
PREVIOUS TREATMENT FAILURE: For patients in their first IUI cycle, it’s generally better to be conservative, because you never know how powerful treatment can be. For patients who have failed IUI many times with many eggs in total, it’s less dangerous to have multiple eggs, so one can afford to be more aggressive. For example, it’s almost impossible for someone to fail with 2 eggs, fail with 2 eggs, fail with 3 eggs and fail again with 3 eggs and then, in the next cycle, when they have 5 eggs, all of a sudden get quadruplets. However, while still rare, it’s more likely for someone who has never tried any treatment to get 5 eggs in the first try and wind up with triplets or quadruplets. In your case, VIRA, after failing one year of trying on your own, three cycles of Clomid with her OB, 3 Clomid/IUI cycles and one injectable/IUI cycle, you have demonstrated that you are at less risk of having higher order multiple gestation as compared to someone who has never failed any treatment.
TOLERANCE FOR MULTIPLES: I have some patients who are absolutely against the idea of twins and want to avoid them as much as possible, even if it means taking much longer to achieve pregnancy. For them, I would recommend a conservative stimulation. On the other extreme, there are those who WANT twins and who are willing to take up to a 10% risk of triplets! For those, once I am convinced they know what they are saying, I would be willing to be more aggressive.
AGE: In younger patients, I’m more hesitant to give a strong stimulation. For older patients, I’m much more willing to stimulate aggressively.

Is there anything non-medical I should be doing to help increase my chances?
These would fall under the area of quitting smoking, reducing stress and optimizing body weight towards a BMI of 21-24.

Vira, as I said earlier, your dilemma is a common one and very vulnerable to second-guessing. Now that you have failed so many IUI’s, you are wondering if you should have done more aggressive stimulation in those past cycles. If you go ahead and do two injectable/IUI cycles with an aggressive dose and still don’t get pregnant, you will have wished that you had gone straight to IVF. However, if you get pregnant on your next IUI, you will be so glad that you didn’t do IVF. Such is the nature of the art of medicine. Thank you for your email and good luck!

This entry was posted on Sunday, May 11th, 2008 at 11:01 am and is filed under Questions and Answers. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.