Fertility 101: Treatment
Superovulation / IUI (insemination) versus IVF (in vitro fertilization)
Traditionally, unexplained infertility has been treated with a step-wise approach, beginning with relatively simple protocols using oral medication for ovulation induction with intrauterine insemination (IUI), followed by injectable gonadotropins for superovulation with IUI, and finally IVF/ICSI for the couples that have not been able to achieve pregnancy. This approach allows the couple to start treatment using relatively straightforward protocols that are less costly. Success rates range from 12% with ovulation induction/IUI up to 20% for superovulation (controlled ovarian hyperstimulation)/IUI. Success rates have not improved over the last twenty years. On the other hand, IVF success rates have continued to climb higher and higher. It is not uncommon for pregnancy rates through IVF to exceed 60%.
With such high success rates through IVF, the traditional step-wise approach may no longer be the best treatment for those with unexplained infertility. In light of new information that compares the cost-effectiveness of controlled ovarian hyperstimulation (COH)/IUI to IVF, COH/IUI does not appear to significantly contribute to pregnancy rates. A recent study was published that compared the time to pregnancy, health care costs, efficacy of treatment, and adverse events of the traditional step-up strategy compared to an accelerated treatment strategy that skipped using COH/IUI. Over 500 couples were randomly allocated to the traditional step-wise approach or to the accelerated treatment approach. The results show that the time to pregnancy was significantly shorter in the accelerated treatment arm with a reduction in treatment related expenses. There were no differences in adverse events, and the two groups had a similar rates of conception at the conclusion of the study. (Reindollar et al. Fertility & Sterility, 2009, article in press)
Another point to consider when deciding to try COH/IUI vs. IVF is the possibility that there will be embryos to freeze with IVF. Embryos can be frozen and used in subsequent treatment cycles. This can allow multiple pregnancies to be established with just one IVF treatment. The cost of a future cycle using frozen embryos is approximately that of a COH/IUI cycle, with a higher chance of pregnancy.
The higher cost of IVF is certainly one of the disadvantages. Couples should consider the Shared Success Program for IVF, which is a partial refund program in the event that a couple is not successful. No refund programs exist for COH/IUI. Another important consideration when comparing COH/IUI and IVF is the risk for higher order multiples (triplets or greater). Although both COH/IUI and IVF are associated with a multiple pregnancy rate near 30%, the risk for higher order multiples is greater with COH/IUI than with IVF. In IVF, we only transfer 2 to 3 embryos in most of our patients, while COH is usually associated with the ovulation of > 3 eggs.
IVF does require two days off work, involves an outpatient procedure, and is considered a less natural way than IUI to conceive. However techniques used in the lab such as assisted hatching, ICSI, and embryo biopsy may be useful in attaining conception and determining why the couple has failed to conceive in the past.