Infertility Treatment Options

Infertility Treatment Options

Intrauterine Insemination (IUI)

Intrauterine insemination (IUI) refers to the placement of sperm within the uterine cavity through a thin, flexible catheter inserted into the opening of the cervix. Before performing IUI, the sperm must be placed through a "wash" process in which they are removed from the semen and placed in a small amount of culture media. Following the IUI procedure, the sperm that are placed in the uterine cavity must swim into the fallopian tubes to fertilize the egg(s) that have found their way into the tubes following ovulation. The fertilized egg(s) must then travel from the fallopian tube to the uterine cavity and successfully implant within the uterus.

The IUI is timed to the day of ovulation as determined either by the use of a daily urine ovulation predictor test to detect a woman's own luteinizing hormone (LH) surge or by the injection of human chorionic gonadotropin (hCG), a hormone that also acts to induce ovulation. Ovulation will generally occur about 24 to 48 hours after the detection of a urine LH surge and about 40 hours after an hCG injection. In some cases, two IUIs may be performed to increase success rates, the first on the day prior to ovulation and the second on the day of ovulation. IUI alone is performed when donor sperm are being used or when a couple is unable to have intercourse due to physical limitations or a concern about disease transmission. In most other cases, IUI follows a course of drug administration for the female partner in order to stimulate egg production by her ovaries.

In Vitro Fertilization (IVF)

In vitro fertilization (IVF) describes a multistep procedure in which a woman's own eggs or eggs obtained from an egg donor are removed from the ovaries and fertilized by the partner's sperm or donor sperm in the laboratory. The resulting embryos are then grown in the laboratory for several days and eventually placed into the uterine cavity with a catheter inserted through the opening of the cervix. IVF may be considered for all causes of infertility, whether unexplained, with normal testing, or when testing reveals the presence of damaged or blocked fallopian tubes, endometriosis, or abnormalities of sperm count, motility or morphology (shape).

IVF is considerably more involved and expensive than IUI because it involves an egg retrieval that is performed under general anesthesia and the use of an embryology laboratory to maintain the embryos for several days. However, IVF is more successful than IUI, provides better control over multiple pregnancy rates, and can be used in situations where IUI is likely to be ineffective, as described below. A more complete description of the IVF process and insurance coverage is also available.

Criteria for IUI vs. IVF

Intrauterine Insemination (IUI)

IUI may be a reasonable first step in the infertility treatment process, especially for women being treated with medication to induce ovulation. It may also be considered initially for couples with unexplained infertility when IVF is not covered by insurance or when there are concerns about the nature of the IVF process. In order to perform IUI successfully, several criteria must be met. First, at least one fallopian tube must be open and there should be no scar tissue within the pelvis that may prevent the eggs from reaching the tube. Second, as is also true for IVF, the uterine cavity must be normal to allow the fertilized egg to implant. Third, there must be a minimal number of sperm with good motility placed in the uterus to ensure that a sufficient number of sperm will reach the egg within the fallopian tube.

The sperm used for both IUI and IVF must be put through a "wash" process that removes the semen and suspends the sperm in a small volume of culture media. If semen were directly injected into the uterine cavity without washing, severe cramping would result from the prostaglandin hormone contained in the semen. Experience has shown that there should be at least 10 million motile sperm per cc for success with IUI. This number is derived by multiplying the sperm count in millions per cc by the percentage motility. Thus, a sperm count of 20 million per cc multiplied by 50 percent motility would result in 10 million motile sperm per cc.

In Vitro Fertilization (IVF)

The requirements to perform IVF are less strict for two reasons. First, the IVF procedure does not require the use of the fallopian tubes and is commonly used to bypass problems with tubal damage, absent tubes or pelvic scar tissue that results from infection or endometriosis. There is one concern, however, about fallopian tubes that are blocked at the far end, near the ovary, from previous infection. There is evidence to suggest that in the presence of this blockage, tubal fluid may drain back into the uterus and decrease the chance that the embryos placed in the uterine cavity during the IVF process will implant normally, reducing pregnancy rates. Opening these damaged tubes surgically, while a possible option, may not be the best choice due to the increased risk of tubal pregnancy that can result. When the tubes are thought to be damaged beyond repair, it is generally recommended to perform a laparoscopy and either remove the tube or create a second blockage at the near end of the tube, next to the uterus, to prevent the fluid from entering the uterine cavity.

The second advantage of IVF is the ability to overcome very low sperm counts, absent sperm movement (motility) or abnormal sperm shape (morphology) with the use of intracytoplasmic sperm injection (ICSI). With the ICSI procedure, individual sperm are injected directly into an egg to improve the chance of fertilization. In cases where there are no sperm present in the ejaculate, sperm can often be obtained either from the sperm ducts or directly from the testes in a procedure known as testicular sperm extraction (TESE).

Success Rates and Multiple Pregnancy Rates for IUI vs. IVF

Since pregnancy rates for both IUI and IVF are quite low utilizing the single egg produced during a woman's natural cycle, both IUI and IVF are generally performed following the use of medication to increase the number of eggs that are produced prior to the IUI or IVF procedure. These medications are described in more detail here.

Clomid with IUI

In women under 35 who take Clomid prior to an IUI procedure, a pregnancy rate of about 10 percent per treatment cycle is expected in women under age 35. Multiple pregnancy, generally twins, occurs in about eight percent to 10 percent of successful treatment cycles. Success rates and multiple pregnancy rates decrease gradually as women enter their later thirties and decline more severely in women aged 40 and older.

Bravelle/Menopur/Gonal-F/Follistim with IUI

In women under 35 who take injectable stimulation drugs such as Bravelle, Menopur, Gonal-F or Follistim (gonadotropins) prior to an IUI procedure, a pregnancy rate of about 20 percent per treatment cycle is expected in women under age 35, also with progressively decreasing success as women age into their later thirties and forties. The higher success rate seen with these drugs, when compared with Clomid, is believed to result from the increased number of eggs produced with the use of gonadotropins and the absence of some of the anti-estrogen effects that result from Clomid use.

However, while the augmented egg production that results from gonadotropin treatment is desirable for enhancing pregnancy rates, it also increases the multiple pregnancy rate to about 25 to 30 percent of successful treatment cycles. Moreover, when sperm are provided through intercourse or IUI, any number of the eggs produced in response to the medication may fertilize and implant in the uterus, resulting in an increased risk of high-order multiple pregnancies beyond twins. In this setting, about 95 percent of the multiple pregnancies that occur consist of twins, about five percent consist of triplets and about one percent consist of quadruplets or more.

Bravelle/Menopur/Gonal-F/Follistim with IVF

In women under 35 who take gonadotropins prior to an IVF procedure (Clomid is not generally used for IVF), a pregnancy rate of about 50 percent per treatment cycle is expected in women under age 35 because of the greater control that exists for each step of the fertility process with IVF. Multiple pregnancy occurs in about 25 to 30 percent of successful IVF treatment cycles but the vast majority of the multiple pregnancies seen with IVF are twins due to the ability to control the number of embryos that are placed into the uterus. As noted previously, success rates and multiple pregnancy rates with IVF decrease gradually as women enter their later thirties and decline more severely in women aged 40 and older as described in more detail here. However, at any given age, IVF will have a higher success rate when compared with the use of IUI.

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