Friday, December 5, 2008

Which to Use & Why: IVF vs IUI

Dislaimer - Please note this is my personal synopsis of the free online radio program hosted by Kim Haun, founder of Conceive Magazine, with guest Dr. Peter Ahlering, an ob/gyn and medical director of the Sher Institutes for Reproductive Medicine in St. Louis. It is in no way meant to quote the either of the parties mentioned above.

To listen for yourself, go to this site and find the show in the archive on the left, dated 7/3/08, titled "IUI or IVF - Which to Use". Live

Ways to try and get pregnant are somewhat limited. They are:

1) Natural/No intervention - OPKs, timed intercourse
2) Ovulation Induction - various meds (clomid, injectables, metformin)
3) IUI
4) Artificial Insemination, often used with 2 & 3
5) IVF

Nature of problems determines what you do. Sometimes treatments are used when they shouldn't really be - when it wouldn't really do anything more than they're already doing.

Breakdown chances of IUI vs IVF

If used in the right circumstances, IUI is helpful.

Patients need to understand what they're trying to achieve. Pregnancy is ultimate, but in reality with ovulation induction you're trying to get multiple folicles to grow and ovulate. You have two ovaries and two tubes (normally) and sperm go both ways down each tube. If you have one or more follicules on each side, you're going to improve chances.

IUI is getting isolated, concentrated and putting it closer to where it needs to be for fertilization (half way there - bypassing barrier of the cervix). Limited because you're not influcing the initial steps of fertilization called ovum pick-up, where ovulated egg is picked-up by the tube and fertilization occurs at the farthest point of the tube from where it's picked up at the uterus. Embroy if the egg is fertilized, it needs to move back down the tube to grow and divide (about 5 day time) and implant into the uterus. All needs to occur still.

In terms of producing more eggs, what are the differences between the various drugs.

Pills - similar to shots, but they are designed to get at least one follicule to grow and ovulate (better than nothing). If you're already ovulatory, the pills don't work real well to get multiples. Clomid isn't very effective at this - in most cases you're getting one or two.

Most doctors don't monitor because they know hyperstimulating or multiple babies is very low, but this still isn't effective because you don't know if it's working.

You wouldn't use clomid in older patients (mid 30s or older). You would go to shots immediately. Pregnancy rates on shots is about double that of clomid. Why? Clomid is better at getting multiple follicules to grow and doesn't have the side effects, including thinning of lining or hostile ferticle mucus because of anti-estrogen effects you get with clomid.

Shots vs Pills - Shots are always more effective for any person.

Clomid & Letrozol - Generally with individuls with ovulation issues.
Metformin - PCOS (not to be used in all ovulation dysfuncation patients); is also used in conjunction with other things like clomid.

If you don't get scanned and you take clomid, and if it doesn't work, and then going straight to IUI probably doesn't make sense. (Jon & Kate + Eight?) Always use ultrasound monitoring because is it doing what you want to do - 1) growing follicles, and 2) not to many follicles.

Taking shots gives you multiple follicles which gives you higher chances. Pills is for women who are having problem ovulating. By the time you generally go to a RE, you've already tried clomid and it didn't work. However, when a person comes and hasn't tried anything, it depends. In young patients who don't ovulate, you probably still start with clomid and do and ultrasound around day 11 or 12 to find a dominate follicle and, if there is one, do an HCG injection and then you know when he window of opportunity is.

IUI Success depends on...
Success of IUI, is it dependent on the more follicules, with out a dangerous level, will increase her chances because a lot of eggs are abnormal and don't produce, but sometimes they can all fertilize. Three is an ideal number to give you the max benefit by getting pregnant, but still minimizing high order multiples (more than twins). If you are older you can do 4-5 follicles, but often these patients don't produce this many because the reserve is lower. These people though probably need to move to IVF.

Why does it increase your chances if you do IVF?
Because IVF bypasses all the things that occur inside - tubal pick-up, fertilization is largely taken out of picture as a problem. Can monitor embroy development and you can select embroys (sperm with ICSI) - you remove the potential stumblling blocks. Goal is to get as many as you can to grow, so you get more eggs (if you can) 10, 12 or more. If you have that many during IUI you don't go forward.

If you were planning on doing an IUI and you produce that many, you can turn it into an IVF pretty quickly, if patients wants. Doesn't happen too often.

What happens when you cancel a cycle?
If you have to cancel a cycle, one method is to prevent ovulation with an injection called Antagonist which stops the LH surge rapidly. Then you take birth control to bring on the next cycle in a timely manner. Then you do the process over again.

Listener Question #1:

Situation: One IUI $1,400 failed. IUI or IVF again?
Answer: IUI three in a row gives a positive result. If you go down IUI and meds route - be in it for 3 or 4 because that's usually what it takes if you have a good cycle - multiple follicules and good sperm specimin. If you get a "good" cycle, most patients who get pregnant will do so within that time. Various problems do determine the outcome.

Listener Question #2:
Situation: If you want to get pregnant, and if money isn't an issue, should you go through all the initial steps, or go straight to IVF?
Answer: Some people prefer to do this to get pregnant sooner and to control high multiples (twins still common), and for other things like gender selection. Age does matter - in both quantity and quality.

Success on First Try with Infertility Treatment?
Should someone walk in an expect to get pregnant on the first try? No, not normally (in best patient profile, 25% chance, say ovulation dysfunction problem) You need to be willing to be in it for 3 or 4.

Listener Question #3
Situation: Husband's sperm analysis 43 mil count, 34% motility, 4% morphology (a subjective assessment). 4th one high as 11% and as low as 3%. Should she rush into IVF or give IUI a chance?
Answer: Wouldn't base all on this. Ask, 4th part of test (DNA fragmentation), you have to find out this answer. "unexplained if" is often related to acult DNA male factor. Is an independent predictor of infertility. If DNA is ok, shots and IUI would be reasonable to try.

Can sperm that has a DNA problem, can it fertilize, but then have a problem down the road? It more effects embroy development. Looking at how the DNA is packed together in the cell itself. Needs to be tightly organized to fit into cell. If it's not packaged together, once it unwravels inside the egg after, it won't develop right. This test has been around for about 6-7 years.

Listener Question #4
Situation: Does accupuncture help if you're doing IUI or IVF? How do you know if someone specializes in infertility - I will ask, but is there one way to check?
Answer: Isn't the make or break. Doesn't really increase chance with infertility treatments. Isn't a problem to do, and there isn't a negative... you might gain other things from it - stress reduction, etc. Is welcome, but not highly suggested, and definitely not required. Has been more popular in last year or two, and no higher increase in pregnancy rates, in this doctor's opinion.

Listener Question #5
Situation: Up until Jan, I had failed to respond to ovulation induction. LH 18.2 FSH 9.6. After ovarian drilling (older before metformin was around as treatment to PCOS), GNRH aganist (lupron), follicules did grow and an IUI was scheculed. Too many so was converted to IVF. 7 eggs retrieved, 5 fertilized (2 grade A put back) no success and no embryos to freeze. Instead of doing IVF again, suggested IUI instead. Does this make sense?
Answer: No not really. Is hindered by the fact that if you did the right protocol with IVF and it sounds like you have PCOS or have a high response to meds you half did IVF with this converstion. In this case IUI might be a step backwards.

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cindy April 13, 2009 at 4:38 AM  

so what did you choose at last?you may try IUI first..after all its much cheaper in cost and dont have to go through all those ivf process...all those needles and injections...
but my dr suggest ivf for us cause he knew that in IUI i had early biochemical miscarriage due to abnormalities in the fertilized embryo..
let me know you choice...take care

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