IVF – Sooner Rather Than Later?
Traditionally, in-vitro fertilization (IVF) is not the first option offered to infertile couples unless the fallopian are obstructed or there is a severe male factor. In these specific situations there is no reason to offer alternatives to IVF because the prospects for overcoming these problems with surgical repair of the fallopian tubes or treatment of the male are clearly inferior to IVF success rates. IVF is the most effective treatment available for infertility and Drs. Neri Laufer and Avi Tsafrir at Hadassah Hebrew University Medical Center in Jerusalem are recommending, based on their review of available literature, that patients with unexplained infertility, polycystic ovarian syndrome patients who fail clomid treatment, and patients 40 years of age or older be treated with IVF first rather than after other treatments fail.
They argue in the February issue of “Fertility and Sterility”, that a comprehensive review (Cochrane, 2010) showed no benefit of clomid treatment whether with or without uterine insemination (IUI) compared to no treatment. When the reviewed the use of injectable medications (gonadotropins), the scientific literature was more confusing because studies done in the United States showed a benefit while a European study showed no benefit. The logical explanation for this discrepancy between United States and European results is that it is much for common for United States physicians to use higher doses of these medications resulting in higher pregnancy rates, but also leading to significantly higher multiple birth rates and ovarian hyperstimulation rates. This philosophical difference in treatment has long been the case, attributable in some measure to the fact that many European nations have nationalized health insurance. Because infertility insurance coverage is in place in many European nations, physicians are more inclined to be less aggressive with stimulation protocols and accept lower per cycle success rates in exchange for reduced multiple birth and ovarian hyperstimulation rates. With IVF multiple birth rates can be controlled by restricting the number of embryos transferred. Since it is the goal of reproductive specialists to reduce multiple birth and ovarian hyperstimulation rates, the argument for utilizing IVF in patients with unexplained infertility is strengthened. The lack of IVF insurance coverage for many U.S. patients remains an obstacle in the way of performing IVF for unexplained infertility.
The authors of this suggest that patients with polycystic ovarian syndrome (PCOS) who fail to conceive with clomid therapy, should be treated with in-vitro fertilization. The rationale for this recommendation is that PCOS patients who fail to conceive with clomid treatment represent a difficult group of patients to treat with injectable medications (gonadotropins), because they are quite sensitive to these medications and are at significant risk of multiple birth as well as ovarian hyperstimulation. IVF treatment of this group of patients has been made much safer through the use of an alternative ovulation triggering agent (Lupron), which has largely eliminated the risk of ovarian hyperstimulation. There remains controversy over whether use of the “Lupron trigger” compromises IVF success. In this group of patients, utilizing IVF in conjunction with use of the Lupron trigger and transfer of a single embryo represents a safer, more effective albeit more expensive treatment option.
The Israeli authors go on to make a strong case for treating patients 40 years of age or older with IVF as compared to clomiphene or gonadotropin stimulation with intra-uterine insemination siting data which demonstrates the per cycle success rate is 19.5% for the former compared to 5-10% for the latter.
These authors make a quite valid argument for IVF as the first line of treatment for patients with unexplained infertility, women of advanced age, and PCOS patients who have failed clomid treatment. While this approach represents an ideal which may be possible in an environment where nationalized health insurance is quite common, it becomes more difficult to implement in an environment where most patients do not enjoy the benefit of unrestricted insurance coverage for infertility care.