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When Is Ovarian Stimulation With Intrauterine Insemination A Futile Treatment?
In the course of caring for infertile couples, various treatment options are often available. Well-controlled randomized trials designed to evaluate treatment outcomes for specific groups of patients provide the data needed to counsel patients properly as to which treatment offers the best prognosis given their specific situation. A study published in Fertility and Sterility in November 2014 from Harvard University provides important data concerning treatment with clomid or gonadotropin stimulation in conjunction with intrauterine insemination (IUI).
A recently published study from Harvard looked at a group of infertile patients who were stratified by their basal follicle stimulating hormone (FSH) and estradiol (E2) levels as follows:
Day 3 Laboratory Testing
Group 1A FSH < 10mIU/mL E2 < 40pg/mL
Group 1B FSH < 10mIU/mL E2 > 40pg/mL
Group 2A FSH 10-15mIU/mL E2 < 40pg/mL
Group 2B FSH 10-15mIU/mL E2 > 40pg/mL
All patients in this study were initially treated with clomid or gonadotropin stimulation in conjunction with intrauterine insemination for 2-6 cycles. Patients who did not conceive with clomid or gonadotropin treatment were then treated with 1-6 cycles of IVF. The investigators looked at cumulative live birth rates per patient and further stratified their data to examine live birth rates occurring from stimulated cycles and intrauterine insemination as well as from in vitro insemination (IVF).
The main finding from this study was that women of all ages who initiated infertility treatment with an FSH of 10-15mIU/mL and E2 levels of greater than 40pg/mL on day 3 testing were unlikely to achieve pregnancy after stimulated cycles with intrauterine insemination. No patients in this group (Group 2B) achieved a live birth (0/19 couples, 0/58 cycles. Also, patients in this group demonstrated:
1 – Lower peak estradiol levels
2 – Fewer mature eggs
3 – Fewer normally fertilized eggs
4 – Fewer supernumerary embryos available for freezing
Of importance, this same group of patients had a live birth rate of 33% when treated with IVF (6/18 couples).
This study provides important information for physicians caring for infertile couples. The American Society For Reproductive Medicine (ASRM) defines treatment as futile when the prognosis for live birth is less than or equal to 1%. By this definition, clomid or gonadotropin stimulation with intrauterine insemination treatment for patients who have elevated day 3 FSH and E2 levels as defined in this study (FSH>15mIU/mL and E2>40pg/mL) would be considered futile. Since this same group of patients went on to have a 33% cumulative live birth rate with IVF, the best approach with this group of patients would be to proceed directly to IVF rather than attempt several cycles of ovarian stimulation in conjunction with IUI before offering IVF.