About Success Rates
Published success rates for IUI, IVF and other fertility treatments may seem irrelevant to many single women because they are often based on couples who come into clinics after unsuccessfully attempting to get pregnant naturally. This can skew the numbers, since a single woman is not necessarily having trouble getting pregnant, but rather simply hasn't had the opportunity to conceive with a partner. So we asked:
Q: When listing the chances of getting pregnant any given month per age, is there data to suggest the success rate for those who actually do NOT have fertility issues?
Mehta: Yes, monthly fecundity (chance of getting pregnant) for a presumably normal couple is approximately 20 percent per menstrual cycle. [Note: This is for women under the age of 35; the success rate drops to 8-10 percent at the age of 40, and to less than 1 percent at age 45.] At the end of the first year, 80 percent of couples with no infertility issues have conceived. This data includes women who eventually need to go on to IVF because IUI fails.
Q: Statistically, what are the chances of success with each of the techniques?
The current wisdom, based on research, is that there is a slightly higher pregnancy rate with two IUIs if the sample is frozen sperm and is an unmedicated cycle. But the downside for the slight advantage is the cost of two vials of sperm and two insemination visits. As one doctor told us, "If the cycle is timed with ultrasound or a shot that triggers ovulation, a single insemination on the second day is another option that ensures more accurate timing. See our comparison chart on page 25.
Ashby: Physicians agree that IUI has about one-third to one-half the success rate of IVF, and that fresh sperm is only slightly more effective - about 2.5 percent - than frozen sperm. All success rates are highly stratified to age. Plain IUI has a 10 to 18 percent success rate per cycle with the use of drugs increasing that rate slightly. IVF has a wide range of success, from 20 percent (for many patients age 40+) to 60 percent (in a 28-year-old woman with no fertility challenges).
Schoolcraft explains that the chance of success of conception with insemination using either fresh or frozen sperm in an otherwise fertile woman is, in general, about 20 percent per cycle, depending on various factors related to egg quality. Fresh sperm, however, is no longer used in a clinic setting if it comes from a donor; a six-month quarantine is required to rule out infectious disease transmission.
In vitro fertilization success rates vary from clinic to clinic, but at the top clinics, pregnancy rates of 50 percent per month are reported (stratified to age), which are significantly higher than those achieved with insemination.
Q: After one round of IVF, my doctor has recommended IUI. Since the success rate for IVF is higher, why would IUI be a better option (other than the obvious cost savings)? I hear that clinics like to protect their success rates, which are reported to SART, and thus might turn away women with a low chance of success. How can I trust the doctor's advice in my case?
Mehta: If a woman has poor egg quality and resultant poor embryos in one IVF cycle, depending on her age, FSH, etc., we may decide to try another cycle with a different protocol. However if someone has an elevated FSH, poor follicle count, gets few eggs on retrieval and has poor quality embryos, often their success with another IVF cycle would be poor. Ethically speaking, if someone has a less than 5 percent chance of success with IVF then I do not recommend it. They would have the same or slightly better chance with IUI.
At our center, if someone has less than five eggs retrieved, the pregnancy rate is very poor. Therefore, in such cases many physicians would recommend IUI or egg donation. This recommendation is not based on statistical concerns for the center's pregnancy rates but because most centers or physicians are against subjecting the patient to the cost, risks and emotional aspects of another cycle that is almost certainly unlikely to work.
Licciardi: Many clinics have a very good pregnancy rate in women with less than five eggs, but it is very age dependent. Younger women can do very well; older women have more difficulty.
Q: Many women like to make informed decisions, including doctor advice but also based on their own values, about whether to take medications to enhance fertility or take a wait-and-see approach for a few cycles. Is there any data on what the per-month chance is of getting pregnant WITHOUT meds for the average woman, presuming age level and FSH are known?
Licciardi: There are many studies looking at the pregnancy rates of women who are trying on their own. For younger women first trying, the odds are about 20 percent per try in the first year, but it should be looked at another way. The odds are much higher when first trying, as high as 35 percent, but they go down every month that pregnancy does not occur. So that after one year of trying, the odds go to 3 percent per month. It's not that you are making your odds worse with time, it's that in your case the odds were low to begin with and the way to find out is to try. Unfortunately, the odds decline with age.
Redmond: I rarely use Clomid(R) or superovulation. The pregnancy rates at my clinic for natural ovulation are 18 percent for women under the age of 35; 10 percent for 35-37; 8 percent for 38-40, 6 percent for over 40.
Q: How do I know if drugs and fertility tests are needed?
Several doctors in our panel said that while fertility drugs increase the odds of pregnancy for women with challenging fertility issues, they are often over-prescribed for the average woman. And there are side effects to be considered. For example, one doctor told us that in up to 10 per cent of IVF cycles, the extra hormones trigger ovarian hyperstimulation syndrome, in which fluid leaks from blood vessels, causing symptoms such as bloating and pain. Around 5 percent of cycles cause moderate or severe OHSS, with a risk of disabling strokes or even death. For every 100,000 women undergoing IVF, about six die. It's wise to be an educated consumer.
Schoolcraft: Generally drugs for fertility are used to induce ovulation. They are typically required if ovulation is not working properly. Simple tests such as a progesterone level on day 21 of the cycle can confirm if ovulation is occurring in a normal manner. Other basic fertility tests should be accomplished before starting donor sperm insemination, such as an X-ray of the uterus and tubes, documentation of ovulation and a pelvic ultrasound.
Q: Some women have been advised that taking Prometrium(R) after IUI will help the baby "stick." Is this effective advice? Why is Prometrium used?
Mehta: Prometrium (a drug designed to mimic natural progesterone) is most useful in the IVF setting because progesterone production by the woman's own body is often low or insufficient. In the setting of natural cycle, or Clomid, or FSH cycles, its use is debatable. It does not help the baby "stick." It helps provide progesterone support in those subset of women that may have deficient progesterone production. Progesterone is important for the survival of an early pregnancy until the placenta takes over at about eight weeks.
Q: Is there a known statistical difference in terms of pregnancy rates between using at-home ovulation monitoring versus using blood-work/ultrasound?
Mehta: I am not aware of any good studies looking into at-home monitoring versus ultrasound and bloodwork on pregnancy rates. When someone is doing a natural cycle with IUI, in my opinion, when they say they have a positive surge, it is good to confirm with an ultrasound to provide objective evidence of the presence of a pre-ovulatory follicle and measure the endometrial lining thickness. Women often report a positive surge, but that does not correlate with their follicles and it may have been a false read.
Licciardi: If a woman is having regular cycles, and is comfortable with the kits, and they change at the proper time, IUI using home monitoring can work as well as office monitoring. Office monitoring for a simple natural cycle can get expensive.
Q: Should I do two IUIs in a cycle or not. And if so, why or why not?
Redmond: Fertility & Sterility [April 2001, 75:4, pp. 656-660] reported a study that compared IUI and ICI in fertile single women. Interestingly they conclude that two are better than one. A single ICI had 5 percent success; double was 9 percent. A single IUI had 14 percent success; double 15 percent. I have interpreted that as: one IUI is better than two ICI, and one IUI and two IUI look the same to me. I've been doing only one - it's a great cost and time saver - and have been very happy with results, although my numbers are not large enough to confirm their findings, especially if I break it down into different age groups.
Wisot: It depends if the ovaries are being stimulated. We try to figure out the right time. By using an ultrasound, if the follicle is still there, we do a second one. If the patient has ovulated already, there is no need to.
I caution patients to be aware of unethical physicians or clinics that will do unnecessary procedures, from two IUIs every cycle without checking to see if it's really necessary, to transferring high numbers of embryos, thereby increasing the risk of high-order multiple pregnancies.
These processes can be done unethically. Ethical rules are a set of values that protect the consumer. I know one doctor who transfers up to eight embryos in his under-35 patients. We usually transfer no more than two for women in that age group. Ethically, to me, it is not right to transfer such a high number, but that doctor does it to increase his success rate.
Licciardi: We don't think there is an advantage in two IUIs per cycle. Since the egg is good for one day and the sperm two, one well-timed IUI should cover it.
However, I have many patients that just feel better having two IUIs. I have no problem with this. Sometimes it's hard to figure out when to do the first. If you are getting a human chorionic gonadotropin (hCG) shot and want two, probably the first UI should be the day after the hCG.
For donor sperm, should you use one vial or two at each insemination? It depends on the recommendations of your lab and the counts from each vial. You would like to get around 10 million motile sperm for each IUI. If you are a little under that's okay. So if one vial is giving you 13 million, that's enough. If you are getting 6.5 million, maybe two (vials) would be better.
Q: When I have an IUI, how long should I stay on the table? Do I need a cap or sponge in my vagina to hold the sperm in?
As one doctor told us, "Technically, after the IUI, the sample is where it needs to be and there is no need for any time on the table. The sperm are held in place with the cervical mucus. No sponge or cap is necessary."
Licciardi: Most of the sperm is above the cervix. Getting up immediately from the table will not change your outcome.
Vaughn: There is a report in the European literature concluding that staying on the table for 10 minutes was associated with the highest pregnancy rate for their couples. Consequently we have encouraged our patients to remain on the examining table for the 10 minutes following their IUI. There is no needed for a cervical cap with an IUI.
Q: Does switching donors after several unsuccessful attempts make sense?
Ashby, who recommends asking a few questions before switching sperm: It depends. How is the donor sperm thawing? Has the donor created a pregnancy before? I think it's irrational to make that judgment about the sperm without having data. Many women spend hours and weeks agonizing over finding the right donor. And so I think it can be insensitive to just say let's switch out the donor sperm without having a good reason to do so.
To learn if the problem is the donor sperm, I recommend asking the physician to check the sample for the percentage alive after thawing, and for forward progression and motility. Typically your physician will have access to an andrology lab to get that data.
Dixon: I would do three cycles and reconsider. I would especially recommend it if two inseminations are being done per ovulation cycle; therapeutic donor insemination is a costly and emotionally charged process. It must also be emphasized that patients should use proven donors. If all other factors are found to be normal in the female, switching donors is a reasonable first avenue to consider.
Vaughn: If there is no success in six months, it is reasonable to consider changing donors. However, it is important to be sure that there isn't some other problem (ovarian reserve, fallopian tube blockage, structural issues with the uterus, etc.)) that is interfering with the success of the insemination.
Sims: If the donor has had proven pregnancies in the past, changing donors would not change the odds of pregnancies in a given cycle. The published pregnancy rates per cycle in women under age 35 with no infertility history is about 15 percent per cycle with IUI. With ICI it is closer to 7 percent to 10 percent with donor sperm. The actual rate for first cycles may be a little higher than this. If the woman is over age 35 and has failed after four to five cycles, I would recommend seeing a reproductive endocrinologist. Sometimes IVF may be more cost effective than continuing with ICI or even IUI cycles.
Redmond: If the donor has proven pregnancies, there is no benefit to switching donors. The problem is going to be female, not male.
Q: I've heard of a new treatment called IVM, as an alternative to IVF. It sounds like it might be safer and cheaper. Is it recommended?
The doctors we asked said that In Vitro Maturation of eggs is not yet ready. This new method involves collecting immature eggs and maturing them outside the body, rather than stimulating women with drugs to produce many mature eggs. It has kinks to be worked out. Said one doctor: "It is very hard to get immature eggs out of the ovary. The retrieval process is the same as IVF. The pregnancy rates while working with one egg is about 5 percent to 6 percent per cycle, and you have to go through multiple cycles. If you are going to take the time and the energy to do IVF, do it so the odds are in your favor."
