Generic Treatment Plans: Average to Aggressive

One of the interesting (and at times frustrating) aspects of moderating the Choice Moms discussion board is that so many women ask other women what kind of medications, treatment and/or testing they should have. The supportive environment is wonderful, of course, as is the sharing of hindsight, resources and often genuinely well-informed advice.

But as our favorite doctors remind us, without complete information about a woman's history, physical issues, lab results, and gamete analysis, any suggestions tend to be speculation.

And denial - and third or fourth opinions - don't always help us either. Women with elevated FSH levels truly need to be suspicious of ovarian failure. Egg donation and adoption might indeed need to be considered.

Having said that, one of the goals of this book is to help us realize that there is not always one right answer. Highly educated, accomplished doctors can disagree on basic philosophies and treatment plans. Your role as an educated consumer is to be part of finding the solution, not merely to accept the first one that comes along. (After all, we wouldn't necessarily be on this particular journey if we didn't trust ourselves to know what is right for us.)

Here, for example, is the basic outline from one highly successful fertility specialist of a plan for the average single woman attempting to conceive:

Dr. Corfman: When you are trying to conceive, you simply need to know if you have good ovulation events, as well as a normal uterus and fallopian tubes. Both are relatively easy to figure out. The vast majority of patients do not need medication, which can lead to unwanted side effects and multiple births.

To test ovulation, the procedure is called hysterosalpingogram (HSG), when a dye is put in the uterus to demonstrate whether everything is working as it should. It documents that the fallopian tubes are open. It also has the therapeutic effect of dislodging mucous and enhancing your chances of conceiving in the first year after the procedure.

You can test spontaneous ovulation with any over-the-counter detector. When it turns positive, an insemination should happen the following day. Your chances of conceiving any given cycle go down dramatically every year over the age of 35. [Editor's note: That's why some doctors are reluctant to work with older women, since it impacts their success rate.]

In our practice, we ask everyone to talk with a social worker, to ensure that they know what they are getting into and have considered what they will someday tell the kids. It's not to create a psychological "pass-fail" evaluation, but to be part of the support system.

One thing I'd like to point out is that FSH was designed to test the ovarian reserve of women over the age of 37, those who have failed with IVF, and those who have low ovarian response to medication. I think now it is way overused and used almost automatically for any woman who is 35 or older. In my opinion, it's an unnecessary expense for some women who have no reason to suspect that ovarian reserve is compromised.

I also believe that if you are ovulating normally, Clomid and other medications should not be used unless six cycles have passed without success. It doesn't boost your chances of conceiving, and does carry the danger of messing up the female reproductive tract.

Q: What if you are 40 or older, tests reveal that your numbers are normal and you've "passed" your Clomiphene Challenge Test. Based on age, and urgency, should you jump to IVF to increase the odds of pregnancy, if you can afford it?

Some women have no difficulty achieving a pregnancy between the ages of 40 and 44. But the majority are better served with prompt evaluation and aggressive treatment.

And many women between 35 and 40 wonder if more elaborate treatment or testing will get them to motherhood faster than average.

The challenge for any woman is to judge the odds, with her doctor's input, and decide what might work. With the above scenario:

1. One recommended path, from a few doctors we asked, is to first consider one or two cycles of COH-IUI (controlled ovarian hyperstimulation with intrauterine insemination, aka IUI with drugs). This gives the doctor the chance to evaluate ovarian response. And it gives you an opportunity to conceive with minimal investment.
2. If you strongly don't want to play around with the odds and can afford it, IVF is generally considered the more successful treatment for the older woman.
3. If COH-IUI doesn't succeed, and it is revealed that ovarian response is suboptimal and embryo quality is very poor (or several IVF cycles using your own eggs do not succeed), many doctors would recommend that egg donation be considered.
4. On the other hand, if early tests reveal you have an FSH level of 10 to 12, you might be directed to skip IUI and go directly to IVF, with the understanding that the chance for a successful pregnancy is reduced.
5. Patients with a day 3 FSH greater than 14 are often offered egg donation as the best medical option.