Sunday, January 17, 2010

Failed IUI In 38 yr old - Inadequate Protocol & Advice


Question:
I'm 38 and my menstrual cycles became erratic after an abdominoplasty removed approximately 1.2kg from my stomach area this past January. I am trying now to become pregnant and have undergone my first intra-uterine insemination (IUI), which failed.

I've had to use Provera twice to start my cycle after it went over forty days. Recently my OBGYN had me take Clomid on days 3-7 then Repronex on day 9. An U/S on day 12 revealed that I had a 20mm follicle so I was given a hCG trigger then had an IUI the next day. A later U/S revealed that the follicle was still there and that the hCG trigger apparently hadn't caused ovulation. Do you have any information on possible reasons why the trigger failed or whether it would be worth my time and money to try this same process again given this first failure?
Thank you very much for your time.

Answer:

Thank you for your question. It is not possible to know if ovulation actually occurred or not. We presume, based on the ultrasound that if the follicle disappears, then ovulation occurred. However, even an ovulatory follicle can reaccumulate with fluid, as we often see after IVF. So, it does depend on when the ultrasound was done. I always do two back-to-back IUI's on my patients. With each IUI, I look with the ultrasound again to see if ovulation occurred. It is generally good at seeing that ovulation occurred because it is within a very short time period that I am looking. In your case, because the ultrasound was done later, it is not accurate. In addition, some people will ovulate later than expected after the HCG injection. Remember, once the HCG is given, people will ovulate within 24-52 hours. I want my patients to succeed, and if that means doing the IUI on a Saturday & Sunday, in order to guarantee this success, then we come in on the weekend.

There is no reason to think that this treatment plan will not be effective, unless there is something else preventing you from becoming pregnant other than ovulation. From your history, the clomid is giving you the chance of getting pregnant with each cycle and you should continue. I would not recommend more than four cycles, however, because statistically, the chances for pregnancy decrease significantly after four cycles. I would also increase your Clomid dose and/or Repronex dose to try to get you to ovulate up to five eggs per cycle.

One thing that needs to be mentioned is the impact of age on your fertility. You certainly can get pregnant with IUI but it is not the best option. At 38 yo, the chances of pregnancy per IUI cycle is 5-10%. Because of this, we generally recommend proceeding with IVF after the age of 36yo. With IVF, in a good program, you can have a 52% chance of pregnancy per cycle. Because of your age, I would limit the number of IUI cycles to three or less. If your OB/GYN cannot get you to form at least 3-5 follicles, then IUI should be abandoned. It is not significantly increasing your chances. You should also have a cycle day # 2 or 3 FSH level done. If it is 7.0 or above, then I would go straight to IVF. You are looking at time passing, which is affecting your chances even with IVF.

Good luck and don't hesistate to query your Ob/Gyn regarding his success rates with IUI's.

Sincerely,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF
www.montereybayivf.com

2 comments:

  1. I am 38 years old and post gastric bypass 6 years. I am down to 270 pounds from 400. I am type 2 diabetic on metformin and blood pressure medicine. I am single and wish to become a mother. With my medical history, should I even attempt IUI or IVF?

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  2. The decision on whether or not to try IUI vs IVF is of course a personal one and based on several personal factors such as whether you want to try naturally and financial issues. However, from a medical point of view, you age is a very significant factor and must be considered. With IUI, you would have a 5-7% chance of pregnancy per month of trying. On the other hand, with IVF, you will have a 60-70% chance of pregnancy per month of trying. But, IVF will be significantly more expensive. But based on the chances of pregnancy per try, in the U.S. we generally recommend IVF in any patient that is 37 years old or older. That is not the only option, however.

    Another option, which many of my patients will do is try 1-3 attempts with IUI and if those fail then move quickly to IVF.

    Good Luck.

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