When is IVF used instead of IUI for Male infertility?

Question:
I was wondering when ivf is used instead of iui to start when male infertility is involved. What do the stats have to be (count, motility, etc) in order to say iui isn't an option?
　
What are the stats for iui and ivf. Do most women get pregnant using ivf?

Answer:
Hello Bill from the U.S.,
　
IUI and IVF are completely different treatments with significantly different pregnancy rates.
　
IUI is a "natural" treatment option in that the body has to do the same natural processes in order to achieve pregnancy. As such, the highest pregnancy rates are 24% per cycle and drop significantly after four attempts. IUI is mainly used when an ovulation induction/timed intercourse treatment fails or if there are "mild" sperm abnormalities. IUI accomplishes one of the steps required for pregnancy. It gets the sperm into the tube to await the egg, but also helps by timing ovulation better. Usually, it would be indicated with any of the following:
1. Count between 10 -20 million
2. Motility between 30-60%
　
IVF is not a natural treatment option because almost the entire process is taken out of the body. The only "natural" parts of the process are ovulation induction in the ovary, embryo hatching in the uterus and implantation. Because of these remaining "natural" processes, there is not a 100% pregnancy rate. Pregnancy rates are very dependent on the age of the eggs. In under 35 year olds, pregnancy rates are now up to 70+% per cycle attempt and go down from that age group. At 43+, it is 25% per cycle. With IVF, the ovaries are stimulated to growth many eggs, the eggs are aspirated from the ovaries, fertilization then occurs in the laboratory where the sperm are added or injected into the eggs, the fertilized eggs are allowed to grow into embryos and the embryos are placed back into the uterus. IVF accomplishes 6 of the 9 steps required to produce a pregnancy. Hence, it has a higher pregnancy rates. In terms of male factors, except for no sperm, IVF can be accomplished with any level of sperm abnormalities and is directly indicated when the findings are severe i.e. less than the above parameters including morphology less than 30%. TESA (trans-epididymal sperm aspiration) is a new technique for men that don't show any sperm in a semen analysis, but have sperm production within the testicle. In this procedure, sperm can be extracted directly from the testicle and used to inject directly into each egg. You only need enough sperm for the number of eggs that a present. So, even if a semen analysis shows no sperm, there is still the possibility of a genetic child with this technique.

If there is no sperm on semen analysis, and you can't afford IVF/TESA/ICSI or don't mind not having a genetic child, then IUI can be done with donor sperm. Donor sperm usually costs approximately $500 per specimen, so the overall treatment cycle would cost approximately $3000 per month of trying.
　
I hope this answers your question.
　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com
　
Monterey, California, U.S.A.
　
for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf

43 yr. old Trying To Conceive Needs High Stim Protocol

Question:

My Medical History: TTC 4.5 yrs. (3.5 with RE) Many IUI's & IVF's. 3 chemical pregnancies - 2 with IUI 1 with IVF. AMA - 43ys young.

Had a Coagulation Panel done - Mutation found -

heterozygous MTHFR C677T

Results negative for Factor V mutation

Factor II DNA Analysis

Results WNL for

ANA

APA

Lupus anticoagulant

Homocystein

Elevated levels for

Protein C Functional (187)

Factor II Activity (133)

Plasminogen (161)

B2 Glycoprotein (low positive)

Do I need to supplement my prenatal with extra folic acid and b vitamins? Baby aspirin? If so - can I just add extra supplements or do I need an Rx for something like Folgard?

Could this be the reason for all of my failed IUI's, IVF's and chemicals? Before finally agreeing to do this testing, my RE kept telling me that immune issues are too controversial and that the risks of their treatment outweighed their assumed potential benefits. I don't know what his thoughts are now as I couldn't get a Dr. callback for 3 weeks.

Many thanks, Dr. Ramirez, for so graciously donating your time in answering our questions! Your services are invaluable! Oh, yes - I am located on the east coast.

Answer:

I'm afraid I am in agreement with your RE, although for slightly different reasons. We do know that the immune system does contribute to miscarriages, although I am not sure that is the problem that you have. There are definitely some very controversial treatments, such as IVIG, which are very expensive and have not been shown to be of benefit in multiple studies. However, the alternative, which I try with all my patients is low dose aspirin (81 mg) per day, progesterone (injections and suppositories) and low dose heparin 2000 U twice per day. This regimen has been shown to help with recurrent miscarriages and is very low risk. That is why I use it. I have had some successful pregnancies in patients with recurrent miscarriages using this cocktail.

However, although you are still very young in my book, your fertility age may be the basic problem. You have shown that you can get pregnant. The problem is an egg problem. It is what I call "age related egg factor." We know that because a woman is born with all her eggs, and they age with her, and the lifetime of the eggs are about 43 years old, they deteriorate with time and age. This deterioration causes internal problems in the egg, including fragile chromosomes. This leads to bad embryos that either don't progress in their development, don't implant or end in miscarriage. There is a 40% chance of miscarriage with each pregnancy in your age group. Chromosomal abnormalities is probably the major reason for your losses.

There are only two ways to mitigate this increased risk: you can keep trying until you are successful (and hopefully you will be eventually) as long as your ovaries are still functioning well, or you can do preimplantation genetic testing (PGD) to identify the normal embryos prior to transfer (however, keep in mind that this is a new experimental technology, is very expensive, and does lower the implantation rate because of the "injury" to the embryo.).

I think that if you were to present to me, I would continue to recommend IVF with a high stimulation protocol and put you on my cocktail. I don't necessarily recommend PGD. I think nature will take care of that. The key would be to keep trying if you are determined to have a baby. There have been successes in your age group but time is running out for you.

I hope this helps,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF program

http://www.montereybayivf.com/

40 Year Old With Multiple Miscarriages Needs Correct Specialist

Question:

I have been trying to conceive for 3 years, have had 3 miscarriages, all between 6-9 weeks (one was trisomy 22, the other two are unknown. Two pregnancies required progesterone suppository supplementation). I am 40 years old, hypothyroid, insulin resistant, have a bicornuate uterus, my DRVVT came back Borderline (lupus anticoagulant, recommended re-test in 12 weeks), positive for ANA's, 1:320 titer, speckled), and compound heterozygous MTHFR gene mutation (variants C677T and A1298C). I am getting ready to try again. I was already taking synthroid 88, and 850 mg metformin twice a day.

My doctor has put me on folgard in addition to my Prenate DHA prenatal vitamin, baby aspirin, 10 mg prednisone twice a day, and I am taking 1 tbs Maca Magic, as well as 1 tsp royal jelly. Should I be taking low dose heparin as well? Lovenox? Start the progesterone suppositories immediately after ovulation?

My high risk pregnancy doctor recommended I not do IVF, because he said that at 40, my eggs are much too fragile to undergo retrieval, fertilization, analysis and reimplantation. He also indicated I would have a harder time getting pregnant after this (likely) failed. Please let me know your thoughts on this. Also, do you have any research you can direct me to, indicating that only 1 in 40 or 50 of my eggs are normal at 40 years old?

Would love to know your thoughts. I can't bear to go through another miscarriage. Thank you.

Answer:

You seem to have lots of reasons for having miscarriages, but probably the most common and predominant reason is your age. This "age factor" leads to spontaneous chromosomal aberrations that lead to abnormal embryos and subsequent miscarriage.In terms of your immune factors, just to cover those bases I would recommend either low dose heparin or lovenox. The progesterone should be started right after ovulation and continued until the pregnancy test is negative or 10 weeks gestational age.

Although you are able to get pregnant naturally, the only method that would increase your chances of a successful pregnancy is IVF. The reason is that multiple eggs can be extracted thereby increasing the chances of having a good egg (normal). It is not for sure, but will statistically increase your chances. At your current age, you probably have 1 out of 40 to 50 eggs that are normal. (When this post was published in 2009 no one really knew how many "good" eggs exist in the 35+ woman...and although it is still not 100% certain, a recent 2013 study has come out with some answers. The study found that 2 out of 20 eggs retrieved from 40 yr old women were chromosomally sound and had the potential of fertilizing and implanting successfully.) When you go through a natural cycle, you are only ovulating one egg at a time, so you can see that your chances that it will be normal is low and the chances of being abnormal is high. That is where IVF can help. With IVF you could get anywhere from 10-20 eggs at a time, depending on your ovarian function. Because time is against you, that is what I would recommend. The aforementioned medications should be used in conjunction with the IVF cycle.

As far as what your high-risk (I assume perinatologist) ob/gyn has recommended, I think you need to decide who knows fertility better. A fertility specialist or a high risk pregnancy perinatologist. As a fertility specialist, I have to disagree with your perinatologist as to your chances of pregnancy. As mentioned previously, IVF is the treatment of choice at your age. He is correct in that the chances of pregnancy are reduced because of the age related egg factor, which means that the majority of your eggs are no longer viable and prone to genetic abnormalities (spontaneous breakages), but is incorrect in saying that IVF will worsen your chances because the "eggs are too fragile for retrieval, fertilization or implantation."

In order to educate yourself regarding age related infertility and egg quality, your best source is ASRM's new website, reproductivefacts.org, sart.org or the CDC website. Each of these have the information you are asking for regarding the age-related reduction in infertility.

Good luck in your journey and don't hesitate to look for the right approach by seeking a second opinion.

Sincerely,

Edward J. Ramirez, MD, FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF

http://www.montereybayivf.com/

Can Tubal Ligation Be Reversed?

Question:

If you have your tubes tied can you have them untied to get pregnant? How is the procedure done and how long does it take and what are the chances of getting pregnant?

Thank you!

Answer:

The term "tied" is actually a misnomer. Basically, all tubal ligation procedures damage a portion of the tube causing the canal to be blocked off. There are various methods and the ability to repair them varies depending on the method. The methods are:

Post-partum tubal ligation (tubes are tied in two places and the tube removed in between). The ends are then cauterized.

Laparoscopic tubal ligation done through a scope. The tubes can be burned, clipped or a ring placed. The clip method yields the best reversal and burning and cutting the least successful reversal.

In addition, there has to be sufficient normal tube present for the tube to function (4 cms). If the fimbria is damaged (fimbriectomy) then this is absolutely not reversable. Most physician do a laparoscopy first to evaluate whether or not the tubes can be reversed before doing the reversal procedure.

Because the tubes are damaged, the chances for pregnancy are reduced and the chances depend on your age. As an infertility specialist and gynecologic surgeon, I can perform microscopic tubal reconstruction. Regardless of age, a complete evaluation is done to eliminate the possibility of other infertility factors. Some of those factors may include: maternal age, surgical risk, and ectopic pregnancy risk. See my page on "Microscopic Tubal Reconstruction".


I do not recommend tubal reversal surgery in patients over the age of 35.

A viable alternative is In Vitro Fertilization, which has a much higher chance of pregnancy per month of trying. Most fertility specialists do not do reversal anymore for this reason. For the same cost, IVF is better and is not a surgery, which means less risk. Cost wise, both are approximately the same and range from $8000-15,000. I hope this answers your question.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

IVF For The Third Time - Embryos Arrested at Eight Cells

I get many, many questions from patients outside the United States. Here is one from Europe from a young IVF patient with very disheartening outcomes.

Question:

Hi, I hope you can help me as honestly don't know where to go from here as been such a tough journey. Here's a bit of history.

DH (38)- asthenozoospermia

Me (35)- very slight PCOS, normal FSH levels

Clomid pregnancy 2008 - sadly ended in Stillbirth at 38 weeks (sept 08), cause confined placental mosaicism.

IVF 1 March 09 - cancelled poor response on too low stim drugs

IVF 2 July 09 - 14 eggs collected, 9 fertilised, 6 day 3 embryos. Transferred good grade 8 and 6 cell at Day 3 - BFN

Natural pregnancy Sept 09 - Miscarriage at 6.5 weeks

IVF 3 Nov 09 - 9 eggs collected, 8 fertilised. Day 3 - 5 X 8 cell 2 X 6 cell embryos. Plus 2 frosties (IVF 2) All looking good and then at Day 4 - all fresh arrested development at 8 cell. 2 frosties reduced cell number - no transfer

Tests so far:-Full chromosome anaylsis with me and DH - clear

Sperm DNA Defrag - within normal levels

Auto-immune tests (me) - slightly raised levels but not significantly. On all IVF's I have been on Short Protocol (Puregon, Luveris) and we have done ICSI. Plus support drugs of Clexane, Aspririn, Prednisolone (3rd cycle only),intralipid infusion (3rd cycle only) Progesterone and estrodial patches (post egg collection).Clinic doesn't seem to have any answers and seems to think worth trying one more time but do you think it would be worth changing clinics?

Are there further tests that would be worthwhile? Is it time to look at Donor and if so is this more likely to be an egg issue or a sperm issue or is it both? Do you think there might be a link between poor quality embryos and stillbirth and miscarriage?

Thanking you in advance for any help you can offer.

Answer:

Hello, let me answer your questions in order:

1. I think it might be reasonable to try a different clinic. Of course it could be just bad luck, but you have had real bad luck. One cancelled cycle and one cycle with arrested development. That's not a good statistic for a clinic, especially considering that you are young. In my clinic, my 2009 pregnancy rates in your age group are 74% per cycle with a 63% delivery/continuing pregnancy rate. I think the national average in the U.S. is 50-60%. Pregnancy rates are highly dependent on the clinic you attend because it can be influenced by the laboratory quality and techniques, as well as, the transfer quality and techniques. Good 8 cell embryos should not arrest, at least not all of them. Some may, because they are inherently abnormal genetically, but not all. I am highly suspicious of this.

2. It sounds like you have been tested for everything that can be tested for and you are fine. I cannot think of any other testing that I would recommend.

3. Abnormal embryos can be an egg issue or a sperm issue. Certainly, PGD can be done to check the embryos with another cycle to see if they are chromosomally normal or not, but I do not recommend it. Recent studies have shown decreased pregnancy rates with PGD, probably due to embryo injury or affects from removing one of the blastomeres. However, I don't think that this is your problem since you have been naturally pregnant twice in the past. If you were going to test your theory however, I would first try donor sperm, since it is the least cost. If you still have poor embryos after that, then you can go to donor eggs. I don't think you should go to donor eggs that this time. I would recommend that you try another clinic and continue trying with your own eggs. For example, I have a patient about your age who recently underwent IVF with me. She had done 5 IVF cycles at another clinic on the East Coast of the U.S. After the 5th cycle, they told her that she had poor egg quality and should use donor eggs. She then moved to my area. I recommended that because she was young, she should continue to try with her own eggs, at least a couple more times.

In her first cycle, she had a great stim, good fertilization, but the embryo quality wasn't so great. Her best embryo was a 6-cell embryo on day#3. She did not get pregnant. In the second cycle, we had great embryos. I transferred 3 8-cell embryos and she is pregnant with a viable pregnancy (singleton). And, it is hers genetically. Sometimes you just have to hang in there.

I hope that helps a little,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Trouble With 2nd IUI & Using Clomid

Question:

Hi, I'm on Clomid for my 2nd IUI (intra uterine insemination), as the first one didn't work out. The first cycle I went for the sonar on cd13 and had the IUI on cd15. The doc would've preferred to do it a day or so later but we couldn't because of lab related things. So this cycle I'm going on cd14. I would like the doc to give me the trigger to do on the eve of cd15 and do the IUI 36 hours later.

I'm worried though, I do ovulate on my own. Is it possible for my body to get the LH surge before I trigger or do I need the trigger to ovulate because I'm on Clomid? I'm taking 100mg a day. Will cd15 be too late? We're dependant on the lab for processing the sperm, so the doc cannot do the IUI on cd16 (a weekend).

Answer:

Clomid does not inhibit your body's natural ovulatory processes, therefore, you can indeed mount an LH surge and ovulate spontaneously before the IUI, if the doctor does not use anything to inhibit ovulation. Drugs to inhibit ovulation are GnRH antagonists, such as Cetrotide, or GnRH agonists, such as Lupron. Most do not use these with IUI cycles. I'm concerned because 36 hours after trigger may be way too late.

There was a nice study done three years ago that showed that if the sperm was not present prior to ovulation, then pregnancy did not follow. Therefore, for docs doing only one insemination per cycle (there is another option of doing two), they usually will plan it for 32-33 hours after the trigger. I prefer doing two, at 24 and 48 hours in order to have fresh sperm closer to the time of ovulation. Unfortunately, the studies comparing these two methods have not shown any significant advantage between them but I believe that is because there are too many variables with IUI. As it is, pregnancy rates are a maximum of 24% per cycle.

Your doc should not be dependent on a lab to do IUI's. He needs to make other arrangements, such as processing the sperm himself in his office.

I hope this answers your questions.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Spotting In First Trimester Not Placenta Previa

Question:

Hi Dr. Ramirez,

I am a 35 yo with no children. I found out I am 7 weeks pregnant and went for blood work and a sonogram since I have been spotting and had sporadic cramps for a few days. My doctor discovered I have low implantation of the embryo and placenta previa from the sono, and low progesterone levels from my blood work.

My doctor said my progesterone levels are 13.5 and should be higher (around 15) so he prescribed Prochieve Vaginal Gel. Is Procheive a good thing and is it needed? Will it produce side effects in the baby?

For the placenta previa, I have read so much negative information which speaks of hemorrhaging to hysterectomy and C-section. While I am okay with the thought of a C-section as it may save my life and the baby's, is there any statistical information available which discusses the probabilities of fatalities and hysterectomies?

With that being said, I am pro-choice and would like to make an educated decision on if I should carry this pregnancy to full term. With all the obstacles in front of me, in your experience and opinion, what are the chances of having a healthy child?

Answer:

First of all, I don't think you need to consider terminating this pregnancy because there is nothing seriously wrong at this point.I think that your doctor is over-calling things. To be frank, the recommendations and diagnosis he/she has given you is inappropriate at this gestational age.

Placenta previa CANNOT be made at 7 weeks gestation. That is a third trimester (after 28 weeks) diagnosis. At your gestational age, the entire amniotic sac is filled with the placenta. The mature placenta has not even developed yet. Placenta previa is when the placenta blocks the cervical opening, which then requires a c-section. As the uterus grows, the placenta will move and 99% of the time, the placenta moves out of the way. So you don't need to worry about it.

In terms of the progesterone, he/she is mistaken about that as well, however, we use progesterone all the time with infertility patients to help support the pregnancy. It is usually started before implantation, however. It would not hurt and Endometrin is the prescription that I use. It will not harm you or the baby. The alternatives to Endometrin, which are just as good, are Crinone and Procheive.

Spotting is very common in the first trimester. We see it all the time with our IVF patients. It does not necessarily mean that anything bad is occurring. However, you are still in the miscarriage risk stage so sometimes, spotting or bleeding could mean that the pregnancy is not doing well and will eventually end in miscarriage. There is no way to know this unless the ultrasound does not show a viable fetus i.e. no heart beat or not growing.

I hope this helps. Don't worry too much.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

www.montereybayivf.com