At Shady Grove Fertility, we believe in a stepped care approach to treatment, starting with the simplest, most affordable treatment options first and move up to more advanced treatments only if needed. More than half of all the treatment cycles we do are considered low-tech and were successful for nearly a thousand patients in 2013. For many patients, it makes sense to start with the low-tech treatment, but when fertility treatment doesn’t initially work, it becomes a question of when to consider transitioning to another treatment to increase chances of conception?

“It might take more than one cycle, but we now have treatment options to help almost everyone,” says Frank Chang, M.D. of Shady Grove Fertility’s Rockville, MD office. “Studies have shown that perseverance with treatment pays off, so if patients are open to using all of their options, we can help almost all of them become parents.” Here, Dr. Chang shares some of the most common transitions patients go through and what guides his recommendations for when to try something new.

The first move is seeking help

The first question most couples ask if they are having trouble conceiving is: When do we stop trying on their own and see a fertility specialist? The easiest way to answer this question is to look at the accepted guidelines based on the age of the female partner.

If you’re a female under 35 years old, you should seek help after a year of unprotected intercourse without a pregnancy. Females over 35 should seek help after only 6 months. If you’re 40 years old or older and you’re just beginning to try, it’s best to talk to a physician right away.

Some patients will start by talking with their OB/GYN, but it’s also perfectly fine to speak directly with a fertility specialist. “The doctors at Shady Grove Fertility don’t require you to have a referral from your OB/GYN or primary care doctor. You can make a consultation appointment directly with us,” says Dr. Chang. Your insurance however, may require some kind of referral or authorization from your primary care physician. Our New Patient Center can determine if you need this type of paperwork before your consultation can be covered by insurance.

Wherever you start, the first step should be diagnostic testing on both partners. “Once your diagnostic testing is done, the question about which treatments are right for you will become clearer,” says Dr. Chang. “It’s best not to start any type of treatment until both partners have been tested,” because many couples have multiple factors affecting their fertility, and they can occur on both the male and female side.

First line therapies: how long is too long for Clomid?

Most couples have the option of starting with low-tech forms of treatment. In fact many patients start with clomid, a form of low tech treatment, while still under the care of their OB/GYN. These treatments don’t have the high success rates associated with in vitro fertilization (IVF) but they are simpler and much more affordable.

Since this treatment can be done with an OB/GYN, many women would prefer to keep doing it month after month rather than transition to the care of fertility specialist. Dr. Chang says this can lead to patients “spinning their wheels” so to speak.

“If we look at the data, we see that after 4 cycles of Clomid, the success rates drop off dramatically, even if the woman is ovulating. If she is over 35 or the couple’s infertility is unexplained, the data show that they should move on even sooner,” says Dr. Chang. “In fact, it’s actually been shown that it is more cost-effective to switch to more advanced treatments like IVF rather than continuing with Clomid.”

Transiting to a fertility specialist

After Clomid or speaking with their OB/GYN, the next step is visiting a fertility specialist, but that doesn’t mean jumping right into in vitro fertilization (IVF). Depending on the couples’ diagnoses and age, there are still several steps a fertility specialist might recommend before IVF. For example, patients might continue Clomid and IUI but add injectable medications. One thing that will change when you work with a fertility specialist is that you will be monitored with ultrasound and bloodwork throughout the stimulation phase of whichever treatment you do. That way, you and your doctor will know if the medications are having the desired effect.

If a treatment cycle does not result in a pregnancy, the patient will meet with their physician to review how the cycle went and how to proceed. “Ultimately patients will make the decision on what to do moving forward with their treatment. I always provide the patient information on their cycle, the success rates, and data that we have which helps them to make the most informed decision,” says Dr. Chang.

“Many patients succeed with these treatments,” says Dr. Chang. “However, if pregnancy is not achieved within a few cycles, we would review their cycles and decide when to move on to IVF.”

Dr. Chang uses a detailed graph to help his patients understand his recommendations about when to switch treatments. “I have a graph that shows the patient’s age and other key factors for her fertility charted with the success rates for IUI and IVF,” he says. “It really helps my patients to be able to see the data clearly and get a big picture perspective.”

For most patients, success rates for IUI drop off after 3 unsuccessful cycles. “Again, I use age as a guide. If the couple is young and they want to try a 4th cycle of IUI, I would support that decision. But with older couples, I’ll try to show them how the decline in success rates correlates to age and advise them to be more aggressive about moving to IVF.”

IVF is the most successful treatment a couple can do using their own eggs and sperm. IVF is also one of the few treatment options where success rates have gone up over time due to technological advances. Women under the age of 35 have a 50% chance of getting pregnant on their first cycle. However, about 59% of women undergoing IVF will have remaining high quality embryo(s) to freeze for a subsequent frozen embryo transfer (FET).

Moving on to donor egg

Some patients, especially those who are over 40 or have other medical conditions that reduce the quality of their eggs, go straight to donor egg treatment. For most patients, however, the move is a result of not having success with IVF. “For these patients, it can be a hard transition, especially if they are younger,” says Dr. Chang, “but the upside is that their chances of success can jump to over 50% when they move to donor eggs.”

For women unable to conceive using their own eggs, donor eggs allow for a woman to carry a child that is genetically linked to the male partner. Donor egg treatment also offers the highest pregnancy and delivery rates of any fertility treatment because the donated eggs come from women between the ages of 21 and 32 which coincides with these women’s peak fertility. Patients using donor eggs at Shady Grove Fertility have a 51% live birth rate with each transfer.

Extensive personal and medical histories are provided on every donor. Once a donor is chosen, the cycle is quite simple for the donor egg recipient. You will take medications that prepare your uterine lining for pregnancy. The male partner will provide a semen sample that will be used to fertilize the donor eggs. Once the embryos are ready, an embryo transfer will take place.

Keeping the big picture in mind

When thinking about moving to another form of treatment it is important to consider how many cycles you have attempted, your age, and the guidance from your medical team based on their data driven decisions. “My advice is to consider the statistics but to do what you feel is right for you and your family,” says Dr. Chang.

He adds, “It’s unlikely that you will need all the options available to you, but if you have a sense of the big picture from the very beginning, it will be easier for you to stay positive and keep moving toward your goal.”