Medical Contribution by: Shruti Malik, M.D.
As a busy New Year begins, it’s easy for important things to get pushed further and further down our “to do” lists. With new resolutions, new gifts, and new plans, doctor visits and consultations can easily become one of those items that we keep putting off, especially if we know we’re at a crossroads and a decision needs to be made about transitioning to a new infertility treatment plan. However, because we know fertility potential is largely affected by a woman’s age, it is important to evaluate or reevaluate your plan accordingly before too much time passes.
When is it time to see a fertility specialist?
On average, it takes a couple 5 to 7 months to conceive.
From a biological point of view, women in their 20s have the highest chance of naturally getting pregnant. For women who are under 35 with regular cycles, we encourage patients to try to conceive for up to a year prior to seeing a specialist. For women who are 35 to 39 with regular cycles and no pregnancy after 6 months or women who are 40 or over with no pregnancy after 3 months, we recommend an initial evaluation with a specialist.
In some patients, it may be beneficial to consider an evaluation even earlier. SGF physicians recommend a baseline fertility work-up when women have:
- History of irregular menstrual periods or absent periods
- Previous abdominal or gynecological surgery, pelvic inflammatory disease (PID), or other sexually transmitted infections (STIs)
- Known structural abnormalities of the uterus or other reproductive organs
- Endocrine (hormonal) disorders such as thyroid disease
- Pituitary tumors or hyperprolactinemia
In the 6 to 12 months prior to seeing a specialist, it is reasonable to consider tracking your cycles. One commonly used app we would recommend is Glow, and it’s is free to use.”.
The initial visit includes a basic work up for both partners. The results will help your physician determine where your treatment plan should start.
At Shady Grove Fertility, while it depends upon your diagnosis, we believe in a stepped approach to care, starting our patients with the simplest, most affordable treatment options first. Your physician will only recommend transitioning to a more advanced treatment if it is absolutely necessary—and you and your physician will make this choice together.
Five basic treatment options used by patients are:
- Clomiphene citrate (clomiphene, Clomid, Serophene) with your OB/GYN
- Clomid (an oral medication that helps treat irregular or absent ovulation) is often the first step in most treatment plans, usually when under the care of an OB/GYN. While it can definitely prove successful for some women, data shows that after three to four cycles, the success rates drop off dramatically, even if a woman is ovulating [i]. If she is over 35 or if the couple’s infertility is unexplained, data shows that she should move on even sooner. Studies demonstrate that it is also more cost effective to transition to more advanced treatment, rather than continue with Clomid, after three to four cycles.
- Monitored Clomid cycle with timed intercourse
- If you started Clomid with your OB/GYN and have since transitioned to a fertility specialist, your fertility specialist may decide to continue with Clomid along with monitoring, bloodwork, and an ultrasound. This usually involves two to five monitoring appointments to ensure you are responding to the Clomid and trigger ovulation.
- Non-medicated cycle with IUI (intrauterine insemination)
- This is another treatment option for couples who may not require ovulation induction or would prefer not to use Clomid or other ovulation induction medications. This is a reasonable option for couples with mild male factory infertility, as insemination places the sperm in the upper portion of the uterus, and thus, closer to the egg.
- Ovulation induction (OI) with IUI
- This is a combination of treatments. Clomid is used to induce ovulation and then the IUI procedure takes place at the optimal time. IUI with Clomid can be useful because Clomid can have an effect on cervical mucus by making it thicker and harder for sperm to penetrate. The IUI bypasses this issue by directly placing the sperm in the upper portion of the uterus.
Injectable medication cycle with IUI
- An injectable medication cycle can be used for women who may have diminished ovarian reserve or certain hormonal disorders, rendering Clomid relatively ineffective. This takes the place of the Clomid, and then the IUI is performed at the appropriate time, placing the sperm in the upper portion of the uterus.
When is it recommended to transition to IVF (in vitro fertilization)?
But what if you have tried all of this? For the majority of patients, success rates with IUI are significantly lower after three cycles. If a younger couple, or woman, wants to try a fourth cycle of IUI, a physician will likely support this decision, depending on the individual diagnosis. But for couples over the age of 35, there is a correlation between the decline in success rates and advanced age (regarding the quality of eggs and the quality of sperm). This may be the time when you should consider IVF or your physician will advocate switching treatments to IVF.
IVF is the most successful treatment a couple can do using their own eggs and sperm. It is also one of the few treatment options in which success rates have increased over time due to technological advances. In 2014, at Shady Grove Fertility, women under 35 had a 53 percent chance of taking home a baby, and women 35 to 37 had a 47 percent chance [iii].
Additionally, many women undergoing IVF will have remaining high-quality embryos to freeze for future frozen embryo transfers (FET), providing patients with many chances for success or the ability to return for additional children later on.
Another part of this process applies to women who are unable to use their own eggs for conception, but can still carry a child in their uterus.
When is it recommended to transition to donor egg treatment?
A physician may recommend donor egg treatment for women who have decreased ovarian function, premature ovarian failure, or genetic abnormalities. Similarly, a physician may recommend donor sperm if the main reason is severe male factor infertility. The majority of couples who undergo donor egg treatment, though, have usually tried other infertility treatments and were unsuccessful.
Donor egg treatment offers the highest pregnancy and delivery rates of any fertility treatment, as the donated eggs come from women between the ages of 21 and 32, which coincides with a woman’s peak fertility. In 2014, donor egg recipients at Shady Grove Fertility had a 62 percent clinical pregnancy rate per embryo transfer and 46 percent of couples took home a baby [iv].
Navigating through Your New Infertility Treatment Plan
It’s important to understand all of the care options available to you. You are your best advocate. Be sure to talk with your physician about the best path for you. Most patients will not need all of these options, but it is important to be aware that they exist and to let them guide you in your decisions about treatment transitions. If you are considering starting treatment or moving to the next step, consider how many cycles you have attempted, your age, and the guidance from your medical team based on their data-driven decisions. But most of all, do what feels right for you and your family. We, at Shady Grove Fertility, will be there with you every step of the way.
Haven’t started your infertility treatment plan? Take the first step and learn more about fertility treatment. Click to schedule an appointment with one of our physicians or call our New Patient Center at 888-971-7755.
[i] Use of clomiphene citrate in infertile women: a committee opinion. Fertility and Sterility. Vol. 100, No. 2, August 2013. http://dx.doi.org/10.1016/j.fertnstert.2013.05.033. (Accessed: 12 January 2016)
[ii] Reindollar, R, Regan M, Neumann P, Levine B, Thornton K, Alper M, and Goldman M. A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial. Fertility and Sterility [serial online]. 2009. Available at: http://www.fertstert.org/article/S0015-0282%2809%2900866-8/abstract. (Accessed: 12 January 2016).
[iii] In Vitro Fertilization (IVF) Success Rates. Pregnancy rate per transfer May 2015. Shady Grove Fertility Center Laboratories in Rockville, MD., Towson, MD, and Chesterbrook, PA. Available at: https://www.shadygrovefertility.com/treatments-success/advanced-treatments/in-vitro-fertilization-ivf (Accessed: 12 January 2016).
[iv] Donor Egg Success Rates. May 2015. Shady Grove Fertility Center Laboratories in Rockville, MD., Towson, MD, and Chesterbrook, PA. Available at: https://www.shadygrovefertility.com/treatments-success/donor-gestational-carrier/donor-egg (Accessed: 12 January 2016).