So you've been trying to get pregnant for a year (or if you're over 35, six months) and it's just not happening. It isn't surprising that you may think you are headed straight for IVF since In Vitro Fertilization (IVF) is the most talked about fertility treatment option. However, your fertility journey will likely begin with tests followed by one of several low tech treatment options.
When I meet with patients they are often times surprised to learn that 50 percent of all treatments preformed are low tech and that there's a chance they may not even need to undergo an advanced treatment option like IVF. Since before the advent of IVF, several effective known low tech treatments options have been helping patients get pregnant. The testing process can begin with your primary care physician, gynecologist, or at a fertility center like my practice at Shady Grove Fertility. The fertility of both the female and male partner should be evaluated. For the ladies you will likely start with blood work drawn on the third day of the cycle. This blood work will assess the hormone levels necessary to produce quality eggs for fertilization. During this same time period you'll also have an ultrasound which will measure the ovaries and uterus looking at the number of follicles the ovaries have recruited called an astral follicle count (AFC). The AFC is a measure of your ovarian reserve, or how many eggs you have. Anti-Mullein Hormone (AMH) is a newer blood test that can help determine the status of a woman's ovarian reserve. This hormone is produced by the immature small follicles in the ovaries, so the higher the AMH level, the higher the number of remaining follicles, or ovarian reserve. AMH levels can be evaluated at any point in a woman's cycle. For more information about day three testing check out these common questions. Additional tests include a hysterosalpingogram (HSG) to look for abnormalities in the uterine cavity and make sure your Fallopian tubes are open and a semen analysis for the male partner to check the sperm quality. The semen analysis is particularly important as it is estimated that 40-50 percent of infertility is due to a male factor. It is for this reason no one should start fertility care without a completing a comprehensive semen analysis.
Once testing is complete appropriate treatment can begin. For women who don't ovulate regularly the most common treatment is a low tech option, an oral medication called Clomid (full name is clomiphene citrate). Clomid is used to induce ovulation and should only be used in conjunction with ultrasound medical monitoring to reduce the risk of multiples and better predict the time of ovulation. When beginning treatment, Clomid can be paired with intercourse timed around suspected ovulation. Clomid can be a very effective treatment resulting in 85% of women ovulating and approximately 43 percent success rate in up to 3 cycles but studies have found a significant decrease in potential success after the 3rd month of Clomid so it is important to transition treatment in a timely manner (A decade's experience with an individualized clomiphene treatment regimen including its effect on the postcoital test. AUGysler M, March CM, Mishell DR Jr, Bailey EJ SOFertil Steril. 1982;37(2):161).
For a patient with a diagnosed mild form of male factor infertility no medication may be required (Cochrane Database Syst Rev. 2000;(2) Timed intercourse versus intra-uterine insemination with or without ovarian hyperstimulation for subfertility in men. Cohlen BJ1, Vandekerckhove P, te Velde ER, Habbema JD). Since the problem is with the partner's sperm a non-medicated cycle with IUI (intrauterine insemination) can be effective. IUI is a 1 to 2 minute procedure where a very small catheter with a concentrated amount of sperm is placed directly into the uterus in close proximity to the eggs thereby increasing the chances of conception. This simple procedure can be done in the doctor's office, does not require anesthesia, and is often times covered by insurance.
For every low tech option there is always a step forward to enhance that effort before moving on to something more advanced. In the case of IUI if the initial procedure does not result in pregnancy a patient does not necessarily have to give up on that treatment. The next step will be to incorporate injectable medication with the cycle. This medication will stimulate the ovaries to produce two to four eggs and when combined with the IUI procedure there is an increased chance of conception. This treatment is monitored closely by ultrasound to ensure against multiples.
While you should be relieved that there are many options before IVF, there are a few words of caution I can offer. First, after a certain number of IUI procedures the chance of conception begins to decrease. Second, the rates of pregnancy for IUI are not as high as IVF which offers about 40 percent chance of success across all age groups. Finally, a woman's age is one of the most important indicators of what treatment will be recommended by her physician. Success with fertility treatments drop dramatically after 35 years of age falling to almost zero in women over 45 unless donor eggs are used. As a woman ages she may not have time, in terms of reproductive years, to spend on less aggressive treatment. While the patient ultimately sets the pace it may be suggested to move to a more advanced therapy sooner rather than later. However, it is important to remember that whatever course your fertility journey takes you on, the expertise and technology does exist to help lead you to parenthood.