NEWS

Considering Infertility Treatments
Posted by: Editor on Nov 09, 2009 in News

This information is provided to patients concerned with the issue of fertility. This problem affects up to 15% of all couples, and more often among women over the age of 34. CNY Fertility Center offers services in Albany, Syracuse, and Rochester, NY. CNY Fertility Center provides a range of diagnostic services. All treatment options are offered including IVF in a low cost setting.

If you are considering treatment in trying to get pregnant, you may be in discussion with your medical staff regarding your specific prognosis (diagnosis) or chances of success. In all situations the individual patient is a major factor in the outcome possibilities. For example after IVF, younger, good prognosis patients will often have extra high quality embryos which can be frozen. This gives them a low cost second chance at another pregnancy through the use of frozen embryos. Low prognosis patients rarely have extra embryos to be frozen.

The couple entering IVF treatment will be involved in an intense daily journey, and expectations for their outcome need to be realistic. The most important fact is to remember that assisted reproductive technology (ART) offers the highest chance for pregnancy. Typical monthly spontaneous pregnancy rates among infertile couples may be as low as 2% per cycle. For some couples, even low prognosis rates of 5-10% are an improvement on Mother Nature. IVF and related variations are available because of intense investigations in the field by many laboratory and clinical scientists since the mid 1970’s. All of this knowledge is available to help you in this journey. Success rates in one month can approach 40-50%, in the best circumstances.

Beginning ART treatments can be compared to watching the effects of rain in the desert. Most of the year the desert is harsh and dry and its beauty is subtle. Yet after a rain, many cacti and succulents bloom with colorful flowers in order to attract pollinating insects or birds. Awareness of the specific odds of success for the couple will be helpful emotionally.

The prognosis will be discussed with you by your doctor. This will relate to the data available in your situation, which predict the number of eggs and embryos which will be produced. More eggs and embryos translate to improved success. Lower numbers often parallels lower quality eggs and embryos as well. The most difficult problem is the positive pregnancy test that occurs in the low prognosis patient who also faces pregnancy loss rates as high as 50%.

The prognosis will determine the dosage of medications used in conventional IVF. It will also indicate if a cycle may need to be canceled. When the patients response is lower than expected it may be advised that treatment cease and another attempt be made. Overlain on all of the emotional stress are the financial aspects of the possible cost of multiple attempts to conceive.

Advanced age is well known as the major adverse factor, but since the average age of patients considering IVF is in the mid 30’s it is part of the reality for many of them. The age of the female partner generally reflects the quality of the eggs.

Other factors can be considered in making a prediction of level of success. The most time tested method of determining the prognosis for IVF or IVM is a consideration of a combination of the age of the female partner and certain hormone levels measured during the menstrual period. The serum estrogen levels can be elevated and will suppress the FSH and lead to a falsely low reading of the FSH level. The normal levels of estradiol, the dominant estrogen, are below 65 to 80 pg/ml.

FSH levels gradually rise as a woman nears menopause. The FSH level is the measurement is most often done on day 3 of the cycle, but may be done on day 2-4 and achieve the same results. Ideally this level in many centers is below 10 miu/ml, but this cut off number varies.

None of the studies on FSH have been able to identify an absolute value for prognosis, according to analysis of 21 studies (Bancsi, 2003). The upper end of normal is often stated to be 10 miu/ml but may range up to 15. This will vary from lab to lab. Thus your doctor cannot tell you exactly where you fit. In discussing prognosis, most often patients find themselves to be in a gray area. The higher the number is, the darker the shade of gray. Older women who have high FSH can be more certain that this test is spelling trouble. A fair number of younger women with high FSH can do well and conceive with IVF. The FSH is most predictive of the number of eggs available and less predictive of their quality.

Research into more direct assessment of the number of eggs in the ovaries has come to the forefront. The hormones inhibin and AMH have been correlated with IVF outcomes in pregnancy or embryo quality. All these complex measurement have been factored into an index by Reprosource. This Ovarian Reserve Index uses all the biochemical markers discussed, considers the age of the woman and distills the data down to one number. It is the least variable from month to month and if combined with the AFC should be the most reliable guide to prognosis.

There are a number of other measures which have been applied and depending on the doctors and clinics may or may not be used in your case. The clomiphene challenge test is an extension of the effort to identify women who have elevated FSH values. This is addressed in a separate article on this website. Ultrasound measures of antral follicle count and more recently, ovarian volume have been helpful.

These other measures of prognosis will be discussed separately and if interested you may click onto these sections.

The cost of IVF therapy for a woman age 35 can be estimated according to her FSH level. The cost of a live birth was estimated in 2002 at $28000 if the FSH was under 10 IU/L and $37000 if over that number. At age 42 with normal FSH the cost was estimated at $122,000 and $309,000 if over 10 IU/L. The numbers would be higher today, but the relationships would be similar. Low cost IVF options are needed for women in the lower prognosis category as well as the young ones.

Previous stimulation – If a patient has been through gonadotropin therapy for IUI or in a previous attempt to conceive by IVF, her doctor has the best possible predictor of her response in subsequent treatment. All bets are off once the number of follicles is counted and the numbers of eggs and embryos are available, then the predictor tests take a back seat to the reality show. How do these ovaries respond under pressure? Once this is established, the numbers mean less.

Selected references

Bancsi et al. Fertil Steril 2008

Sun W et al. A new approach to ovarian reserve testing. Fertil Steril 2008; 90: 2196-2201

Wunder Dm et al. AMH and inhibin B as predictors of pregnancy by IVF ICSI. Fertil Steril 2008; 90:2203-09

Jbm rev 9-22-09

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