Let It Snow, Let It Snow, Let It Snow

Here I sit on a Wednesday afternoon watching DC clear out in anticipation of a "major snow event." In the mid-Atlantic this means that a snowflake may be spotted somewhere on the Beltway. I just returned from Boston where I spent a long weekend visiting my parents. As some of you may recall, Boston was hit with yet another major snowstorm last Friday (8-10 inches). Amazingly enough, we left DC on time Friday PM and I don't think that the kids in Boston even got a snow day! It was pretty impressive to see how clear the streets and sidewalks were within a few hours compared with the days of paralysis that we experience here. Oh well. As the Boy Scout motto says...."Be Prepared!" It helps to have a lot of snow removal equipment.

I am pleased to report that my parents continue to amaze us all with their resilience. Both are 87 years old and honestly I really thought that they were in trouble this past summer. My Mom can no longer climb up to the second floor of her house so she has dropped off of the list of active readers of this blog....that leaves 4....


The highlight of the weekend was a party for my older brother Steven who is off to Vermont to become the CEO of a small hospital in the Green Mountain State. There were 50 guests crammed into his home in Newton and it was fun to see cousins that I hadn't seen in years. Yours truly gave a heartfelt speech lauding my brother's accomplishments. My Dad, in true general surgeon form, first called me his "most verbose" child and then followed it up referring to my brother as "accomplishing more than I ever thought possible given how he was as a teenager..." Oh well. Perhaps verbose is accurate as here we are in the 3rd paragraph and you have learned nothing more about reproductive medicine.

So back to reproductive medicine....One pretty consistent truth about fertility treatment is that the treatments that are cheap and easy and require minimal effort don't work as well as those that are more expensive and more intense. However, some patients are ready for intense therapy and some cannot afford it. Also, some insurance companies mandate IUI before IVF so there are many factors that go into the decision to undergo an IUI treatment cycle. So how are the chances for success? Well, that is an excellent question....so excellent that it is today's Question of the Day from the 2nd Edition of 100 Questions and Answers about Infertility...

39. What are typical pregnancy rates for IUI?

The pregnancy rates for IUI vary widely, depending mostly on the female partner’s age and the presence or absence of any other infertility factors. In patients younger than 35 years old, an estimated one-third to one-half of patients will achieve pregnancy within 1 to 4 treatments. In patients with unexplained infertility, most studies demonstrate a per-cycle pregnancy rate of 6% for the Clomid/IUI combination and 9% to 12% for the gonadotropin/IUI combination, compared with a spontaneous pregnancy rate of less than 5% per month. Many fertility doctors will try 1 to 4 cycles of Clomid/IUI and then 1 to 4 cycles of gonadotropin/IUI. If pregnancy has not occurred after the fourth treatment, most experts would abandon these treatments and proceed with more aggressive therapy such as in vitro fertilization. The optimal number of IUI treatment cycles should be individually determined by the patient and her infertility specialist.

Some patients develop a seeming resistance to fertility medications, demonstrating reduced responses with repeated stimulations. This problem is especially prevalent in women who are more than 37 years old. Thus IVF should be considered as a first-line treatment in these patients as opposed to multiple gonadotropin/IUI cycles.

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New Year's Resolution

So making my New Year's Resolutions on January 20th is probably not a good sign when one of my resolutions is to stop procrastinating....oh well. I hope that all of you are doing well in this new year of 2011. I think that once you get over the hill you start to pick up speed....that is the only way that I can explain how I managed to get to the 3rd week of January with no additional blogs.

My New Year's Resolutions involve the usual assortment of health related issues as well as being a better parent/spouse/friend/doctor/church member etc. In terms of this blog, however, I resolve to get through all 100 questions from the 2nd Edition of 100 Questions and Answers about Infertility before 2012!

So without further ado here is Question 38....and this question about the use of IUI is commonly asked as most patients would prefer less intense therapy compared to more intense therapy if they could be successful. Of course, if I knew who was going to conceive and who wasn't then I would be God and wouldn't have to come to work anymore.....

38. How do I know if IUI is an option for me and should I use fertility drugs in conjunction with an IUI?

IUI is a good option for many infertile couples. It can be performed in conjunction with a woman’s natural cycle or can be combined with the use of fertility drugs. IUI can also be effectively used in couples who have sexual dysfunction or infrequent coitus for either medical or nonmedical reasons. For example, some couples may have busy work schedules such that one or the other partner is frequently out of town around the time of ovulation. If the male partner’s sperm is obtained and cryopreserved (frozen) in advance of ovulation, the physician (or nurse) can perform an IUI and, ideally, facilitate pregnancy without the woman missing a menstrual cycle.

The best candidates for IUI are those couples without tubal disease (female partner) or severe male factor infertility (male partner). Women with severe endometriosis or a history of pelvic adhesions are not good candidates for IUI. Although couples with male factor infertility can attempt IUI, the success rates are fairly low in such cases, and prompt consideration should be given to IVF (and ICSI) if pregnancy fails to occur after three or four attempts.

IUI in combination with fertility medications may provide a reasonable treatment option for some patients. There appears to be a synergistic benefit to the combination of fertility medications (either Clomid or injectable gonadotropins) with IUI compared to either treatment by itself. For this reason, most infertility experts recommend IUI to their patients when treating them with fertility drugs even if the semen analysis is normal.

In women who fail to ovulate regularly, the goal of drug therapy is to induce the growth and release of a single mature egg. This treatment is known as ovulation induction. In contrast, the treatment goal for women with regular menstrual cycles is to induce the growth of multiple follicles with the subsequent release of multiple eggs. Hence the term superovulation (also called controlled ovarian hyperstimulation) is used to describe this treatement. During a cycle of superovulation and IUI, the goal is to develop 3 to 5 mature follicles, whereas the goal in an IVF cycle is to produce more.

Clomid is usually the fertility drug of first choice for both ovulation induction and superovulation with IUI. Women who fail to respond to Clomid or who fail to conceive may be candidates for treatment with injectable fertility medications (gonadotropins) combined with IUI. In some cases, it is best to skip the treatment with Clomid and instead proceed directly with gonadotropin therapy; this decision depends on the severity of the couple’s infertility situation.

In women who have normal menstrual cycles, it would appear on the surface that IUI alone without fertility drugs would be as successful as IUI with fertility drugs. Unfortunately, this simply is not the case. Instead, the combination of IUI and fertility drugs to induce superovulation yields a synergistic benefit over either treatment alone. However, superovulation (either with or without IUI) can lead to multiple pregnancy. Historically, nearly all of the multiple multiples (such as sextuplets and more) have been the result of superovulation. Unfortunately, there is really no way to control the outcome of this game of reproductive Russian Roulette. Patients must understand that if there are more than two follicles present then the possibility of a high order multiple pregnancy is a reality. In such cases a frank discussion needs to be held with the patient to review the risk and alternatives to avoid a poor outcome.

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