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No Regrets with Fertility Treatment Decisions
a blog by Serena H. Chen, M.D., IRMS Reproductive Medicine at Saint Barnabas, January 10, 2012
Infertility is all about statistics and probabilities. For most people, the problem is that it is difficult to wrap your head around all the numbers.
Understanding the Statistics
Mother Nature is very inefficient — most eggs and sperm never make a baby. Fertile couples who are trying to conceive are more likely to be unsuccessful than successful each month – there is only a 15 to 20 percent chance of success and an 80 to 85 percent chance of not succeeding. The chances are cumulative, though, so if 15 to 20 percent of fertile couples conceive each month, then after three months 48 percent of people are pregnant, and by one year 85 percent of people are pregnant. For example, let’s say there are 100 couples trying to conceive. After the first month, 20 are pregnant. The remaining 80 couples continue to try, and 20 percent of them conceive the next month (16 couples). Now, after two months, 20 + 16, or 36 have conceived. The remaining 64 couples continue to try, and another 20 percent conceive in the third month, or 12 more couples. Now, the overall pregnancy rate for this group is 36 + 12, or 48 couples (48 percent). At the end of one year, only 15 couples have not conceived, and these couples officially meet the definition for infertility. (Remember, if the woman is 35 or older, the American Society for Reproductive Medicine (ASRM) considers you infertile after only six months of trying because age has such a dramatic effect upon fertility. Fertility specialists believe that older women should be evaluated earlier).
So, let’s say you come into my office, and you have been trying to conceive for two years, and you are 37 years old, and we do all the testing and find that you have unexplained — most likely age-related— infertility. After two years of trying with unexplained infertility, you could still conceive on your own. After all, the definition of unexplained means that all the ingredients are there: The sperm look OK, the tubes are open, the ovaries are making eggs, and uterus look OK. Your chances are now 1 percent per month – much lower than the normal 15 to 20 percent per month. This adds up to about 30 percent over the next two years, but by then you will be 39, and age will be even more of a factor at that time, making it more difficult to conceive, even with assistance.
So, what are the options? What about the fertility pill Clomid? (Clomid is the most well-known brand name, the generic name is clomiphene citrate.) Well, Clomid is very popular, but not so effective in this situation. Clomid is the first line of therapy in polycystic ovarian syndrome (PCOS), but it is used a lot in unexplained infertility, because it is cheap, easy and not as intimidating as those needles. The only problem is that Clomid alone is unlikely to improve your chances of pregnancy compared to nothing unless you are having some sort of ovulatory problem (like PCOS). Now, Clomid combined with IUI (intrauterine insemination) is another story — that will get you to a 5 to 10 percent conception rate per cycle, which is a big improvement over the 1 percent chance you have now, but still not really a “normal” level of fertility.
To get to that point —a 15 to 20 percent chance of conceiving each cycle — you need those injections. Injections and IUI will yield a 15 to 20 percent pregnancy rate each cycle for about four cycles before the success rate drops. However, the pregnancy rate with injections and IUI comes with a price — a much higher multiple pregnancy rate along with all the complications of multiples, including higher miscarriage, birth defect and preterm delivery rates. Clomid increases the chance of twins from the normal 1 percent to about 5 to 10 percent. The risk of triplets is much less than 1 percent with Clomid. However, with injections, there is a 25 percent rate of twins, and triplets and above becomes much more common, 2 to 4 percent risk or even higher. In fact, most of the triplets that you see are actually from injections and IUI, rather than in vitro fertilization (IVF).
IVF pregnancy rates per cycle are higher still. Although they can vary significantly depending upon the program and patient characteristics, the bottom line is that for any individual patient, IVF pregnancy rates are usually always higher than pregnancy rates you would achieve with all other treatments except egg donation. Although IVF is more costly up front, in the long run, it is much more cost effective. Many patients can achieve very high pregnancy rates with only a one or two embryo transfer, so complication rates can actually be significantly lower than with injections and IUI.
Bottom line: For most patients, IVF costs less per baby than any other fertility treatment.
The Numbers Only Tell Part of the Story
The numbers are nice to know, but people are not statistics. Ultimately, you are either pregnant or not pregnant. So what if this particular treatment has a 60 percent success rate if it does not work for you? After years of training, hundreds of papers and books read, many thousands of patients seen and cared for, what I really need and want as a physician is not statistics, but a crystal ball!
The couple who sits before me now would gladly go through a few more fertility treatment cycles if they knew with 100 percent certainty that at the end of all of those cycles, they would have a baby. As much as I want to, I cannot give them that answer. What if they go through so much work, spend so much time, undergo so much stress, spend so much money, and they come up with nothing? What then?
Deep breath, sigh. They are clearly anguished. They look at each other — what are we going to do? How will we decide? He is not totally sure it is worth it. They have one child via IVF, and he remembers how tough it was and is grateful for their beautiful little girl. He worries about his wife. The doctor says the drugs are safe, but what if the doctor is wrong? Maybe we should not push our luck, maybe we should just be grateful for what we have. And yet, he sees what his wife sees. Their little girl wants a sibling. They would love to give her a sibling. When they were younger and newly married, and their whole lives lay before them, they talked about having two or three or even four kids: how far apart they would be, what names they would have, would they go to private or public school. Now many years later, they have their one precious daughter, and they don’t really know if they can have another one. The doctor says it is worth a try, but is it really? How much of a try?
What can I say to this couple? Shall I continue to blather on and on about all the stats in my head? Do these stats really have any meaning on a personal, practical level? I have to tell them the truth — there is no right answer. Most couples have more than one option open to them – at the very least it is no treatment or treatment. And most of the time there is more than one treatment option. As the doctor, I tend to feel that the “best” option is the one with the highest per cycle pregnancy rate. That option is often IVF, which many patients do not consider a “best” option. If IVF is not covered by your insurance plan, it often becomes your “worst” option. If you are afraid of needles or are a devout Catholic, then IVF is not an option at all. I tell this couple: Here are your options, the final decision is yours. I review with them the details: all the statistics, all the probabilities: pregnancy rate, multiples rate, miscarriage rate, insurance considerations, time considerations, logistics, etc. Still, everything is as clear as mud. We still need that crystal ball.
It comes down to this: No Regrets. Until we find that crystal ball, No Regrets will have to do. You need to find the path that will allow you to have no regrets or at least no regrets that you cannot live with. You need to know, no matter what the outcome, good or bad, and let’s face it, we are talking about the bad outcome because who has regrets if things turn out the way you want them to? You need to be able to say: "I am glad I did it this way. I needed to do it this way. I have no regrets. Those three IVF cycles were worth it. They were really tough, but now I can move on to child free, adoption, egg donation, etc. Now I can move on because I gave it my all — I got the second opinion, I thought about it, talked about it, anguished over it."
You need to feel that you were true to yourself, and you did the right thing, regardless of the outcome. No Regrets. You don’t want to think back 10 years down the road and say, "I should have." No Regrets. Most people who seek help conceiving will eventually succeed, but what if you are not most people? No Regrets.