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Tuesday, January 13, 2009

Barren Advice: Twenty-Four

This is the 24th installment of Barren Advice. You can ask questions that are fertility or non-fertility related.

Barren Advice is posted each Tuesday-ish. If you have your own question for Barren Advice, click here to learn how to submit. Please weigh in with your own thoughts in the comment section and indicate which question you're addressing if there are multiple questions in the post.

Dear Mel:

I am writing to ask about IUI along with Clomid. Does this ever work for anyone? My fertility doctor recommends a few attempts with this approach, but she says it has a 5% chance of working, which is less than the standard statistic of 10% per month for a woman over 35. In my quick review of the blogs on your blogroll, none of them were successful with this approach, only with IVF. Our insurance does not cover any fertility treatments, so we'd rather not waste $ and time on a 5% chance!

--Anonymous and Blogless

If your doctor told you that you would have a 5% chance doing IUI with Clomid, a 10% chance doing IUI with Follistim, a 30% chance doing IVF, a 60% chance doing IVF with donor gametes, and a 99% chance doing adoption*, it would make the most sense to go with adoption. Except that you want to experience pregnancy so then it would make the most sense to go with IVF and donor gametes. Except that you'd like a genetic connection to the child you're carrying which means you should do IVF. Except that you're paying out of pocket for every procedure, so it doesn't make a lot of sense to start with the most expensive so you drop back down to the IUIs're back in square one staring at the statistics again.

The problem with success rates is that (1) you don't know which side of the percentage you're going to fall until you do the procedure therefore, looking at them is a lot like gambling and (2) success rates are not one-size-fits-all. You may have a 5% chance of an IUI with Clomid working, but another person may have a 30% chance of the same procedure working. Therefore, I throw all numbers out the window when making a decision because they're meaningless. Instead I look at the overarching facts associated with each procedure and what problems it can and cannot compensate for or overcome.

I'd look at diagnosis and age as your determining factors. IUI is great for a number of problems including mild male factor (not azoospermia), absence or acidic cervical mucous, and the ever dreaded diagnosis of unexplained infertility. It is not great for egg quality issues, high FSH, or uterine anomalies (though IVF can't overcome some of these issues either). This doesn't mean that IUI doesn't work if you have egg quality issues, but what I'm saying is that it isn't a procedure that is meant to circumvent that problem. Therefore, I'd take a look first at your diagnosis and consider whether or not IUI is being thrown at the problem because it's less expensive but it isn't truly the best fix.

The other thing I'd look at is age. I'm assuming from the wording of the question that you're over 35. What you would try if you were 25 is very different from what you'd try at 35, especially if you would like to have another child after the one you are trying to conceive. How aggressive I'd be would depend on how far over 35 you are (40? I probably wouldn't spend a lot of time with IUI. 36? I may give it more consideration) as well as the hormone levels on your day 3 blood work.

I think one problem is that the choices aren't (or shouldn't be) just IUI with Clomid or IVF. You could try a few combinations of injectable drugs with IUI, for example. Even with IVF, there are a multitude of protocols your doctor could follow--some more aggressive and more expensive than others. The protocol is chosen based on a host of factors.

I feel for you because we don't have coverage either so almost everything is out of pocket. You don't want to spend more than you have to and you don't want things to be more invasive than necessary. But at the same time, you don't want to waste time.

I guess this is the analogy I would use for making the decision. You dated a lot of people (I'm assuming) before you met your partner. And those past relationships not only gave you information that made your current partnership more successful, but they also were educated tries along the way. If you had known they wouldn't work out, you probably wouldn't have spent the time just as if you know a procedure won't work out, you probably don't want to spend the time (and money). But every cycle gives your doctor more information--from how your body responds to drugs to how your uterine lining grows. And that information may be what makes your first IVF successful vs. gathering some of this information with your first IVF cycle before you go on to the next one. Every relationship gives you information too--so those old relationships that didn't work out weren't truly a waste of time.

In other words, it is the difference between dating around with low stakes rather than jumping straight into marriage with the first person you meet and either having it work out or having to go through a messy divorce.

I will state this clearly here: sometimes, you don't have a choice with what you try first because diagnosis dictates a clear-cut solution (or a best solution). It sounds as if the playing field is open to you because you don't have a diagnosis that points in a single direction. Therefore, I'd always choose low-key over invasive. You may hear from people below that they have regrets that they tried the IUIs because they didn't work or you may hear from people who are ecstatic that they tried IUIs because they did work. Either way, their experience is their experience and not a prediction of your experience. You may not have regrets if you have some IUIs that don't work if they streamline your first IVF cycle. Or you may have regrets if you have limited funds and you spend them on something that has a lower success rate (IUI almost always has a lower success rate than IVF).

Regardless, it's a decision you're going to have to make because it is a very personal decision but my advice is to always take the path where you'll have the least regrets while, at the same time, holding yourself in check with the regrets department by remembering that a negative cycle doesn't always mean a waste of time.

No really, the beauty of a blog advice column is that you get to weigh in with your two cents too. Let the questioner know if you support the advice, add to the response, or dispute it completely.

Leave a comment in the reaction box below--only keep in mind that conflicting advice is embraced and rudeness is not. Want to ask your own question? Click here to see what you need to send in order to be included in a future Tuesday's installment of Barren Advice

*all success rates are fictional. True success rates are based on a plethora of information and aren't one size fits all.


Guera! said...

I was facing even more dismal statistics when I went through IUI with Clomid and HCG. My doctor wouldn't even tell me the exact statistics because he knew I would consult the internet. My chances were less than 2%. All three rounds failed. But this is how I look at statistics. I am terrified of flying. If someone told me there was a 5% chance the plane I was about to board would crash there's not a chance in hell I would get on it. If I knew I had a 5% chance of winning the lottery you better believe I would buy a ticket. I'd love to know what you decide to do.

Cassandra said...

Personally I think most of my Clomid or injectables + IUI cycles were wasted time, but I also was not emotionally ready for IVF when I did my first round of treatments.

I do think it's very valuable to do at least one round of injectables prior to IVF -- since people respond so differently to the medication, it's worthwhile to figure out the right dosage for your body before jumping into IVF.

The cost-to-odds ratio also varies widely depending on how much you'd be paying for a Clomid + IUI cycle. I've always cycled with REs and therefore paid several thousand for each IUI cycle, but I know others who've paid only hundreds or even nothing (some are insured, and some figure something out -- for example, there's a practitioner in our area who does "creative" coding for insurance and gets all of her patients' IUI cycles fully covered).

There are IUI babies out there, so it definitely works for someone, but I think there are probably more people for whom IUIs never worked who then moved on to IVF -- sometimes after a few, sometimes after lots.

Best of luck, in whatever you decide.

Jess said...

I think that a pp made a good point about doing at least one round of iui/injectibles before IVF to show how you respond to the drugs. IVF is sooo expensive that it doesn't make much sense to go in blind.

I was YOUNG (think VERY early 20's) and had/have unexplained (think all checked out fine with both of us) IF and we did multiple (maybe 5-8?) rounds of IUI with no meds, IUI WITH meds like 4-6 times, and IVF twice, and an FET once...getting pg on the second fresh IVF. So statistics, as Mel said, DO mean very very little.

MY personal feeling would be skip the iui/clomid. If anything go for iui/injectibles a few times (my clinic reccomends 4 or less) before going onward.

Good luck!

Jess said...

**disclaimer....I DID get pregnant with iui/injectibles on our second shot, but I miscarried. I didn't get pg again till after an IVF, FET, and then one last IVF.

Anonymous said...

I was 30 when we started trying and had 1 m/c.A year later I went to a RE and he diagonised me with high FSH (13.5) and anovulatory cycles.He told me Clomid was not an option.I did 2 rounds if IUI + injectibles and became pregnant but it was an ectopic.After a 3 month break I did 3 more rounds of IUI none of them worked and my RE suggested moving on to IVF.

I did 2 IVF's but am a very poor responder.My first cycle of IVF got converted to IUI cos I ovculated early (even before retrieval) and my 2nd IVF I had only one egg fertilized and could tranfer only one which resulted in a BFN.I got frustrated and changed clinics.The new doctor wanted me to do clomid challenge and since he did not want me to waste a cycle he did an IUI.That is the cycle I got pregnant and am now due in a couple of weeks.Clomid worked the first time when that was not even an option with my old RE.

All I wanted to say is you just never know what'll work.Good luck with whatever you decide.

gwinne said...

Oh, statistics... I'm in a field where only 30% of people get jobs, but that didn't keep me from going into the field. A 20% percent chance of having twins seems like a whopping huge number (a risk I won't take) but a 20% chance of an IUI working is something I'll try. I think we make the numbers tell us what we want to hear.

As I read it--and I might be wrong--it's not clear from the question if the variable in question is the *clomid* or the *IUI*

luna said...

mel, I think your answer here is dead on, couldn't be more perfect.

of course I can only say how I felt spending time and money doing 4 IUIs in 6 months before moving to IVF. yes, my RE learned how I responded to injectibles, which was good. but we spent 6 months and a few thousand dollars doing treatments that probably never would have worked for me. did we have to try them? at the time, yes we felt we did. they were the least expensive and least invasive options. but once you hit your late 30s and you're on a budget, time and money are the most precious resources. only you can determine those priorities.

I fully agree with mel though about ignoring the odds. they really don't mean much to me in decision-making anymore.

holly said...

I'm on the blog roll and did 4 clomid IUI's and each of them "worked". I only ovulate when taking clomid. My bigger problem is staying pregnant.

Clomid IUI's are cheap, and they do work, sometimes.

Ellen K. said...

In my own experience and observation of many IRL and online friends, the big problem with multiple IUI cycles is not the low success rate, but burnout. IUI cycles may be less expensive but they can be quite exhausting with all the monitoring and ovulation testing. And you can get really bogged down in trying out different medication combinations. My recommendation to anyone considering IUI would be to give it one or a few tries, but definitely no more than 4 total (not 3-4 with Clomid and then 3-4 with injectables), especially if you are older than 35 and paying out of pocket.

IUI does work for some, but it frustrates many others.

Good luck!

Anonymous said...

Mel, thank you so much for answering my question in so much detail and with so much compassion. Thank you everyone for your comments and personal stories.

Since asking this question, I've found out how much IVF costs without insurance, and it's pretty much out of our reach no matter what. So we will probably do at least one clomid/IUI cycle. My RE has a very strict progression of approaches, so we couldn't do injectables before clomid, and can't do clomid without IUI. It's frustrating, but you all know that!
--Anonymous and Blogless

WiseGuy said...

Hey there Mel, I have nothing earth-shaking to add to your advice, since I have a track record of always falling on the other side of the statistics.

Anyhow, Congratulations in advance. I checked the numbers on the Weblog Awards and there is a clear winner - YOU! :)

KimboSue said...

We did IUI with Clomid, Menopur, and Follistim and were successful. We did not have to go the IVF route, so there is always a chance of you getting a BFP on IUI alone!

I do not ovulate, have mild PCOS and DH has low count.

Wishing 4 One said...

As always great barren advice Lolli!

I think you are a winner too, lets declare it early... you are leading with 34.6% !!!!

ms.bri said...

Me! Me! I am a Clomid/IUI success story.

The decision was different for us since we used donor sperm. So IUI as a starting point was the normal thing - there were no "natural" tries to be had. I did 5 unmedicated IUI's before I started Clomid. I got pregnant the second try with Clomid, miscarried, then got pregnant again the next time we tried with the same protocol - that time resulted in my son!

My protocol is seemingly unheard of by many people but worked. I seem to have a progesterone deficiency but instead of treating with suppositories (couldn't abide them) or pills (I tried both), they treated me during the Clomid rounds with a "booster" of HCG. At 6 DPO, I injected myself with the same HCG I used for a trigger shot. This told my body I was pregnant, I guess, and made me produce progesterone appropriately. I don't really know why it worked, but it did.

Flmgodog said...

I am obviously 1 of the 5% that got pregnant with Clomid and IUI. I had a host of other issues, one being RPL. So the getting pregnant wasn't a problem. We did win the biggest lottery with our daughter, 1st try with clomid and IUI. We only even did it because the Dr. told us to do a few cycles of it and then move on while we were doing other testing.

Anonymous said...

IUIs didn't work for us but I don't regret them because they were inexpensive.

I want to echo that your response on this was perfect, Mel!

Brenna said...

Such great advice! The RE we saw in Atlanta also had a fairly set progression of treatments (IUI with Clomid, IUI with injectibles, etc.) so I understand where you're coming from completely. We went through it, tried various IUI combinations and then finally ended up with IVF (we got pregnant on our first cycle, though sadly our babies came prematurely and didn't survive). I do feel a bit like we wasted time and money on the IUIs, particularly now that we know we need ICSI...but I understand why doctors start with IUIs and Clomid to see how women respond.

Aurelia said...

Well, as someone who suffers from RPL and ovarian failure, I can say that IVf is not necessary quite often.

I really do believe though that those stats would go much higher if people were appropriately tested for everything, (bloods, hsg, clotting issues) and even had a lap for endo and fibroid removal, etc...prior to any fertility treatment. Those are almost always covered by insurance, and in Canada are definitely covered.

I've just seen too many people waste thousands of dollars on IUI and drugs and IVF and then have miscarriages or high risk pregnancies that resulted in disaster.

For example, when I first started trying, my endo was in remission, but I had already had a lap, and knew to be on the lookout for problems. We were okay for the first pregnancy, but the second was a disaster, and I continued to have issues, not with conception but with maintaining the pregnancies.

DHEA, reversed my high FSH and let me get some improved eggs. Femara/letrozole kept them growing properly. Progesterone support helped my lousy luteal phase, and baby aspirin, and heparin meant I stayed pregnant with a good placenta.

None of that would have been solved with IVF.

That said, the issues with multiples in fertility pregnancies continues. Twins and triplets and higher order multiples are higher risk and happen more often with medicated IUI as opposed to IVF where you can control the number of embryos.

The Europeans, and possibly soon some provinces in Canada, are paying for IVF if people agree to single embryo transer just because it lowers the risks of multiples and the associated NICU costs.

Anyway, to anonymous, just get the right tests just in case you have RPL, and if you can't do IVF, then try not to get overstimmed and try not to do it when you are making lots of eggs, even if it's tempting.

babyinterrupted said...

We recently finished our 2nd failed IUI and honestly, I can't say I regret trying that. We knew that IVF had much better statistical chance of success. But I wasn't entirely ready to jump to IVF, and we wanted to at least try the less-invasive option on the off chance that it could succeed. I did get helpful information about my body's response to the protocol (Femera/Ovidrel), and I suspect that information will be useful now that we're going for IVF. It's such a personal decision, really, and there are valid arguments from every perspective. Best wishes in your decision making.

chicklet said...

I did clomid with IUI and while it didn't work for me, I was and am still glad I did it. It was way cheaper than IVF and less invasive, and gave us time to adjust to getting into bigger and bigger treatments which are much more emotional too. I'd do it again if given the choice. An IUI can be exciting and disappointing while an IVF can be terrifying adn devastating - exciting and disapointing were a better place for me to start.

jenn said...

I fall into that 5% also. I was set for a Clomid Challenge cycle (the last test in my REs battery before graduating to the 'bigger' stuff) We decided that if it was out of pocket $1000- it might as well be out of pocket $1400 for an IUI combo. It was the only shot we could really take for 6 months or so, and we were amazed & blessed it worked.
Even if it hadn't we would have done at least 3 IUI's with clomid before going to injects, then 3 of those, etc. Our clinic is a member of the 3 tries club.

Good luck with your decision- I don't really have any advice other than the clomid is cheaper, iui is also & less invasive, and if you have to save up that much for ivf you might as well try a few rounds of iui first if it makes sense for you.

oh- we are/were unexplained with perfectly clear & normal tests, great sperm counts & motility & just slightly below good morphology. I was 28 at the time

Sarah said...

i totally agree with the learning curve argument. i used to feel like i wasted a year on my 3 clomid IUIs and 2 injectable IUIs, but by the time i got to IVF we knew exactly what meds i needed to get the ideal response so in retrospect i feel the IUIs (though maybe i wouldn't have done quite so many) contributed to our getting lucky on the first IVF cycle. i also was just not ready to consider ivf before i felt we'd explored other options first.

Phoebe said...

Like some others said, I did one IUI first because I was not ready emotionally to do IVF. I was surprised how devastated I was when that failed. It was at that point that I was done screwing around with something that has such a low success rate. First IUI try for me was at age 40 with my husband's 13 year old frozen sperm. First IVF ended up being an expensive IUI, but we learned what protocol didn't work for me. I was on high stims, so an IUI with injectibles wouldn't have worked for me. I don't put much credence in statistics. When it happens to you, it's 100%.

SarahSews said...

We were unexplained, and both 31 when we started doing clomid IUIs. Our second one "worked" but the pg ended just as quickly as it began. We went on to do 3 femara + IUI cycles and one big bust of an injectables + IUI cycle before doing one last ditch clomid + IUI cycle before we stopped treatment. We could not afford IVF, we were unexplained and just out of energy. It didn't work for us but I know it has worked for others.

We ended up pg again a year after our last IUI. I miscarried again and got pregnant again without treatment. That third pregnancy resulted in our son. The odds of us getting pg on a given cycle after three years of TTC (1 year before treatment, one year in treatment and one year after treatment ended) without a live birth were 1% each cycle. That 1% is now teething.

Anne said...

What Mel said about age as a factor is undoubtedly correct. At 25 with some issues, none huge, IUIs with clomid are a good idea for us. They address our problems: annovualtion (the clomid works for me) and semi-low sperm count. They also are an expense that we can, at this point in the game, afford. From what everyone has said, if they don't work (we are on #2), we'll probably try injectibles, and then move on from there. I also hold out hope that they might learn something from these IUIs that will help them further diagnose any issues we have.

We, and most others, have to start somewhere, and I don't think with certian factors and age, that IUIs are a completely hopeless place to start. There are already a good number of success stories in the comments above mine. Thanks for addressing this concern, Mel.

Bea said...

There's a mathematical answer to this question and Mr Bea worked it out for us back in 2005 when we were considering treatments and it turned out that, for a natural IUI at our clinic's rates, we were better off doing them ONLY if the chance of success was OVER 5%. For clomid, a 5% success rate would have been in the "don't bother" category. This only works for our clinic's costs, though, you have to run the formula on your own clinic and I can't remember it.

Basically, he worked out that IUI was going to cost $x per % chance of getting pregnant, and IVF was going to cost $y, and if y was less than x then we would be financially better off gambling on IVF.

It is roll-of-dice stuff, though. It's like, anyone can win at blackjack without counting cards, but you'll tend to win better if you do.


Bea said...

P.S. This focusses heavily on finances, but failed are emotionally hefty as well, so in some ways in accounts for the emotional toll a bit, too - but that's a more personal equation.