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“˜Diminishing Returns’ With Successive Fertility Treatments

August 5, 2010

A new study by researchers at the University of California-San Francisco (UCSF) finds that successive attempts to become pregnant using fertility treatments may produce diminishing returns after two or three tries.

The research may help couples trying to conceive determine the number of cycles of a certain type of fertility treatment they should undergo before moving onto other types of treatments, the researchers said.

A variety of options are available to treat fertility problems, depending on the underlying cause of infertility.  For instance, women with ovulation problems may turn to fertility drugs that stimulate the ovaries to produce and release eggs. 

Other options include intrauterine insemination (IUI), where a catheter is used to place sperm directly into a woman’s uterus.  IUI, which is frequently used in addition to fertility drugs, may be used in situations where the man has certain fertility problems, such as low sperm count, or when the underlying cause of a couple’s failure to conceive is not known.  

Another option is in-vitro fertilization (IVF), a procedure where a woman’s eggs are fertilized in the laboratory and the resulting embryos implanted in the uterus days later.

In the current study, researchers analyzed the rates of success with these three types of treatments in 408 couples with fertility problems.

Among all the couples, 21 percent did not use any of the three treatments, although some had other non-cycle based procedures, such as surgery to remove uterine fibroids.

Overall, the pregnancy rate among this group was 28 percent over 18 months.

By comparison, couples who had undergone one to two cycles of fertility drugs alone had a pregnancy rate of 85 percent.  Those who underwent one round of IUI treatment had a pregnancy rate of 71 percent, while 59 percent of those using IVF became pregnant after one cycle.

However, the researchers found that the benefit of each of the three fertility treatments declined after a certain number of attempts.

The six couples who had gone through three or more cycles of fertility drugs alone had a pregnancy rate of 29 percent, while the advantage of IUI over no cycle-based treatment was non-existent after the third attempt.  Similarly, the advantage of IVF was no longer observed after the second attempt, with just 35 percent of the 52 couples who underwent three or more attempts becoming pregnant.

The study’s findings, along with those of previous research, suggest that individual treatments have “diminishing success” over time, said lead researcher Dr. James Smith during an interview with Reuters.

“Medications only, IUI and IVF are all effective treatment choices, but their benefits don’t continue indefinitely.”

“If couples are not getting pregnant after several cycles of each, a change to a different strategy is probably warranted,” said Dr. Smith, an assistant professor of urology at UCSF.

A number of factors are involved in selecting a fertility treatment, such as costs and intensity. 

IVF is more intensive than either drugs or IUI, and includes daily injections, additional clinic visits and discomfort, Dr. Smith explained.

Not surprisingly, the costs are far greater for this form of treatment.   For instance, among the couples involved in the study, the average cost of medication-only cycles over 18 months was about $1,200, compared with $3,600 to $8,600 for 18 months of IUI, and $24,000 total for IVF, Dr. Smith said.

The average cost for one IVF cycle is $12,400 in the United States, according to data from the American Society for Reproductive Medicine.

Whether or not the treatment is covered by insurance varies according to the type of plan and where the patient lives, since states have varying laws regarding coverage of fertility treatments.

But couples should weigh the greater intensity and costs of treatment against the diminishing chances of success and associated emotional consequences of continuing with a less-intensive treatment that has so far been unsuccessful.

As a general rule, however, the per-cycle success rate is greater with IVF than with IUI, Dr. Smith said.

Couples who do not become pregnant after two cycles of IVF still have some options, and might consider using donor eggs or sperm, he added. 

The couples in the study’s IVF group did not use donors.

Altering a couple’s particular IVF “protocol” might also be effective, Dr. Smith said.

The study was published online July 26, 2010 in the journal Fertility and Sterility. 

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