SANTA BARBARA, CALIF. – Given the state of the economy, lower cost alternatives to in vitro fertilization appear to be gaining favor, spurring a look back into history at the potential for superovulation and intrauterine insemination to achieve pregnancy in infertile couples.
At a conference on in vitro fertilization and embryo transfer, an audience response survey found that 58% of the audience of more than 100 specialists reported that they currently performed more superovulation/intrauterine insemination (IUI) cycles than IVF cycles.
"Last year, it was a third" of the audience, said Dr. Bill Yee, medical director of Reproductive Partners Medical Group in Westminster, Calif., and a presenter at the meeting, which was sponsored by the University of California, Los Angeles.
Dr. Yee reviewed early papers on superovulation/IUI, including a series documenting a pregnancy rate of 16%/cycle in 85 patients (Fertil. Steril. 1987;48:441-5).
"That was damned good in the mid-’80s," and rivaled the results of early IVF, said Dr. Yee.
A renewed interest in the technique led Dr. Yee to investigate recent results using gonadotropin/IUI in more than 7,000 cycles among participants in IntegraMed America’s group of fertility centers that includes Dr. Yee’s offices.
In 2009, the group’s overall success rate averaged 10%/cycle in patients aged 41-42 years; 13.6% in those aged 38-40 years; 15.5% in 35- to 37-year-olds, and 20.3% in those younger than 35. Dr. Yee’s own practice’s results during 2009 and 2010 were 7.8%, 10.7%, 13.5%, and 24.3% in the same age categories, respectively.
"The overall success rate per cycle is not too bad," he concluded, noting that each cycle costs far less than an IVF cycle.
The use of clomiphene followed by IUI was less successful in Dr. Yee’s practice, achieving pregnancy rates of 6%-9% per cycle in patients younger than 40, and no pregnancies in the group older than 40.
Higher-order pregnancy – a risk of hyperstimulation and IUI – was the result in 2%-3% of pregnancies in the large IntegraMed series.
As Dr. Yee was collecting the data, a pertinent overview appeared "just by chance" on the occasion of the quarter-centennial of the technique’s use in treating infertility (Fertil. Steril. 2012;97:802-9). The overview authors compared higher-order multiple rates in 10 studies that employed high doses (150 IU or more) of gonadotropins vs. 7 studies using 75 IU or less and determined that the risk of triplets or above was "practically zero," when the lower dose was used.
Indeed, although twins resulted from as many as 29% of successful inseminations in the low-dose studies, no higher-order multiples were reported in 1,123 cycles. When higher doses of gonadotropins were used, as many as 9.3% of pregnancies involved higher-order multiples.
"Maybe the take-home message is that despite the fact the patient is 45 [years old,] maybe we should stick to 75 IU or less just to prevent the risk of higher-order pregnancies," said Dr. Yee.
Dr. Yee also discussed natural or "minimal" stimulation using clomiphene during IVF and noted that the approach can achieve a 10% pregnancy rate/cycle in so-called "poor responders" as a final alternative to using donor eggs.
"You have to individualize," he said, but such an approach would cost a couple approximately $5,000/cycle vs. $16,000-$17,000, primarily by reducing visits, procedures, and medications.
Dr. Yee made the following general recommendations for budget-conscious patients:
• In patients younger than 40 years with unexplained infertility or mild "male factor" infertility, try one cycle of clomiphene/IUI followed by one cycle of low-dose FSH/IUI.
• In poor responders who require IVF, try natural or minimal stimulation IVF with clomiphene alone as a "viable alternative" to standard IVF.
• For clomiphene IVF cycles, freezing embryos with subsequent frozen embryo transfer appears to lead to higher success rates.
Dr. Yee reported no financial disclosures relevant to his talk.