Patients who come to a fertility specialist want to become pregnant as soon as possible. There are various treatment options now available for infertility; some have higher pregnancy rates and some have lower pregnancy rates. These treatments have markedly different costs and differing levels of complexity.

Very commonly patients may start with a less effective treatment because it is easier to do or less expensive. It is not unusual to see a couple first try treatment with clomid , perhaps combined with IUI (intrauterine insemination) for three or four attempts. If not pregnant, they may proceed to using injectable fertility medications , known as gonadotropins, also combined with IUI. In vitro fertilization, IVF , is sometimes viewed as the treatment of last resort despite the fact that it has the highest chance for success. The reason for this is that IVF is the most expensive treatment and the most complex.

A randomized clinical trial was recently done to determine whether it would be more beneficial for infertile women aged 21-39 years to shorten the standard infertility procedure protocol.

Standard Protocol

What is the standard or conventional procedure?In this study, the women going through the conventional treatment had:3 cycles of clomiphene citrate/ intrauterine insemination (CC)/ IUI3 cycles of gonadotropin/ intrauterine insemination (FSH/IUI)Up to 6 cycles of In-vitro Fertilization (IVF)This procedure is said to be conventional because of its step-wise fashion. The procedures become more invasive as the treatment is continued.

Accelerated Protocol

What is the accelerated procedure?Women going through the accelerated treatment had:3 cycles of clomiphene citrate/ intrauterine insemination (CC)/ IUIUp to 6 cycles of In vitro Fertilization (IVF)The gonadotropin/ intrauterine insemination (FSH/IUI) was completely eliminated from this treatment pattern.

Why omit the FSH/IUI?

Gonadotropin IUI has historically been a mainstay of infertility treatment before IVF. Its cost and unavoidable multiple births, especially high-order multiples, and the risk of hyperstimulation syndrome have brought this treatment under closer scrutiny. The ability to achieve higher pregnancy rates with fewer embryos transferred through IVF has evoked further questions regarding the role for gonadotropin/IUI.

• As time has gone on, IVF success rates have doubled in women younger than 40 while FSH/IUI rates or treatments have NOT changed in 20 years.
• FSH/IUI is associated with an increased risk of unpreventable high-order multiple births
• Multiple births place a large burden on the health care system because these are often complicated pregnancies. The babies often require a large amount of expensive care.

Main Outcomes Measured:

• The time it took to establish a pregnancy that led to a live birth
• Multiple-birth rates
• Pregnancy rates per attempted treatment
• Cost-effectiveness:

the ratio of the sum of all health insurance charges for all couples divided by the number of couples delivering at least one live-born baby

STUDY RESULTS

Time to Pregnancy:

• 64% of couples in the study delivered at least one live born baby as of April 30, 2006
• The time to pregnancy was shorter in the accelerated group compared with conventional protocol. The average time to pregnancy was 8 months in accelerated group and 11 months in other conventional group.

Multiple Birth Rates:

• Multiple birth rates didn’t differ significantly
• 21% vs. 23% (conventional vs. accelerated)

While the rates didn’t differ significantly in this study, others have shown that multiple births do occur more frequently in doing FSH/IUI procedures.

Per cycle pregnancy rates:

• For CC/IUI, FSH/IUI, and IVF were 7.6%, 9.8%, and 30.7%, respectively

Cost effectiveness:

• Observed charges per delivery were $9846 lower for the accelerated group than with the conventional group
• The difference in the infertility treatment-related charges per delivery was $5802
• The observed incremental difference in charges per couple was a savings of $2,624

DISCUSSION

• Couples in the accelerated arm became pregnant at a faster rate and with fewer treatment cycles.
• The results suggest that compared with conventional treatment, accelerated treatment saves money and results in a greater proportion of couples with delivery of a live-born baby.

For all analyses performed regarding charges (i. e., treatment charges per couple and per delivery, total charges per couple and per delivery), the total charges were less for couples in the accelerated compared with the conventional arm.

CONCLUSION

A randomized clinical trial demonstrated that FSH/IUI treatment was of no added value to the treatment protocol. In states that require comprehensive Insurance coverage, rates of success are higher because there is a lesser dropout rate

As clinical practice moves to limiting the number of embryos transferred during IVF procedures in young women to one or two embryos, eliminating gonadotropin/IUI from the step-wise infertility paradigm will result in pregnancies with the lowest possible risk for multiple births.

Compared with conventional infertility treatment and when the woman is younger than 40 years, an accelerated approach to IVF that starts with CC/IUI, but eliminates gonadotropin/IUI, results in a

shorter time to pregnancy

, with

fewer treatment cycles

, and at a

suggested cost savings

.