Many patients I have seen who have failed to conceive using Clomid, and think IVF is the automatic next step. Not so. Clomid really is not associated with a good pregnancy rate. There are other protocols which do work better. Of course, for those who need it, IVF is one of them.
There are really 3 medical indications to do in vitro fertilization (IVF). One is for tubal damage. Tubal damage most commonly results from either previous infection or prior tubal ligation. Efforts at repairing the fallopian tubes usually results in may result in tubes that are open, but they are still damaged. If a fallopian tube is damaged, there is a significant risk that any pregnancy which may occur will be a tubal pregnancy. That is life threatening. Since IVF bypasses the tubes, there is no increased risk of tubal pregnancy.
A second reason to perform IVF is for severe male factor issues. If sperm are not formed properly, or they do not swim adequately, or if there are just too few of them, they need help to fertilize an egg. Once we have eggs in the embryo lab, we can literally inject sperm into eggs (ICSI). There is still no guarantee that fertilization will be achieved, but in the vast majority of the cases in which we perform ICSI, we are able to produce good embryos. Our pregnancy rates with ICSI are very nearly that of straight forward IVF.
Some newer technology now enables us to detect, in embryos, inherited diseases carried by one or both future parents. The first such inherited disease to be detected in embryos was cystic fibrosis. Today, there is an extremely long list of genetic diseases which can be diagnosed in embryos, and avoid having children stricken with those abnormalities. We have to remove one of the cells from a day 3, 6 to 8 cell embryo. Removing a single cell does not jeopardize the embryo, when the biopsy is performed by a skilled embryologist. There are now 2 different techniques to examine the DNA of the embryo and compare it to the DNA of the parents. The older technique is polymerase chain reaction (PCR). That is the same technology highlighted in some of the TV crime shows. The second technique is referred to as micro array analysis. Material from a single cell taken from an embryo is placed in a tiny well, in what amounts to a computer chip, and the chemistry of that cell can be analyzed. Once it is determined which embryos are identified which are not affected by the disease in question, normal embryos can be placed in the uterus of the intended mother.
Finally, there is a non-medical reason to consider IVF. Many patients do not have any insurance coverage to help pay the expenses of fertility treatment. At least in our practice, both the cost of 4 cycles of using FSH to stimulate ovaries and performing IUI and 1 IVF cycle are about the same. Also, the pregnancy rate for a single IVF cycle is about the same as for 4 IUI cycles. If we do not achieve a pregnancy with IUI, the next treatment protocol to try is IVF. A few of my patients have felt it more cost effective to skip efforts at IUI, and just do IVF. Although I do not encourage that practice, I find it difficult to argue with the logic. I those circumstances, I have acceded to their requests.
IVF is certainly a very useful tool to help a couple achieve a pregnancy. With improved technology and understanding of the physiology of embryos, our pregnancy rates have become extremely good, and I expect them to improve more. It is, however, important to keep things in perspective. IVF is just 1 more tool, and should not be the only tool.
Dr. Jacobs is a Reproductive Endocrinologist, practicing in Carrollton, Texas, a northern suburb of Dallas. He completed his residency training in obstetrics and gynecology at Baylor College of Medicine in Houston, and remained at that institution to become its first fellow once Baylor achieved accreditation for an advanced training program in Reproductive Endocrinology and Infertility. Dr. Jacobs has served on the faculty of several medical schools and was director of Reproductive Endocrinology at Texas Tech Health Science Center in Amarillo. Currently, in addition to his clinical activities caring for infertile patients and those with recurrent pregnancy loss, he is Chairman of the IVF committee at Baylor Medical Center in Carrollton. Barry Jacobs, M.D., 4323 M. Josey Lane, Suite #201, Carrollton, TX 75010www.texasfertility.comPhone: 972-394-9590 Fax: 972-394-9597
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