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2020

Success chances with IVF After Failed IUI

Author Name: Dr. Swathi Mothe || Mentor Name: Dr. Reema Sircar on April 27, 2020

Once Sub fertile couple fails 2-3 IUI cycles, they are generally taken up for IVF as the next step after reviewing all the other possibilities and after an informed discussion with them. Does IVF gives more positive results after failed IUI? Definitely the answer will be yes. When comparing the results of IUI with IVF, IVF has a much higher success rate as compared to IUI that is 50-60% in former as compared to 7-15% in latter. It’s true the IVF will costly compared to IUI, but it’s worth every rupee as it offers far higher success rate.

WHAT IS IUI (INTRAUTERINE INSEMINATION)

It is a process where washed sperms are directly placed in to uterus which helps the fertilization and chance of conception by the availability of highly concentrated, motile, morphologically normal sperms close to the egg at the time of ovulation.

WHO SHOULD BE OFFERED IUI

• A patient with Unexplained infertility
• In case of mild endometriosis
• A hostile cervical condition
• Patients with vaginismus
• Ejaculatory dysfunction of male
• Retrograde ejaculation in male

IUI can be done with
• Husband semen(IUI-H)
• Donor semen(IUI-D)

SCENARIOS WHERE IUI IS NOT AN IDEAL TREATMENT

• A women with diseased fallopian tubes
• Advanced maternal age
• Female with Severe endometriosis
• Severe male infertility(low sperm count, abnormal sperms)
• Male with zero sperm count

SUCCESS RATE: – The overall success rate of IUI will be 7-15% after three to four cycles of IUI.
COMPLICATIONS: Intrauterine insemination is a relatively simple and safe procedure, and the risk of serious complications is low.

The risks include infection, spotting, multiple pregnancies (when coordinated with ovulation induction drugs) can occur with IUI.

TIMING OF IUI
It can be performed at the time of ovulation usually within 24- 36 hours after the LH surge is detected or after HCG trigger injection administered and ovulation is predicted by ultrasound.
IUI is much more affordable than IVF and tends to be much less invasive, cycles are easier to complete.

WHAT IS IVF

IN VITRO FERTILIZATION (IVF) is a type of assisted reproductive technology (ART), It involves retrieval of eggs from a women ovaries and fertilizing them with male sperm outside the body in the lab. This fertilized product is known as embryo which can transfer to the women’s uterus.

IVF IS THE BEST OPTION IN FOLLOWING CONDITIONS

• Female with Severe endometriosis
• Severe male infertility
• Bilateral fallopian tube blockage in females
• Women with irregular periods (Anovulatory cycles)
• Poor egg quality
• Genetic problem for mother or father
• Unexplained infertility
• Male with zero sperm counts
• Premature ovarian failure
• Menopausal women

HOW IVF CAN BE PERFORMED

It involves several steps
1. Stimulation
2. Maturation induction
3. Oocyte retrieval
4. Sperm collection and fertilization
5. Embryo culture
6. Embryo selection
7. Embryo transfer

STIMULATION: – The aim of any regimen for stimulation is to obtain multiple eggs which can be fertilized with the sperms to get good quality embryos.
Stimulation can be done by using gonadotropin injections

MATURATION INDUCTION
While giving gonadotropin injections, follicular monitoring will be done by transvaginal ultrasound. Once the follicular size reaches appropriate size then induction of maturation will be done by giving HCG injection or Gnrh agonist which is known as trigger. Egg retrieval can be performed at a time usually between 34 to 36 hours after trigger.

EGG RETRIEVAL OR OOCYTE RETRIEVAL
The egg retrieval from the patient will be done by using trans vaginal probe of ultrasound along with ovum pickup needle.
Through ovum pick up needle follicular fluid is aspirated and passed to embryologist, from which they identify the oocyte.
This process is a short procedure which will take 20 – 40 minutes, usually this procedure is done under general anaesthesia.

SPERM COLLECTION AND FERTILIZATON
Semen is collected from the husband or if it is a donor sperm semen sample will be thawed and keep it ready for IVF.
Sperm is prepared by using different types of sperm washing techniques like swim up technique or density gradient technique.
Washed sperm now can be used for IVF or in case of low sperm count they can be used for ICSI (Intra cytoplasmic sperm injection) where a single sperm will be directly injected in to the egg, then this fertilized egg is transferred to growth medium and left about 48 hrs to 5 days.

EMBRYO SELECTION
After 3 days to 5 days of fertilization now embryos will be ready for transfer.
It is necessary to select best embryos out of multiple embryos.
Embryologist will assess the quality of embryo by using morphokinetic scoring.
We can transfer these embryos to mother uterus after 3 to 5 days of fertilization or can be freezed if planning for FET(Frozen embryo transfer).

EMBRYO TRANSFER
This is final and critical step of IVF, where embryos will be transferred to women’s uterus 3 to 5 days after egg retrieval and fertilization by using catheter.
In case of frozen embryo transfer , prepare the women uterus with estrogen followed by progesterone, Embryos will be thawed on the day of transfer and can be used.

COMPLICATIONS OF IVF

1. OVARIAN HYPERSTIMULATION SYNDROME
It is the complication induced by ovulation induction drugs, symptoms include abdominal distension, abdominal pain, abdominal bloating, nausea, vomiting, oliguria and electrolyte imbalance and hypercoagulability can be observed in lab investigations.
2. MULTIPLE BIRTHS
IVF increase the risk of multiple births if more than one embryo transferred to mother uterus.
A pregnancy with multiple foetuses carries a higher risk of preterm labour, low birth weight and NICU admissions.
3. MISCARRIAGE
Rate of miscarriage for women who conceived with IVF is similar to that of natural conception about 15- 25%
4. ECTOPIC PREGNANCY
About 2-5% of women who conceived with IVF will have an ectopic pregnancy.

IVF SUCCESS RATE

Age is the primary factor that most affects IVF success rate. Women younger than age 35 have 50-60% chance of having a baby with first IVF cycle. Women who do not get success in first IVF cycle still has a very good chance of getting pregnant on second, third and subsequent cycles of IVF.

According to SOCIETY FOR ASSISTED REPRODUCTIVE TECHNOLOGY (SART) clinical report the average cumulative live birth percentage and chance of live birth from IVF by age are
55% for women under 35
40% for women age 35-37
26% for women age 38-40
13% for women age 40-42
4% for women over the age of 42

The cumulative success rate for a live birth increases with additional IVF cycles for all women.
Success rate also depends on
• Patient selection
• Diagnosis and protocols used
• Laboratory quality
• Use on add on techniques

The major limiting factor for success with IVF is female age which results in diminished ovarian reserve. This problem can also occur but less often in younger women. Donor egg is the only option available in such situation.

CONCLUSION
To conclude IVF is the only best option available after failed IUI. A couple can try IUI of minimum 3 to 4 cycles if they fail to conceive it is better to proceed with the IVF as the success rate is far higher in IVF procedure as compare to IUI.

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