The Infertility Conundrum
Posted by MDViews on March 25, 2014
Tears spilled on my desk as she described her four-year trial with infertility. Married for six years, she and husband actively tried to achieve pregnancy for four years prior to her visit with me. After one year of no success, she saw her OB/GYN doctor. After testing, her doctor determined her to have open tubes, normal labs and a fertile husband. Try another year, she was told. After no success, her doctor tried her on Clomid, a medicine that caused ovulation2, even though she ovulated every month. After six cycles of that without success, she visited a Reproductive Endocrinologist (RE), a doctor who finished an OB/GYN residency and an additional two years of training in Reproductive Endocrinology. The RE recommended Clomid and intrauterine insemination or IUI3. If no success after three cycles, she recommended Follistim shots4 and IUI for three cycles. If that failed, she recommended in vitro fertilization.
My patient and her husband tried the Clomid and IUI, but couldn’t afford the Follistim and IUI or the in vitro fertilization.
She returned to her OB/GYN doctor and received more Clomid, again, without success. She and her husband, both Catholic, lived with the guilt of trying IUI, a fertility procedure not approved by the Catholic Church. Her complaints of severe pain with her periods and pain in her pelvic area fell on deaf ears as her OB/GYN told her in vitro fertilization was the most effective way to achieve pregnancy, and recommended a return to the in vitro clinic.
Pregnancy rates after an in vitro cycle average 30%. I checked three fertility clinics in the Twin Cities and found one charged $16,500 for each in vitro cycle, another $22,000 and a third clinic $23,000 per cycle.
Pregnancy rates after one cycle of a fertile couple who has unprotected intercourse are 25 to 30%. Last I checked, the cost was $0. Pregnancy rates after one cycle for a couple with endometriosis5 is lower than that, often around 5% to 10%. As excellent medical studies have shown, however, surgical treatment of endometriosis and pelvic scarring improves pregnancy rates, often greatly. Not only that, surgical treatment constitutes a one-time event that often relieves pain and increases pregnancy success for many cycles.
If a woman has a 20% success rate per cycle after surgical treatment of endometriosis, her chances of pregnancy at the end of one year are much higher than the 30% chance after one in vitro cycle, or the slightly higher chance after two in vitro cycles. I rarely find a patient who has tried three or more in vitro cycles.
She heard about our clinic and underwent surgery at which time I discovered and surgically treated her severe endometriosis by careful handling of tissues, thorough treatment of endometriosis and placement of adhesion barriers to prevent recurrent scarring.
The surgery brought relief of her pain.
She conceived on her own the next month.
She is now on baby number two since the surgery.
In order to understand the tragedy this represents, you need some history. Back when I did my residency in OB/GYN, the Reproductive Endocrinologists were the best surgeons in the department, often the entire hospital. They performed difficult endometriosis surgery, tubal reconstruction and treated scarred tubes, which often required the operating microscope. Now, RE’s in my area do not come to the hospital, much less perform surgery. At the two hospitals where I work, not one Reproductive Endocrinologist performs surgery in spite of in vitro clinics in our service area.
In the last five to ten years, in vitro procedures for infertility have become the default treatment to the elimination of all other treatments. General OB/GYN doctors in my community have a laissez-faire attitude toward the surgical treatment of endometriosis and make little effort to treat the disease thoroughly surgically even if they find it at laparoscopy6. This, in spite of good data on the effectiveness of surgical treatment to improve fertility and relieve pain7.
1) Fallopian tubes – tubes that carry the egg to the uterus from the ovary. Fertilization actually happens in the tube.
2) Ovulation – When the egg pops out of the ovary and can be fertilized.
3) Intrauterine insemination (IUI) - A procedure in which a semen sample is specially prepared for safe insertion into the womb, or uterine cavity itself.
4) Follistim – A hormone given in daily injections to cause the ovaries to make eggs, sometimes several eggs.
5) Endometriosis - A female condition in which uterine lining cells implant in the pelvis and cause pain, scarring and infertility.
6) Laparoscopy - A minimally invasive surgery to look inside the abdomen in order to diagnose and treat a condition, often endometriosis or infertility.
7) UpToDate states in the section Reproductive surgery for female infertility, "laparoscopic surgical treatment was associated with a significant increase in the ongoing pregnancy/live birth rate..." October 2013.