Is it time for IVF?
IVF: Those three little letters mean so much, especially to a fertility patient. Often, patients come into the fertility clinic thinking they will need “just a little” help and that they will conceive with minimal intervention. However, IVF is becoming more and more common and has many advantages and is recommended for certain infertility diagnoses. Patients often wonder: When is it time to move on to IVF?
Here is a guide to deciding whether IVF is the right next step for you.
Age and ovarian reserve
As women age, their eggs get older. Women have a finite number of eggs, and as they age, the quality of those eggs decreases. Older women have eggs with more chromosomal errors, which result in embryos and pregnancies with a higher risk of genetic problems, which can cause failure to conceive, miscarriage or a pregnancy with an abnormality such as Down’s syndrome.
There are many tests to accurately assess a woman’s egg health (ovarian reserve). Based on these tests, if you have low ovarian reserve, your doctor might recommend treatment such as IVF. We know that as women age, particularly for women over 35 to 37, IVF has much higher success rates than other fertility treatments. We also know that over the age of 37, and particularly over 40, the success rate of IVF decreases quickly, so your doctor might recommend pursuing IVF sooner to have a more optimal response.
IVF also allows patients the opportunity to screen embryos with genetic testing (PGT-A: preimplantation genetic testing for chromosomal errors or aneuploidy) to avoid pregnancies that result in miscarriage or any chromosomal abnormalities. Typically for women over 35, fertility doctors will recommend IVF within six months of starting treatment at a fertility clinic to maximize outcomes and to avoid losing time with more conservative treatments.
During the initial infertility testing, most patients have a test called a hysterosalpingogram or sonohysterogram to check whether the fallopian tubes are open. If this test shows blocked tubes or that a patient has abnormal tubes due to other reasons, such as prior infection, endometriosis, scar tissue, or prior ectopic pregnancies, then IVF is the best way to conceive.
By doing IVF, the fallopian tubes are bypassed, and the eggs are removed from the ovaries after stimulation with fertility medications, fertilized in the laboratory with sperm and placed back into the uterus. This avoids the scenario of the eggs and embryos having to travel through the fallopian tubes to the uterus.
The male factor: low or abnormal sperm
Testing the male partner and doing a semen analysis is part of the routine infertility work-up. If sperm testing shows very low counts, low motility, or abnormal shapes that cannot be corrected by treatment with medication or with a urologist (i.e. a male fertility specialist), typically resulting in sperm counts less than 5 million, or if a patient fails multiple IUIs (intrauterine inseminations), then the recommendation is often to move to IVF with ICSI (intracytoplasmic sperm injection).
By selecting and injecting one sperm into each egg, fertilization is enhanced and can produce a pregnancy when it is not possible by natural means or with IUI. Your fertility doctor can assess whether IUI is an option or whether IVF with ICSI would have a higher success rate in each individual case.
Often, IUI (intrauterine insemination) with fertility medication is suggested by fertility doctors as an initial treatment to increase the number of ovulated eggs and help sperm reach the tubes, to increase the odds of fertilization and pregnancy. Typically, we suggest up to six IUIs before considering moving on. For women under the age of 35 with normal IUI counts, doing up to six IUIs is reasonable; but for women over 35 or with IUI counts less than 5 million, it is reasonable to consider moving on to IVF.
Recurrent miscarriage is often tricky because many patients will feel that they have no issue getting pregnant but have trouble keeping the pregnancy. However, most miscarriages are due to pregnancies that have chromosomal errors from the egg. One way to help avoid genetic abnormalities in the embryo and pregnancy is to do IVF and screen the embryos with preimplantation genetic testing (PGT-A). By selecting the normal embryo from a batch of embryos obtained after IVF, there is a higher chance that the pregnancy will achieve a successful outcome.
Desire to have multiple children
Women are delaying fertility for many reasons, and it is not uncommon to see them start a family over the age of 35. As fertility doctors, we often see women conceive with conservative treatments at 35 to 37, only for them to come back at 39 to 41 and have much more difficulty conceiving their second child because they are now much older.
One of the benefits of IVF is that it allows us to retrieve multiple eggs and ideally create extra embryos that can be stored for later use for baby number 2, number 3, etc. For those couples who are starting at a later age, with the women over 35, IVF early on is a good option to potentially have extra embryos stored for later use.
These embryos don’t age, and an embryo made at 35 has the same genetic risk as a 35-year-old’s even if it is implanted in a 39-year-old’s uterus. PGA-T genetic testing can help to identify normal embryos, and many patients feel secure knowing that they have extra normal (euploid) embryos stored in the IVF lab that have a high chance of pregnancy.
Avoiding known genetic mutations
Some couples with a history of hereditary disease, specifically those caused by mutations of single genes, may consider doing IVF for preimplantation genetic testing (PGT-M) to avoid passing on the condition. Some examples of genetic diseases that can be detected in embryos and prevented by genetic testing are cystic fibrosis, Huntington’s disease, and sickle cell anemia. Patients who do IVF for this purpose should decide to do IVF with genetic screening of the embryos in consultation with their fertility doctor and a clinical genetics counselor.
Women are also taking time to find partners and to focus on themselves, their career, and their personal goals. Fortunately, IVF technology is steadily improving, and we are in an age when our laboratories are very adept at freezing eggs and embryos! Many single women and couples are opting to freeze eggs or embryos in order to pursue other goals prior to starting a family. While this isn’t a 100% guarantee, it definitely gives some peace of mind and can reduce the stress around having kids ASAP.
For those women and couples who know they will not have kids till later and for women who are over 35, fertility preservation is a good option to have as “insurance” until the time is right to conceive. Some women have a medical situation that prevents them from conceiving, whether it be medication they are on or a medical issue such as cancer. Fertility preservation is an option for many of these patients as well, to “preserve” their fertility by freezing eggs or embryos. Sperm can also be frozen for men who are undergoing treatment that might affect fertility.
It is always best to have an open discussion with your fertility doctor about whether it is time to move on to IVF. If you are thinking about it, book an appointment to discuss the pros and cons and to decide whether it is the right time for you.