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Older infertile couples should try in vitro fertilization first

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By Dennis Thompson
HealthDay Reporter

TUESDAY, May 6, 2014 (HealthDay News) -- Middle-aged couples who want to have a baby but are having trouble conceiving should go straight to in vitro fertilization (IVF), skipping other types of fertility treatment, a new clinical trial recommends.

Researchers found that women aged 38 and older were more than twice as likely to become pregnant through IVF within their first two cycles of treatment than if they used oral or injectable fertility drugs. They also were twice as likely to have a successful birth from that pregnancy.

"In this age group, time really is of the essence," said lead researcher Marlene Goldman, a professor of obstetrics and gynecology at Dartmouth's Geisel School of Medicine, in Lebanon, N.H. "Moving to a more effective treatment quicker is the way to go."

By the end of the trial, more than four out of five babies successfully birthed had been conceived using IVF.

The normal progression of fertility treatment calls for artificial insemination combined with the oral fertility drug clomiphene first, followed by insemination accompanied by injectable medications called gonadotropins or follicle-stimulating hormones (FSH), researchers said in background information.

If those two methods fail, doctors then proceed to IVF. The mother's egg and the father's sperm are joined in a laboratory dish, and the resulting embryo is then implanted into the mother's womb.

Insurance companies have been reluctant to cover IVF, which can cost between $6,000 to $15,000, compared with $500 a cycle for oral medication and $2,500 a cycle for injectable fertility drugs, Goldman said. Only about one of every five states require that IVF be covered by health plans.

By going directly to IVF, doctors can help women in mid-life conceive despite the "double whammy" of fewer eggs produced by the ovaries and eggs that are genetically abnormal due to their age, said Dr. Avner Hershlag, chief of the Center for Human Reproduction at North Shore University Hospital in Manhasset, N.Y.

"We fertility doctors should not allow our patients to age under our watch," Hershlag said. "Insurance companies should be encouraged to change coverage following this important, well-designed study."

The study, which was funded by the U.S. National Institutes of Health, was published online April 29 in Fertility and Sterility.

In this study, 154 middle-aged couples with unexplained infertility at two Boston fertility centers were randomly split into three groups. One group received oral fertility treatment, the second received injectable medication and the third went straight to IVF.

The participating couples had to have been trying to conceive for at least six months, without previously using any of the treatments in the study. The female partner had to be between 38 and 42, and both partners had to be in relatively good reproductive health.

Within two cycles:

    - 49 percent of those who received IVF became pregnant and 31 percent gave birth.

    - 22 percent of those with oral medication became pregnant and 16 percent gave birth.

    - 17 percent of those given injectable medication became pregnant and 14 percent gave birth.

    All couples that had not been successful in their first two cycles of any treatment used IVF in their subsequent treatment cycles. The couples in the immediate IVF group of the study ended up needing 36 percent fewer total cycles before conception than the couples who began with oral or injectable medication.

    By the end of the treatment, 71 percent of all couples in the study had conceived a clinical pregnancy and 46 percent delivered at least one live-born baby. About 84 percent of all live births in the study came about as a result of IVF.

    These findings should cause insurance officials to reconsider their refusal to cover IVF, given that pregnancy occurs more rapidly with IVF and with fewer complications, said Dr. Tomer Singer, a reproductive endocrinologist at Lenox Hill Hospital in New York City.

    Singer noted that the oral and injectable medications work by hyperstimulating the ovaries, which often causes a woman to conceive twins or triplets. Those pregnancies tend to be more complicated and more costly.

    "If insurance companies will realize they may save money by following this route of treatment, this will eventually be the way to go," Singer said. "We are covering standard insemination, and those patients are taking the risk of twins. That will cost us so much more than helping a couple achieve a healthy pregnancy with one embryo."

    Based on their findings, the study's authors also recommend that middle-aged couples who are reluctant to use IVF off the bat should opt for oral fertility drugs over injectable fertility medications.

    "With the older women, doctors sometimes skip clomiphene, thinking that the pregnancy rate is higher with FSH," Goldman said. "We didn't see any benefit of using FSH, where the cost is higher and there's an increased risk of multiple births compared with clomiphene."

    More information

    For more about fertility treatment, visit the U.S. National Institutes of Health.

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