Thalia's fertility journey

Yet another study showing IUI doesn't help

After the last time I posted about this, a lot of you commented about how IUI had been the right treatment for you, and how at least it was affordable in the US, unlike IVF for many people. Also, a couple of you had diagnoses where IUI was the appropriate treatment - medium-level sperm issues, a lack of cervical mucous, etc. I am fairly sure that this study excludes those factors so read on.

A study published today shows that for those with UNEXPLAINED infertility, treatment with either IUI or clomid had no discernable effect. The doctor on the BBC news this morning pointed out that if you aren't ovulating, then clomid is an appropriate treatment. If you are, it has no effect on your chances of becoming pregnant. Here are the details:

In the six-month study, participants had all suffered unexplained fertility problems for more than two years.

Overall, 101 women ended up having a successful pregnancy.

Of those who tried to conceive naturally, 17% became pregnant and gave birth to a live baby.

For clomid, the birth rate was 14%, and insemination 23% - not significantly different from the chances of success with no intervention.

However, the women undergoing active treatment were more reassured.

The last sentence tells you why doctors keep on prescribing clomid and IUI when they are not specifically indicated. It's very hard to tell a patient to go away and do nothing, or that they are better off with IVF when, in most places in the UK, the local health authority will have a 2-3 year waiting list for IVF and lots of restrictions about who can be enrolled on the list. Or in the US because the patient may not be able or willing to take on the huge cost of IVF before they've "tried everything," or at all.

I'd like to look at the statistics for countries like Israel, where IVF is readily available and paid for by the state. Do more couples go straight to IVF, bypassing these intermediate and less effective treatments?

The thing to be careful about is asserting - IUI is the right treatment because it worked for me. This study shows that you are just as likely to have become pregnant by being sent away to keep going for six months as you are to have conceived with IUI, even if you've already been trying with no success for two years before that. It's just a probability game, and you happened to have hit the one month with IUI when you most likely would have achieved pregnancy without it. However, this is only true if you have unexplained infertility, not if you have a specific condition where IUI can help.

It makes sense if you say - I couldn't bear doing nothing any more, and IUI was the affordable option. That's a personal choice, not about the statistics. It's of course fine to say, we couldn't afford IVF so we went for IUI, but it actually is probably not a good use of your money - you could have saved the money you spent on IUI and spent it on something unrelated to fertility treatment.

Clomid is a bit of a different story - most people hate taking it and it can actively inhibit fertility by drying up cervical mucous. If you are ovulating, it really really should not be given to you. It's just a nonsense treatment.

So the point here is that the numbers by no means tell the whole story. They don't tell the story of how bloody miserable it is to try every month to no avail. At least by taking clomid or doing an IUI you feel like you are taking action to deal with this horrible problem. They also don't tell the story of the money flows in infertility - the intense rationing of IVF in the UK, the extraordinary cost for those in the US whose insurance doesn't cover IVF. Numbers are powerful but not omnipotent. Everyone has to make the decision that's right for them. I just wish the doctors and the insurance companies and the NHS would review their standard procedures and at least start having these conversations with people.

Thank you Mr Steptoe and Dr Edwards

In 11 days time, Louise Brown will be 30. She has her own son, Cameron, who was conceived spontaneously just over two years ago. She comes across as a nice, thoughtful, sensible and articulate woman, very aware of the role she's played but in no way starry because of it.

We owe a lot to her parents, to Mr Steptoe and Dr Edwards, and I'm sure a lot of unsung nurses, embryologists, researchers and other doctors without whom the good gentlemen would not have been able to treat Mrs Brown, who had blocked fallopian tubes. It's hard with scientific progress to disentangle the multiple threads that come together into the tapestry which is an individual breakthrough, but these articles give you a sense of the long line of clinical and scientific progress without which IVF would not have been possible. I did not previously know that the first IVF pregnancy ended in an ectopic, for example, although I was aware that Mrs Brown's pregnancy resulted from harvesting a single egg, caught just after ovulation, since the drugs to produce controlled ovarian hyperstimulation and to control ovulation were not yet well developed (hyperstim was already in use, just not put together into the edwards/steptoe protocol).

If we think back to all those many pieces of work, the century (at least) of work on human fertility which led to Louise's birth, we can marvel all the more at what's been developed since. The drugs to help us to produce multiple eggs in one go. Agonists, antagonists and recombinant chorionic gonadotropin (hcg) to control when ovulation happens. ICSI. The understanding that many women need progesterone support after artificial induction of ovulation to support a pregnancy. The use of trans-vaginal needle aspiration rather than laparoscopy to retrieve eggs. Laser surgery for endometriosis. Hysteroscopies to remove fibroids. The ability to freeze embryos. The use of estrogen therapy to support frozen cycles. Progesterone suppositories to replace nasty intra-muscular injections. Automatic dispensing pens for FSH rather than having to mix powders. The understanding of the role of blood clotting in recurrent miscarriage. And so on.

It is extraordinarily difficult to deal with the fact that - and oh so much more so to experience - after all that progress there are still some of us for whom the technology doesn't work, and some of us whose infertility has no apparent cause. In the next 30 years I believe many of those situations will be treatable. Probably not all, but more than today. Roll on progress.

Until more of the causes of our infertility are treatable - and until women's fertility is no longer over at 42 or so - thank you for all that progress has already given us. Thank you to Mr Steptoe and Dr Edwards. Thank you to Mr and Mrs Brown. To Louise and to her sister Natalie - the first IVF-conceived woman to bear a child. Thank you to all those couples who participated in early work on IVF, who agreed to be guinea pigs. Thank you to those who agree to be experimented on today - trying new drug protocols, participating in randomised trials. Many of our children would not be here without you. Thank you.

Bits and pieces of hope

Some interesting articles relating to infertility recently. Here's a digest:

1. Potential for a new kind of pain relief - aromatase inhibitors (those currently used in treating breast cancer) have been shown to be very effective for relief from endometriosis-related pain.

2. PGS does not improve pregnancy rates, or reduce miscarriage rates. The British Fertility Society strongly recommends it is not offered to women unless as part of a defined clinical trial. I think we kinda knew this one - I've certainly seen comments to this effect, but important if your doctor is currently suggesting it.

3. Australian scientists are engaged in a long range study to look at what genes are expressed in blastocysts, and how these vary between blastocysts which turn into live take-home babies, and blastocysts which fail to implant or to turn into embryos which survive through the pregnancy. Very interesting story, which has already identified (no shit Sherlock) that genes involved in cell adhesion, cell communication, and response to stimuli, are all involved. They've also found that up to 20 cells can be removed from the cell lining layer of a blastocyst with no adverse effects. They are aiming to promote single embryo transfer - but arguing that for this to be widely accepted, couples need to have greater faith that SET is likely to work. What I don't quite get is how to transfer this to the clinic setting, as you would presumably have to do the gene amplification within a day so that you could put the blasts back before they start trying to implant. Or perhaps they plan to work backwards so that you could take a cell from a day 3 embryo and test it against their findings.

4. In the realm of "Thalia feels very smug," a finding that many doctors are moving away from ever recommending IUI, and going straight to IVF, which in the long run is often cheaper and less traumatic for couples as it's more likely to work. I've always thought IUI is a waste of time, given how little it improves your chances over trying alone, even with the addition of clomid and/or injectibles. It's also more likely to lead to higher order multiples in the hands of over-eager docs in the US, so a good thing if it's on the decline. Old-fashioned technology.

5. Data that says that IVM may not be the way to go in many instances. Eggs matured in the petri dish have a different pattern of development than those matured in vivo. Which also means that labs should be working to develop culture media that better replicate the ovarian environment.

6. Feed your male partner folic acid. It reduces the level of DNA abnormalities in sperm.