Infertility Advice & Injectables Questions


#1

Hi Everyone - I am hoping for some second opinions/advice on my infertility situation, as well as for some advice on injectables.

I am 38 and have been trying for about 1 yr and a half to conceive. I know all of you can relate to how difficult this is. In my case, I have unexplained infertility - my tubes are open, I seem to have good egg reserve, my husband’s counts are good, etc.

I started seeing a fertility doctor about 6 months ago and I have now gone through 3 unsuccessful IUI’s with clomid and I am in the middle of my 4th IUI cycle with letrozole. I should find out in a few days if this cycle “worked”, but to be honest, I am feeling really crampy and I am not optimistic.

With this said, my doctor is suggesting that I consider injectable medications or IVF for my next cycle. I need to make this decision fairly quickly because I would be expecting my period this week.

With injectables, I am concerned about the risk of high order multiples - particularly because I have unexplained infertility (9 resting follicles on each ovary as of my last ultrasound!). I would have 10 kids if it were safe, so not worried about the # of kids, but the safety for the babies since beyond twins has many risks.

Does anyone know what the risk of high order multiples is with injectables?? Also, is anyone familiar with the risk of ovarian cancer related to injectables??

My doc has also suggested perhaps skipping injectables and moving straight to IVF. IVF is NOT covered under my insurance, so this would be a big expense. In addition, as you all know, it is a MUCH more intense process which frightens me.

Does anyone have an opinion on what my next step should be? Is it premature to move forward with injectables at this stage given that I’ve only had 4 IUI’s?? I did hear somewhere that your chances of success with IUI drop dramatically after 4 attempts, but not sure if this is true…

Any opinions and advice are greatly appreciated. Sorry for the long post…I don’t know anyone else who is going through this, so it is tough to get good advice in this area. Thanks!! Best of luck to all of you out there!!!


#2

Hi there, and welcome to the community. It’s a good place to get advice and opinions, since there’s inevitably someone somewhere who has already been there and done that. Of course, ultimately we’re not doctors…

Injectables are supposed to help create higher quality eggs than just oral medication. Clomid in particular is known to have some side effects that make it not work for some women; letrozole is a totally different kind of medication that still kind of does the same thing, but again, it doesn’t always work.

My RE was pretty aggressive in trying to find the magic combination that worked for me, since he was pretty confident that IUI was our ticket. I did two rounds of Clomid, then one round of letrozole, then two combination cycles, where I started with letrozole and then took Follistim. As I recall, the reason for this was so that the oral medication could ‘recruit’ follicles, while the Follistim helped them to develop. As it turns out, this combination is indeed what worked for me because I did get pregnant both times we tried it.

As for the risk of higher order multiples? I really don’t think it’s particularly higher than it is with any other method. Now, remember, I’m not a doctor and so my feelings on the matter are just that, feelings, shaped by my observations of various women on this-here board and their experiences. When you move to injectables, your RE should step up your monitoring by a lot, and there are a LOT of REs who will flat out cancel a cycle if they think the risk of HOM is too great. (They count the follies they can see in an ultrasound, they measure your hormone levels, and they make their best, most educated guess.) Is the risk totally eliminated by this? Not at all. On the other hand, there are two women in my due date group who ended up with quads, one as a result of IVF, one just from taking Clomid.

As for the idea that your chances of success dropping after 4 attempts, that’s kind of sort of a bit of misinformation. It’s not like there’s some switch that flips somewhere after attempt #3 or #4 or whatever that automagically makes it impossible after that point. It’s more that if it hasn’t worked after 3 attempts or something you need to change what you’re doing, because the odds are that whatever you’re trying doesn’t necessarily work for you. (Alternatively, if you’ve only been developing one follicle a month, there’s the added ‘bonus’ that your odds of getting pregnant are still not any better than the average normal couple, and technically they’re supposed to try 6-12 times before thinking there’s a problem.)

Unfortunately, I have no idea what kind of risk factors are involved with injectables (or any kind of fertility medication) and ovarian cancer.

I hope that helps. Good luck!


#3

Hi…I agree with everything that LookingGlass posted.

If you are concerned about the risk of multiples, be sure to talk to you RE. He might start on the conservative side. Maybe even doing something like Clomid first may be worth investigating. If you start doing objectibles, you should be monitored with ultrasounds and if your follicle count is too high, they may cancel it or you may opt to candle it. If IVF is cost-prohibitive for you and IUI is covered, then I would exhaust all IUI options possible first. My insurance covers 3 IUI attempts but we never did the third because we discovered I had very low AMH. It just wasn’t worth wasting any eggs (if I had any) for IUI so we are paying out of pocket for IVF. If you have good counts, maybe working with drugs will help increase your odds. Good luck!


#4

Thanks for the info! I have tried clomid and letrozole - I have been responding fairly well to it - 2- 3 eggs each cycle.

With injectables, my RE says the goal will be 5-6 eggs. Without the control of IVF where they know exactly how many eggs they are fertilizing, he said the possibility is definitely there for more than 2. I don’t know the exact stats.

Since I have been responding well to clomid/letrozole in terms of egg count, I just wonder if we’re jumping the gun going to injectables or IVF prematurely.

With that said, I am 38 and have been trying for awhile, so I am eager to get the show on the road!!!


#5

Have the follicles you’ve gotten with the medicine you are on all been mature? It may be that he’s trying to increase your chances of more mature ones?


#6

Yes, there have always been 2 - 3 mature eggs. This is one of the reasons why I am a bit confused…


#7

The RE can do low doses of injections to make sure you don’t get to many mature follies. If you are monitored closely they can up or lower your meds if needed. Another thing to remember is NOT all mature follies will have an egg in them. Goodluck!


#8

I responded to your other thread, but the rates of multiples for injectibles are higher than other treatments, and it’s about 25% chance of twins, 5% chance of triplets and higher. (The triplets make up about 4 percentage points of that 5%.) Clomid, for instance, is about 5% chance of twins, with triplets and higher making up about 1 percentage point of that 5%. I would work with your RE to decide, for instance, if he will push for fewer mature follicles, or consider cancelling cycles earlier if more eggs are growing than you’re comfortable with.

As far as the success rates, it’s not that suddenly, after the 4th try, you’re less likely to get pregnant with a treatment. It’s that, statistically, if that treatment is going to work for you, it will work within the first four cycles. It sounds like a moot distinction but it’s actually important. So, for instance, if you take a very large group of infertile women for whom it makes sense to give them medications (for instance, their tubes aren’t blocked and they don’t have polyps and things that prevent implantation), you’ll see roughly the following spread. Start them all out on Clomid and 80% will get pregnant within the first 3-4 cycles. 15% more will get pregnant within the next 2-3 cycles. The remaining 5% are not likely to get pregnant on Clomid no matter how long they take it. If you give that 5% injectibles, their rates are about the same–80% in the first 3-4, 15% more in the second 2-3. So it would really be irresponsible of your doctor to continue you on injectibles past that six month window, and some doctors prefer not to spend your time and money past the first 3-4-cycle window. Now, that’s a huge simplification of the stats, but that’s the basic idea.

As far as whether to go straight to IVF, you’ll have to decide how you want to proceed, but especially since it sounds like your insurance covers some of the cost of the injectibles, I think there’s nothing wrong with giving yourself 3 or 4 cycles on injectibles just to see if it can work for you and save you a crap ton of money.