Without a doubt IVF is the most effective method of achieving a healthy, successful, singleton pregnancy as long as it is performed in a ‘Center of Excellence’ where an elective single embryo transfer (eSET) is the norm. Nevertheless, ovulation induction (OI) with clomiphene, letrozole or gonadotropins followed by intrauterine insemination (IUI) remains a first line therapy for treating unexplained infertility; but, when is enough, enough? Despite recommendations that OI should not be performed more than 3 or 4 cycles without achieving a pregnancy, some patients have experienced months and even years on the same ineffective OI therapy without success. Reasons given for using this less effective therapy include it being less expensive, less invasive and easier than proceeding on to more effective IVF. This is known as the ‘Street Light Effect’ after the old vaudeville act where the man is looking under a street light for his lost keys because that is where the light is rather than in the adjacent park where he dropped them in the dark. Balance is necessary between cost, convenience, successful pregnancy and multiples (twins, triplets, or worse). Cost of a successful pregnancy is of fundamental importance as is time to pregnancy since reproduction is largely an age related phenomena.
While OI is indeed less expensive than IVF, just how safe and effective is it compared to IVF performed in a ‘Center of Excellence?’ In a prospective, randomized, multicenter trial of the three most common ovarian stimulation strategies (clomiphene, letrozole, gonadotropins) in 900 women with unexplained infertility presented at the 2014 ASRM Annual Meeting, live birth rates were only 19% of cycles with letrozole, 23% of cycles treated with clomiphene, and 32% of cycles in women treated with gonadotropins. Rates of multiple gestations were 13% in women treated with letrozole, 9% in women treated with clomiphene but 32% in women treated with gonadotropins. These numbers should be compared to successful pregnancy rates and multiple gestations in an IVF Center of Excellence where pregnancy rates exceed 50% for women under age 35 and has high as 35% in women at age 40. In these centers where an elective single embryo transfer is routine, twin rates are less than 5% and higher order multiples (triplets or higher) are less than 1% of pregnancies. Another advantage of IVF in young women is that often following eSET there are additional embryos suitable for vitrification (freezing) allowing these women the potential opportunity of an additional pregnancy without going through another more costly IVF cycle.
Which is best, ovulation induction or IVF? This discussion undoubtedly generates more heat than light especially form those whose only resource is OI or from those centers where less than the National Average singleton success rates occur. Unfortunately this situation puts many patients at risk of a ‘Buyer Beware’ situation. Therefore it is incumbent on all to research not only the best individualized treatment but also the best provider and center to deliver that treatment.
Wondering which treatment path is best for you? Contact us, we can help.