Optimal treatment for poor responders to ovarian stimulation: does in vitro insemination offer any advantages to intrauterine insemination?

Conversion of in vitro fertilization cycles to intrauterine inseminations in patients with a poor ovarian response: Risk of multiple pregnancies

PURPOSE

To determine the risk of multiple pregnancies (MP) following conversion of in vitro fertilization (IVF) cycles to intrauterine insemination (IUI) when a poor ovarian response (POR) is diagnosed during controlled ovarian stimulation (COS).

METHODS

We undertook a retrospective study in our teaching hospital from January 2012 to December 2017. We included all IVF cycles with POR that were converted to IUI (<5 follicles ≥ 14 mm and peak estradiol level < 1000 pg/mL on trigger day).

RESULTS

Overall, 205 IVF cycles that were converted to IUI in 128 patients were analyzed. Mean age was 34.1 ± 4.6 years, mean antral follicle count was 11 ± 5.3 and mean AMH was 1.8 ± 2.9 ng/L. The main causes of infertility were unexplained (41 %) (84/205) and diminished ovarian reserve (35 %) (72/205). Of all the cycles converted to IUI, 53 (26 %) had one mature follicle on trigger day, 56 (27 %) had 2, 56 (27 %) had 3, and 40 (20 %) had 4. The live birth rate (LBR) was 7.3 % (15/205), and the miscarriage rate was 28.6 % (6/21). There were 3 twin pregnancies, but no higher order pregnancies; the MP rate was 14.3 % (3/21). There was no significant difference in the MP rate between patients with 1-2 mature follicles and patients with 3-4 mature follicles (18.2 % vs 10 %, p = 0.99, respectively).

CONCLUSION

In IVF cycles converted to IUI for poor response, the risk of MP is acceptable (14 %) with no higher order pregnancies, even with 3 or 4 follicles ≥14 mm on trigger day.

Cost-effectiveness analysis comparing continuation of assisted reproductive technology with conversion to intrauterine insemination in patients with low follicle numbers

OBJECTIVE

To compare the cost effectiveness of proceeding with oocyte retrieval vs. converting to intrauterine insemination (IUI) in patients with ≤4 mature follicles during assisted reproductive technology (ART) cycles.

DESIGN

Probabilistic decision analysis. The cost effectiveness of completing ART cycles in poor responders was compared to that for converting the cycles to IUI.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Cost-effectiveness analysis.

MAIN OUTCOME MEASURE(S)

Cost effectiveness, which was defined as the average direct medical costs per ongoing pregnancy.

RESULT(S)

In patients with 1-3 mature follicles, completing ART was more cost effective if the cost of a single ART cycle was between $10,000 and $25,000. For patients with 4 mature follicles, if an ART cycle cost<$18,025, it was more cost effective to continue with oocyte retrieval than to convert to IUI.

CONCLUSION(S)

In patients with ≤4 mature follicles following ovarian stimulation in ART cycles, it was on average more cost effective to proceed with oocyte retrieval rather than convert to IUI. However, important factors, such as age, prior ART failures, other fertility factors, and medications used in each individual case need to be considered before this analysis model can be adapted by individual practices.

In vitro fertilization versus conversion to intrauterine insemination in the setting of three or fewer follicles: how should patients proceed when follicular response falls short of expectation?

OBJECTIVE

To determine whether in vitro fertilization (IVF) cycles with suboptimal response should be converted to intrauterine insemination (IUI) or proceed to oocyte retrieval (OR).

DESIGN

Retrospective cohort.

SETTING

Academic medical center.

PATIENT(S)

All patients initiating IVF from January 2004 through December 2011.

INTERVENTION(S)

OR versus conversion to IUI.

MAIN OUTCOME MEASURE(S)

A total of 1,098 patients were identified whose IVF cycles were characterized by recruitment of three or fewer follicles, excluding patients with bilateral tubal disease or severe male factor. Cycles with three follicles were defined as those with three follicles ≥ 14 mm with no fourth follicle ≥ 10 mm. Cycles with two or fewer follicles were similarly defined. Outcomes were compared for patients proceeding with OR (n = 624) versus converting to IUI (n = 474). Age-adjusted relative risks for pregnancy were calculated, stratifying for number of follicles.

RESULT(S)

The likelihood of retrieving at least one mature oocyte (82.9% vs. 94.8% vs. 96.2%), having at least one zygote (61.9% vs. 76.8% vs. 84.2%), and undergoing transfer (57.1% vs. 73.0% vs. 83.3%) increased significantly with increasing follicle number. Patients with three or fewer follicles were 2.6 times more likely to achieve a live birth with IVF versus IUI (9.3% vs. 3.4%). This benefit was only apparent when at least two follicles were present. No benefit was gained by performing OR in the setting of one follicle.

CONCLUSION(S)

IVF compared with IUI presents superior pregnancy rates in the setting of two or more follicles. Assisted reproduction programs may benefit their patients by pursuing IVF in this scenario.

IVF conversion to IUI in poor responders: an observational study

PURPOSE

The purpose of this study was to evaluate the significance of converting an IVF stimulation cycle with poor ovarian response to an IUI cycle.

METHODS

Between January and December 2007, 47 cycles of IVF conversion to IUI were retrospectively studied in 44 infertile women who had a low response to ovarian hyperstimulation for IVF. Patients' characteristics, ovarian stimulation, and ovarian response and outcome were collected and compared with those of 41 women undergoing ovum pickup for IVF with poor ovarian response (n = 44 cycles) in the same period.

RESULTS

Women in the conversion group had slightly lower ovarian reserve, shorter stimulation with higher rFSH doses, lower peak estradiol and fewer mature follicles than in the IVF group. Pregnancy rates were comparable in both groups, though clinical pregnancy rate tended to be higher in the conversion group than in the IVF group.

CONCLUSIONS

Thus, pregnancy rate in the conversion group compares favourably with IVF outcome in such circumstances. This means that IVF conversion to IUI in poor responders who are suitable for IUI is a valuable alternative that should be considered in their management.

Conversion from assisted reproductive technology to intrauterine insemination in low responders: is it advantageous?

OBJECTIVE

To examine cycle outcomes among patients demonstrating an attenuated ovarian response that proceeded to oocyte retrieval to those converted to intrauterine insemination (IUI).

DESIGN

Retrospective cohort study.

SETTING

Large private fertility center.

PATIENT(S)

First planned autologous assisted reproductive technology (ART) cycles among women demonstrating a poor ovarian response to hyperstimulation (≤4 follicles≥14 mm, peak E2<1,000 IU/L at hCG administration).

INTERVENTION(S)

Oocyte retrieval or IUI conversion.

MAIN OUTCOME MEASURE(S)

Live birth and clinical pregnancy.

RESULT(S)

A total of 269 IUI conversions and 167 oocyte retrievals followed a poor ovarian response to gonadotropins among first planned ART cycles. Number of follicles≥14 mm (2.3 vs. 3.5) and peak E2 levels (555 vs. 743 pg/mL) were lower for IUI conversions compared with those proceeding to ART. Peak E2 was similar between groups after adjusting for follicle number (IUI: 611 pg/mL; ART: 652 pg/mL). Stimulation response was similar between treatment groups with equivalent follicle numbers. Undergoing oocyte retrieval was associated with significantly improved pregnancy (odds ratio [OR] 3.6, 95% confidence interval [CI] 1.8-7.4) and live birth outcome (OR 3.5, 95% CI 1.7-8.0) after adjusting for age and follicle number.

CONCLUSION(S)

Among women demonstrating a poor ovarian response to gonadotropins, proceeding with planned ART resulted in significantly higher pregnancy rates than converting these cycles to IUI.

Oocyte retrieval versus conversion to intrauterine insemination in patients with poor response to gonadotropin therapy

We compared cycle characteristics and outcomes for planned in vitro fertilization cycles with five or fewer developing follicles that proceeded to retrieval (n = 170) with those that converted to intrauterine insemination (IUI) (n = 50). The risk of no embryo transfer was 24% in cycles that proceeded to retrieval. Live birth rate per cycle started was similar for IUI (6%) compared with retrieval (7%).

Poor responders in IVF: cancellation of a first cycle is not predictive of a subsequent failure

Management of women with a poor response to controlled ovarian hyperstimulation during IVF remains a frustrating challenge. The present study included 96 cycles from an equal number of women with a poor ovarian response and successful oocyte retrieval. Poor response was defined by the presence of at least one of the following characteristics: three or fewer oocytes on retrieval, serum estradiol level less than 500 pg/mL on the day of hCG administration, and serum FSH levels less than 20 IU/L. The same patients had a previous cycle cancelled because of a poor ovarian response whereas in the second cycle they preferred to continue the treatment despite the poor prognosis. We obtained 241 oocytes in the 96 IVF cycles. The fertilization rate was 60.2%. Three oocytes per cycle were retrieved in 56 cycles (58.3%), two oocytes per cycle in 33 cycles (34.4%), and one oocyte per cycle in 7 cycles (7.3%). In 19 cycles (19.8%) no fertilization was achieved. An embryo transfer was finally performed in 74 out of 96 cycles. Pregnancy rate was 12.5% per cycle and 16.2% per transfer. Among the 12 pregnancies achieved, 7 were in the 3-oocyte cycles and 5 in the 2-oocyte cycles. No pregnancies were achieved in the 1-oocyte cycles. Our data demonstrate that continuation of therapy in poor responders undergoing IVF can be an option despite the low pregnancy rates. The prognosis of these patients is not affected by a poor response in the first cycle and for some of them the outcome can be favorable.