Fertility

Choosing a path when you have DOR / IVF, Embryo Banking, IUI

There are many hard choices when you start with treatments. I’m hopeful this post will help with prospective as you decide which path is for you. In my groups, these choices seem to be some of the more confusing ones for people to sort out.

First, DOR – this can be defined so many ways. Someone with an amh of 0.9 and an AFC of 12 can be labeled DOR if they are 30 years old but they are clearly in a better spot than someone with amh 0.09 and AFC of 2 at 30 years old. And someone with amh of 0.9 and AFC of 12 who is 40 would not be in the same shoes as the 30 year old with the same numbers due to decreasing quality as we age. So, as you think through the path for you, you have to consider your individual situation.

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IVF

Sometimes jumping into IVF makes the most sense. If you are hoping for more than child, are young, say under 35, and have OK numbers (AFC is decent, Amh is slightly low, FSH is normal), it is reasonable to hope for a pregnancy AND something left over for the next child. Just be aware that it isn’t the most likely outcome. I have seen stats show anywhere from 35-45% of cycles end with extra embryos to freeze, and this includes everyone, even those who make a lot of eggs.

Also, remember that only about 37% of all first time IVF cycles in women under 35 result in a live birth. Obviously stats change all of the time, but read up on it and go in with an open mind. All of this is to say, IVF is not a guarantee. IVF works by taking a group of eggs, fertilizing them and narrowing them down to the best ones to transfer. In some of us, because we retrieve so few eggs, and you generally lose some before transfer, there is no narrowing down.

So I would think through these questions and possibly discuss them with your doc:

  • At my age, about what % of eggs can we expect to be healthy?
  • With my lab values and AFC (and any previous response from any other cycles) what kind of response do you think I’d have?
  • How much will each try at IVF cost me (us)?
  • How many children do I (we) want to have?
  • Are there any values like FSH where you would refuse to do IVF with me?

Some of the downsides of IVF is that it is quite expensive and usually cost prohibitive to do enough cycles. If you do have success but have nothing left to freeze and want another child you will be ‘9 months of pregnancy + however long breastfeeding ‘ older when you start for another child. If you do get pregnant but have a miscarriage, you will be 8 or 12 weeks or longer out of the TTC game. PGS testing can help decrease the chance of a loss greatly, but it is, like everything else in this world, no guarantee.

Embryo Banking

Embryo banking is essentially doing several retrievals over a period of time, likely PGS testing anything that makes it to blast, and then transferring when you have banked your total number of desired embryos. Banking can be a really helpful tool for women with low response. Think of the normal woman who gets 15 eggs in one cycle, maybe 9 fertilize and then she ends up with 5 blasts. Now think of DOR and getting 3 eggs per cycle, doing 5 cycles, getting 9 to fertilize and 5 blasts. Banking has its downsides obviously. It’s physically hard on the body to cycle over and over and over. It’s emotionally trying – imagine doing cycles and having nothing go to blast or no blast pass PGS – that is likely to happen a cycle or two for all of us. It can be quite costly depending on where you do it and it can be hard to find clinics who have packages or pricing to make it work for you. It also is long. You may think 6 cycles equals 6 months, but don’t count on that. You can be benched a cycle for cysts, or your hormones are out of whack, or your cousins wedding happens to fall at the wrong time, etc… I would plan on double the time. If I was planning to do 6 cycles, I’d give myself a year to complete them.

However, if you can endure all of that, you can end up 1 year older with enough PGS embryos to build the family you desire. It’s awful to go through but I think of it like labor – you won’t remember all the pain once you are holding your precious baby.

Questions to discuss with your doctor about embryo banking may include:

  • Can I (we) afford multiple cycles, is there any sort of package?
  • How do I (we) determine the plan – how many cycles to do vs how many embryos do I need?
  • Am I (we) prepared for the emotional rollercoaster?
  • If I(we) happen to end up with more blasts than I need, what will be done with them?

IUI

Some people give IUI a bad rap. They talk about success rates vs IVF as if they are comparing apples to apples. The reality is in most cases, they are speaking of a cycle that consists of an oral med and trigger shot (based solely on follicle size) compared with a cycle consisting of some sort of priming, an agonist or antagonist, injectables or injectables and oral meds, trigger based on estradiol levels, lining thickness and follicle size.

Most women couldn’t do IUI with the same protocols that are used for IVF because they would make too many follicles. It would put them at risk for high order multiples. When you are DOR, and only making a few follicles, there is no reason not to do a full, scientific protocol. When looking at success rates when IVF was canceled to IUI due to poor response, there isn’t a lot of difference between continuing IVF or doing IUI. If your tubes and sperm are good, you may benefit from being able to afford more cycles to allow you a greater chance to find the good egg. Let’s say egg #11 is the good egg, and you make 3 a cycle, then you’d be on cycle 4 when it finally appeared. Can you afford to do 4 cycles of IVF? Doing IUI with a full protocol is more expensive than just oral med and trigger, due to the medication cost, but still is a lot cheaper than IVF at most places.

Questions to discuss with your doc about IUI:

  • What protocol will you do with IUI? Is it the same as you would do for me with IVF? If not, why?
  • How much will the IUI cost? What’s the difference between IVF and IUI costs, monitoring, retrieval, transfer, PGS vs, sperm wash and insemination?
  • Do I(we) want more than one baby? If I get pregnant with one baby now, will I have time later to do this again?

Overall, the decision on how to proceed is a highly individualized and personal one. So much depends on how many kids you want, how much you can spend, and how old you are, not just for quality of eggs but also time to spend. I started with a doctor 4 years before I had my son. That’s a long time. We had several early losses. Each one cost me 8-12 weeks of TTC time. I had the one late loss which cost me overall 10 months of TTC time. It all adds up very quickly. If you are starting at 38 and want 2 or 3 kids, banking is likely the better route to be sure you have time. You can transfer a frozen embryo at 44 but making an embryo at 44 is a lot harder. If you are starting at 30, your eggs are good quality and you have more time so losing 12 weeks to miscarriage or breastfeeding for a year won’t make as much of an impact on your chance to have another.

Lastly, whatever you decide, try not to second guess yourself. Commit to it and move forward. Especially after I lost my twins, I regretted not having banked embryos and was so scared that I’d never have success, starting from nothing again. Then when I had my first, I regretted it even more as I was now months away from 40 and starting again, with nothing, except even worse labs and less, older eggs. I was beyond lucky to have a natural conception baby at 41, my second son. And now looking back, I hate that I suffered with blaming myself and saying I should have this or that. The regret and second guessing can really eat you alive. There is so much else in this process to get you down. There is no right answer or right choice, so trust yourself and know that at the end of the road, no matter how it turns out, you made the best decisions for yourself.