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

Capsule:
In patients undergoing IVF, oocyte retrieval compared with intrauterine insemination conversion is associated with superior pregnancy rates in the setting of at least two follicles.

Authors:
David E. Reichman, M.D., Vinay Gunnala , M.D., Laura Meyer, M.D., Steven Spandorfer, M.D., Glenn Schattman, M.D., Owen Davis, M.D., Zev Rosenwaks, M.D.

Volume 100, Issue 1, Pages 94-99, July 2013

Abstract:

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.

  • Micah Hill

    Thank you David and colleagues for the nice paper. As with Lauren, I was also curious on your thoughts about patients over the age of 40 with 2 or 3 follicles. Are you more likely to recommend IUI conversion in those older patients? I was also wondering if your group uses follicle flushing routinely in patients with so few follicles?

  • Lauren Johnson

    Congratulations to David and colleagues on an interesting study. Your paper addresses an important dilemma that patients and infertility specialists routinely face. Your data suggest that the benefits of proceeding with IVF are more profound among those who are 40 or younger. Do you think there is a role for IVF in this situation in women older than 40?

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