A Tunisian woman is now pregnant with 12 babies. We even know the sexes. The still unidentified “Super Pregnant” woman is having six boys and six girls after two years of infertility and miscarriages. The world of reproductive medicine didn’t do right by her and neither did the insurance industry- because by now we should all know better. Unfortunately, it is often intrauterine insemination with fertility medication that is covered by insurance and IVF that is not. So a woman has the unfortunate choice of insurance coverage for her treatment and possibly risking a terrible outcome versus state of the art medical treatment. And it’s not about bad decisions made by bad doctors – those occur in every field of medicine. It’s about the science of reproductive medicine leaving behind techniques and procedures that some experts in the field of infertility simply feel we should be moving on from and not having their hands controlled by the insurance industry. I know – not a new debate – but one that is still on the stove and boiling over.
This is not about too many embryos being transferred in an IVF cycle – this is way more common a cause of high order multiple births than the “Octomom” scenario. Here we are talking the famous “Sextuplets” or “John and Kate Plus Eight”. We are talking about the almost impossible to control outcome of the use of gonadotropins (fertility drugs) combined with intrauterine inseminations (IUI’s). And it is this procedure that invites regulation or restriction of its use like no other. It is is this procedure that patients are often forced into doing before attempting IVF by many insurance companies.
In an IUI cycle with fertility drugs – a woman’s ovaries are hyper stimulated to produce many eggs – and then sperm is introduced to her uterus in the hope of achieving pregnancy. Unlike IVF – the doctor is not in control of how many fertilized embryos will implant. In fact in an IUI cycle – the doctor often does not know if any fertilization will occur at all. An IUI with fertility drugs is the ultimate fertility crap shoot. You could achieve no fertilization at all – or be on your way to a high order multiple birth.
Women with open fallopian tubes and no male factor infertility are either encouraged or forced to try IUI’s with fertility drugs before moving on to in vitro fertilization (IVF) because of outdated thinking that IUI is less invasion and less expensive than IVF. But the fact is for many of us that have been through it all – IUI’s and IVF – I can personally attest that doing an IUI cycle with gonadotropins involves almost the same hard work for the patient as an IVF cycle. For the patient – most of the discomfort – time and energy is in the use of the fertility drugs. There is the injections (no matter how small the needles are) – the blood work and the ultra sounds. All of this is the same in an IVF cycle. The only difference is instead of an insemination – the patient under goes an egg retrieval and embryo transfer.
For the patient – most of the discomfort, time and energy is in the monitoring of the fertility drugs and timing either the retrieval or the insemination. With IVF – we can control the amount of embryos that are transferred (and most reproductive endocrinologists are very ethical and do follow ASRM Guidelines). So why are we still doing IUI cycles with fertility drugs? The easy answer is the upfront cost – but the fact is that reproductive medicine keeps advancing and adjusting itself – and the insurance companies as well as some doctors just aren’t keeping up.
The best candidates for IUI’s (the younger patient) are also the best candidates for minimal stimulation or micro IVF) which only has a slightly higher fee than a traditional IVF cycle with a higher success rate than a stimulated IUI cycle and a much lower chance of high order multiple births. And with the high success rates that IVF cycles now enjoy per single embryo transferred, isn’t it time to simply move on from doing the low tech – high risk IUI cycles at all? I think so. And perhaps I will take it on the chin for saying so.
We have so many better treatment options for infertility patients than what we had 20 years ago – can’t we simply agree that we just won’t do IUI’s with fertility drugs anymore? And if the physician community stands together on this – might it just force the hand of insurance companies to take stock of reality and do the right thing by patients?
After all – It doesn’t even make good television anymore – we all know what happened to John and Kate – they are sharing custody with their eight.