Once the decision has been made to proceed with fertility treatment, many patients wonder if it is going to work for them. For an overwhelming majority of patients, the answer is yes, but overcoming infertility may involve a course of treatment, meaning it might take a couple of tries to achieve pregnancy. In cases where the first cycle isn’t successful, the key when looking to start another cycle is optimizing fertility treatment to increase the chance of success.
How can your fertility treatment protocol change to increase the likelihood of pregnancy?
When a treatment cycle does not result in a pregnancy, some patients see the attempt as a failure. This couldn’t be further from the truth. Changes in medication, treatment type, and introducing genetic testing can all lead to an increased likelihood of pregnancy next time around.
“The reality for patients is that fertility treatment is a great diagnostic tool,” explains Dr. Shruti Malik of Shady Grove Fertility’s Fair Oaks, VA and Arlington, VA offices. “Treatment allows us to gain valuable insights into your fertility that no diagnostic test can give us. Each attempt gives us an opportunity to make changes until we get the formula just right so that conception can happen.”
The key is to tailor each subsequent treatment to address what we learn about the patient in the previous cycle. “These minor tweaks and changes often lead to the outcome each patient is looking for,” says Dr. Malik.
Optimizing Fertility Treatment: Look at the Medication
No matter the treatment type, one of the most commonly made changes after an unsuccessful cycle is to the medication protocol. These adjustments may help increase or decrease the number of follicles, affect uterine lining thickness, and impact other key parts of your cycle.
Intrauterine Insemination (IUI) Medication
For most women, whether under the care of an OB/GYN or a fertility specialist, clomiphene citrate (Clomid) will be the first medication they use to help them conceive. Clomid is a common oral medication that helps treat irregular or absent ovulation. While it can work really well for some patients, others may experience a thinning of the endometrial lining that may impact the ability for an embryo to implant in the uterus.
For patients under the care of a fertility specialist, your physician will monitor both the growth of the follicles and the thickness in the lining throughout the cycle. If the lining does not become as thick as desired or the cycle does not result in a pregnancy then an alternate dose of Clomid or another medication such as Letrozole may be an option in a subsequent cycle.
Letrozole works in a very similar way as Clomid without the side effect of a thin lining. If a follicle does not develop, or the first cycle with one to two follicles is not successful, then your physician may add an additional medication, gonadotrophins, to the medication protocol. Gonadotrophins stimulate the ovaries to produce between two to four follicles, which gives the sperm more targets to hit, thus increasing the chances of pregnancy.
In Vitro Fertilization (IVF)
The most common change to medication in an IVF cycle comes when planning the stimulation medication dosing. If a cycle does not result in the number of eggs expected, then either the type of medications may be changed and/or the dosing will be increased in the next cycle. This will allow the patient to recruit and develop more follicles from the beginning instead of having to try to catch up mid cycle.
Optimizing Fertility Treatment: Transitioning to a New Treatment Type
More than half of all the treatment cycles preformed at Shady Grove Fertility are low-tech options such as IUI. “We believe in a stepped-care approach to treatment, starting with the simplest, most affordable treatment option first and moving up to more advanced treatments when medically indicated,” explains Dr. Malik.
“For many patients, it makes sense to start with a more basic treatment, but if that treatment doesn’t prove to be successful, it becomes a question of when to consider transitioning to another treatment to increase the chances of conception,” Malik adds.
In women under the age of 35, the success rate with IUI is between 16 to 20 percent. “The goal here is to bring the patient to the chances of pregnancy per month seen in the fertile population, which is around 20 percent.” As patients move to more advanced treatment options, such as IVF, the chance of pregnancy in that same age group more than doubles to 50 percent.
“IVF treatment can be very insightful as to why previous attempts did not work,” explains Dr. Malik. IVF treatment answers many of these questions we have about the patient and the factors that can impact her ability to conceive.
- Is there a viable egg available and is that egg mature?
Eggs that are being prepped for ovulation, grow and develop within the follicles found in the ovaries. However, not every follicle will contain an egg. During IVF treatment each egg is aspirated from the follicles during the egg retrieval. This allows us to confirm that, yes, there was in fact an egg in the follicle. After the eggs have been removed from the ovaries, physicians have a unique opportunity to determine if the eggs are mature. An immature egg cannot be fertilized making this a key piece of information in understanding the patient’s specific fertility. - Is the sperm able to fertilize the eggs?
During IVF, fertilization is done in an embryology laboratory, which allows embryologists to confirm that fertilization occurred. “There can be instances where the semen analysis looks great but the sperm is unable to fertilize the egg,” explains Dr. Malik. “This is a factor that can only be discovered when you are able to monitor the fertilization process as is the case with IVF,” adds Dr. Malik. When fertilization does not occur, your physician might recommend intracytoplasmic sperm injection (ICSI), which allows us to inject a single sperm into the egg increasing the rate of fertilization. - How do the embryos develop?
Another factor that greatly impacts the outcomes of treatment is the quality of the embryos. Embryos undergo a rating system to determine the high from low-quality embryos. Higher quality embryos are more likely to implant and become a viable pregnancy. Similar to the case with fertilization, this can only be evaluated outside of the body. The quality of a patient’s embryos can help inform the physician’s recommendations for a subsequent cycle. For patients who have low quantity or low quality embryos, the physician may suggest other treatment options such as donor egg treatment.
When egg or embryo quantity or quality becomes a barrier to conception, as commonly seen in women over the age of 40, then moving to donor egg treatment will significantly improve the outcome of treatment. For women over 40, chances of pregnancy via donor egg treatment is approximately 56 percent per cycle, double what the same age group would experience with IVF treatment using their own eggs.
Optimizing Fertility Treatment: Genetic Testing
Genetically abnormal embryos can implant and start a pregnancy but will often result in a miscarriage during the first trimester. “There are many patients that can easily get pregnant either on their own or with the use of fertility treatment but they’re unable to maintain the pregnancy,” says Dr. Malik.
The most common cause of first trimester miscarriage is a chromosomal abnormality within the embryo. As a woman gets older, her likelihood of having a genetically abnormal embryo increases. If you’re experiencing recurrent pregnancy loss (two or more consecutive miscarriages), your physician will discuss the option to genetically test each embryo with preimplantation genetic screening for aneuploidies (PGT-A), previously known as preimplantation genetic screening- PGS, to find those that are genetically normal.
During PGT-A, an embryologist biopsies each embryo to look for any chromosomal abnormalities that would likely result in implantation failure or miscarriage.
When a cycle does not result in a pregnancy or ends in a miscarriage it’s important to understand all of the care options available to you. Be sure to talk with your physician about the best path for you. Most patients will not need all of these options, but it is important to be aware that they exist and to let them guide you in your decisions about treatment.
Medical Contribution by: Shruti Malik, M.D., of Shady Grove Fertility’s Fair Oaks, VA and Arlington, VA offices.
Editors Note: This blog was originally published in December 2018.
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