Wednesday, August 19, 2009

IUI versus IVF versus laparoscopy

If your diagnosis is unexplained infertility, it can often be difficult to decide as to what your next action step should be. This is because there are multiple options, and patients often have a hard time choosing which one is right for them.
Often the advise you will get from a gynecologist will be completely different from that which you get from an infertility specialist , and this makes a bad situation even worse because patients don’t know whom to trust.

In the past, a diagnostic laparoscopy used to be a standard part of the infertility workup. By introducing a telescope into the abdomen , the gynecologist could inspect the pelvis ; confirm the fallopian tubes were open ; make a diagnosis of endometriosis ; and remove peritubal adhesions. Not only did laparoscopy allow the gynecologist to make an accurate visual diagnosis , it also allowed him to treat certain problems at the same time, such as peritubal lesions and endometriosis.

Since this was minimally invasive surgery , it was quite easy to convince patients to signup for it; and since it was an operative procedure , gynecologists could charge high fees for doing it. In fact , for many gynecologists, laparoscopy is the most frequently performed surgery they do.

However , in my personal opinion , a laparoscopy is often overused and misused. Most infertility specialists use this procedure very sparingly today, because even though it may be “ minor surgery “ , it is still far more invasive than the other modern options which are available today. Doing a diagnostic laparoscopy to establish tubal patency is overkill, because this can be done as reliably with a simple hysterosalpingogram. While an operative laparoscopy can remove peritubal adhesions and treat endometriosis , it is still unclear whether these operative procedures actually help to improve the patient's fertility. While some patients may conceive after a laparoscopy, for which the gynecologist takes the credit, the pregnancy may not be because of the laparoscopy itself.

What about choosing between IUI and IVF ? Both have advantages and disadvantages, and should not be thought of as being competitive procedures, but rather as being complementary procedures. An IUI is much simpler to do and is much less expensive , but also has a lower pregnancy rate, and patients need to weigh the risks and benefits before choosing between the two. As a useful rule of thumb , for young patients, IUI would be the first option. However if three IUIs fail, then it's time to move on to IVF.

If you are confused because you are receiving contradictory advise, you need to formulate your own treatment plan, which takes into consideration your own personal preferences as well as your medical problems.

1 comment:

  1. Dr. Malpani,

    I have just finished my third round of clomid, estradiol, and progesterone medications with no success. I am currently seeing an OBGYN who has not monitored me through any of the cycles. I have a history of one ovarian ectopic pregnancy, which was known to have caused scarring. I was also diagnosed with another possible ectopic pregnancy. It was terminated early because my progesterone levels were very low and my HCG levels stopped doubling. My husband and I have been actively trying to conceive for a little over a year with no success. We have had two chemical pregnancies but no further luck. My OBGYN has suggested a laparoscopy as my next treatment. I am concerned that it would just be pointless. Should I be seeing a RE? Would you recommend a lap before recommending IUI or IVF treatments? Also, I am 25 years old and otherwise in great health. I have had a hysterosalpingogram, which showed clear tubes. My husband's sperm analysis came back fine. Any advice would be greatly appreciated.

    Thanks,
    B

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