Melanie Cole, MS (Host): Getting pregnant isn't always as easy as you might hope. And for many couples that can take some extra work or possibly medical intervention. That's where intrauterine insemination or in vitro fertilization come in. We're talking about that right here today, on Fertility Talk with the Reproductive Science Center of New Jersey.

I'm Melanie Cole and joining me is Dr. Alan Martinez. He's a specialist in reproductive endocrinology and infertility at the Reproductive Science Center of New Jersey.

Dr. Martinez, thank you so much for joining us today. I love when you're on because we always have such a lively, great discussion. Tell us the difference between IUI and IVF, because I think people don't really understand what those two are.

Alan Martinez, MD: Thank you for having me on again, Melanie. Appreciate it. So IUI, or intrauterine insemination, is a treatment option for patients that is usually reserved for those with appropriate ovarian reserve on laboratory testing, functioning fallopian tubes, and overall a general good sperm quality. It is the use of medicines to recruit eggs, and essentially it increases the chances that both egg and sperm come together. So maybe recruiting more than one egg and bringing sperm closer to the target so that egg and sperm meet in the fallopian tube, fertilize, and then make their journey and travel down to the uterus. So that's IUI.

For IVF, it involves stimulation of the ovaries. But it is also used in patients that may have a lower egg quality, that may have tubes that are not functioning, or blocked, or absent. It allows us a treatment modality where deficits in sperm or poor sperm function can be overcome with greater efficacy. So the IVF involves stimulation of ovaries to recruit eggs, but then before those eggs are released into the fallopian tube, they are removed in the laboratory, and egg and sperm are brought together in the setting of the lab to create embryos, and it opens up the whole world of the development of embryos, and also allows us to genetically test embryos to make sure they don't have any conditions, such as cystic fibrosis or various other conditions, as well as the number of chromosomes, specifically called the ploidy status, to make sure that you are transferring back an embryo into the uterus that has a normal genetic makeup.

Host: Isn't that amazing? The technology that's available today, Dr. Martinez. It's so fascinating. So how do you work with a couple to decide between IUI and IVF and how does age, I mean, you've mentioned a few of the reasons you might do one or the other, but how do age, infertility, those kinds of conditions come into play when you're making that decision?

Alan Martinez, MD: Yes, the maternal age specifically is a very important component. When I meet with couples or patients, we assess and consider both their age. We obtain laboratory hormone assessments, which tell us about the full picture of how the ovaries are behaving for a given age. We know that as a female ages, specifically 36, 37, and 38 years of age and older, that the miscarriage rate exponentially goes up. And that's a direct result of the aging of the eggs which is a direct estimation of the strength of the chromosomes of each individual egg that is being used to try to conceive. The maternal age is definitely the primary factor, and patients above 37, 38 years of age, oftentimes, to overcome that low egg quality or the abnormal chromosome eggs that exist in a patient;

the use of IVF allows us to treat and help those patients at a more productive and a more efficacious level.

Host: Under which conditions, Dr. Martinez, would you recommend IUI as a first line treatment? Is there a sort of an order that you follow at any time?

Alan Martinez, MD: It's a very good question, Melanie. Talking along the same lines, a younger patient, especially a patient less than 35 years of age, with appropriate functioning anatomy, specifically the tubes, as well as access to overall good sperm, either through a partner or through donor sperm, can be an ideal candidate for IUI.

And that's often where we start with the literature and research saying that in those good candidate patients, starting with IUI is a excellent modality of treatment. And usually completion of three or four IUIs in total is an adequate attempt at that specific level of treatment. Which then if a couple or a patient is unsuccessful after those attempts, the indication to move to IVF definitely becomes a viable option.

Host: What about success rates, Dr. Martinez? How do they compare?

Alan Martinez, MD: Yes, overall, the IVF is going to give you the highest success rates. In an excellent patient that is a candidate for IUIs, and in a perfect scenario, most of the IUI treatment is modalities can get you back to around 20 percent per treatment cycle. With IVF, because you are looking at the egg maturity, you are looking at fertilization, you are looking at development of embryos, and in the ultimate treatment case of biopsying embryos to look for the chromosomal makeup, you can bring the rates up to 60 plus percent per transfer of an embryo after IVF with embryo biopsy and testing.

Host: I imagine that one of the more common questions that you receive, and we hear this question about fertility treatments across the board, are the risk of multiple pregnancies. Tell us a little bit about how that compares between IUI and IVF. Do we end up with multiples? How does that work?

Alan Martinez, MD: Well, there are clear guidelines that exist from the American Society of Reproductive Medicine about how aggressive or the goals of both IUI and IVF treatment. Therefore, with IUI treatment, the goal is to, in a maximum case, recruit one, two, or three mature eggs and expose those eggs that are ovulated to sperm.

In those cases, if a cycle is appropriately managed and there is not an excess of an ovarian response, the ultimate multiple pregnancy rate for IUI should remain around five to eight percent, which is a little bit more elevated than if a couple was naturally trying to conceive with a background multiple rate of about two to three percent. So while it increases it, it does not increase it, it's an acceptable level of increase, and we do our due diligence to make sure we monitor patients for their ovarian response to indeed keep them safe in those IUI cycles.

Now, for IVF, the fascinating aspect of this is that we are helping nurture embryos in the laboratory, and we are testing those embryos for their genetic status or to make sure that they are euploid embryos. And when we do this, the indications are really to transfer pretty much across the board, one embryo per cycle attempt. Therefore, the multiple pregnancy risk is minimized and overall it is about three to five percent. And that is essentially when an embryo splits into a form of an identical twin.

So, both of these treatments, both IUI and IVF, only mildly increase the multiple pregnancy rate, with actually the IUI treatment, because you're only exposing the female uterus to one embryo, you have a lower overall multiple pregnancy rate than in many IUI cycle attempts.

Host: That's so interesting. You just gave us such a good lesson, Dr. Martinez, you're such a great educator. Now, what about cost? Because again, we know and we've heard that fertility treatments can be expensive. Does insurance cover both of these? Do they choose one over the other? What about the cost difference?

Alan Martinez, MD: Yes. And that is a topic of discussion along with the desired treatment modality in couples. And overall, the IUI, in most cases, is going to be a lower overall cost versus the IVF, which involves a higher level of involvement of both medications that are taken oftentimes, work by personnel in the laboratory for a given practice, as well as all the manipulation and preparation that goes into preparing a patient to conceive. The availability of coverage depends on where the patients are located in the United States, as there are various coverage options in different states, and specifically in the state of New Jersey where we are located, the levels of coverage depend on the individual policy holder and what that company has selected.

So, therefore, there are some coverages that may entail only IUI treatment as an option. Some is of a point system set up to where you can have a IUI be a certain value, point value system, and IVF is a different point value system and they have a total number of points.

And some of the coverage cover a unlimited number of IUIs and a certain number of IVF cycles, so you can really have a vast array of coverage. And so we always meet with our patients. We have excellent financial advisors and we'll walk the patients through that process to see what kind of coverage and make the best choice for them as the individuals.

Host: So as we wrap up, and you've taught us so much today and given us a lot to think about, Dr. Martinez. What advice do you give couples as they come to see you? They're trying to decide. You're looking at the various factors you've discussed here with us today. How do you help them decide? And how do you help them to deal with the emotional toll and the bit of a roller coaster that they may embark on when they attempt fertility treatments?

Alan Martinez, MD: You used some of the same words that I mentioned as far as the rollercoaster Melanie, and my goal in the attempt at Reproductive Science Center of New Jersey is really to be a very supportive environment. We want to welcome the patients in, we want to establish a trust relationship with the patients and it's a shared decision making process.

So we gather information and that's our responsibility is to obtain this information, to synthesize it and to present it in a way that the patients can understand, follow, and so that they specifically know what treatment percentage possibilities they have, based on their individual patient case. And then once they understand this;

they can feel confident in that they can make the best decisions. But I do mention to them that it is a process and it is more of a marathon than a sprint. In many cases, you can have a rollercoaster effect where they may start out. They may get lucky and they're right off that rollercoaster, they have an ongoing pregnancy and they're happy.

Other times it may be consistent with some up and downs and it may take them a little while to get there. But, the trust is the most important part, and for them to be educated and understand exactly what their opportunities are and their options, and let them decide. That sense of empowerment is something that helps out patients tremendously.

Host: Thank you so much, Dr. Martinez. You're a great guest as always. Such a nice man. Thank you again for joining us. And for more information, please visit fertilityNJ.com to get connected with one of our providers. That concludes this episode of Fertility Talk with RSCNJ, the Reproductive Science Center of New Jersey. I'm Melanie Cole. Thanks so much for joining us today.