How Do I Know When to Move from One Tier of Fertility Treatment to the Next?

Karen Jeffries, @hilariously_infertile

Part teacher. Part Mom. Part wife. Fully inappropriate. Forever infertile.

While we all know there are many tears while undergoing fertility treatments, we also know there are different tiers of treatments. But what are they? I am often asked, by my followers, how does one know when to move up through the tiers of infertility treatments? Before we discuss how to move from one tier to the next, first let us clarify what the tiers of infertility are.

Tier One: The At-Home Tier
Tier one is when you are figuring it out. This tier applies mostly to heterosexual couples who are no longer stopping conception on their own. My favorite term: you pulled the goalie. This is where you are tracking your ovulation, tracking your periods, having as much intercourse, planned and unplanned as possible. Picture: legs up. You might purchase a home ovulation kit during this time. You might even see a naturopathic medical professional to help you with hormones levels and overall general health.

Tier Two: Standard OB-GYN
This is where you start dipping your toe into asking for traditional medical assistance. Most likely your OB-GYN will tell you that it is common to stay in tier one for six months before moving on. They might run some blood tests, hormone levels and they might do an ultrasound of your uterus and ovaries, they might even start you on some oral medications like Clomid, or the like, to improve your ovulation.

Tier Three: Fertility Clinic
Tier Three actually has two tiers within it.

Tier 3A: IUI – Intrauterine insemination

A basic, very Hilariously Infertile way of describing IUI is that the man gives his sperm sample, the lab cleans his sperm – picture a sperm car wash – and then the doctors take a glorified medical turkey baster and shoot that sperm right up into your uterus. I like the turkey baster analogy, but I also enjoy thinking of it like those t-shirt cannons they use to propel t-shirts into the seats at crowded stadiums — both are fun. Most times you will be taking medication, either orally or through injection, to increase your ovulation during the IUI cycle and sometimes you will receive a trigger injection to help your body release the eggs prior to the t-shirt cannon turkey basting procedure.

Tier 3B: IVF – In vitro fertilization

IVF is the next round of intervention. The female is injecting hormones into her body for the first half of the month. Then the clinic will put the female under general anesthesia and harvest, for lack of a better word, her eggs from her ovaries. Then those eggs are put into individual petri dishes and they mingle with the sperm — I like picturing a cocktail party, but whatever floats your boat. Five to eight days later you could have a fresh transfer, meaning the now fertilized embryos are not frozen prior to going back into the female’s uterus oven. Or you could send your embryos off to be genetically tested in which case you will put those defrosted popsicle embryos back into her uterus oven at a later date. Branching off from this could be donor eggs, donor sperm or surrogacy.

Great, now that we have reviewed procedures that I am sure you are all too familiar with, let’s get into the big question. How do I know when to move from one tier of fertility intervention to another?

I went to my OB-GYN after six months of trying on my own and not getting my period. According to the experts, that was the right call. Dr. Lora Shahine from Pacific Northwest Fertility in Seattle says, “Professional guidelines recommend evaluation and consultation after one year of trying for a couple that is trying with regular predictable menstrual cycles and female partner age less than 35. Guidelines recommend evaluation after 6 months if the female partner is 35 years or older. Reasons to seek a medical professional sooner are irregular, unpredictable menstrual cycles consistent with ovulation dysfunction and seeking alternative family building options like donor sperm. There is no guideline specific to each person so it is ok to ask questions and have a consultation sooner rather than later.” Basically if you are under 35 and have regular monthly cycles, seek help after one year, if you are older than 35 with regular cycles wait six months. If you are any age but have a medical condition Dr. Lowell Ku from Dallas IVF explains, “For women who have known issues such as PCOS, endometriosis, tubal issues, lowered ovarian reserve, husband with lowered sperm count/quality, we recommend seeing the REI earlier to seek treatment and speed up the time to conception.” Essentially, if you fall into this bracket, don’t wait.

When I first consulted my fertility doctor, he explained my condition to me; PCOS, Polycystic Ovary Syndrome. He explained that because of my PCOS, I don’t ovulate. He gave me three options: clomid and intercourse, clomid and IUI, and IVF. I was still not emotionally sane about the whole infertility diagnosis, but I didn’t want my doctor to know how crazy I was going in my head, and I didn’t want my husband to know either, although looking back — he probably knew. I decided to go forward with Clomid and IUI, middle of the road, like Goldilocks I thought. I wanted to be more aggressive than we were at home, but I also didn’t want to go balls to the wall— yes, that is the technical term. We started with our first IUI. I also did an HSG procedure (hysterosalpingogram) where they shoot saline into your fallopian tubes and you feel as though you might die, and then they tell you it is all done. I had no blockages, clear to proceed forward once I could walk again.

I was part of that naive, idealistic group of patients that actually thought IUI would work on the first time. I still have not met anyone where IUI worked on the first round. I find myself rare that my second IUI resulted in a pregnancy — it happens, but we sometimes refer to these IUI pregnancies as unicorns on social media. My second IUI was a success, unicorn, and that is my first daughter Zoe. According to my fertility doctor, Dr. Frederick Licciardi from NYU Fertility in New York City, “Pregnancy rates with IUI vary from 1-20% depending on your age, problem and type of drug used. IVF always has a 2-3 times pregnancy rate over IUI. Most people go with 3 IUIs then IVF, but some decide to directly go to IVF. Insurance coverage plays a large role in these decisions.”

When Zoe was around 18 months old we wanted to start trying for another child. My clinic told me to go directly to them because I don’t ovulate and it made zero sense for me to try on my own. Essentially, don’t go back to tier one, is what they told me.

We started again with Clomid and IUI, my first IUI failed and the doctors believed that I did not ovulate that month at all. I remember thinking that was weird because we started me on the same amount, or milligrams, of Clomid that worked for my successful IUI with Zoe. Another four failed IUIs – five total – spanned the months of June, July, August, September and October of 2014. After my fifth failed IUI, I decided, and my husband supported me, that I wanted to move forward with IVF. I had zero data, zero consultation, zero statistics to support my decision to move onto IVF. I only had my gut instinct. I kept thinking, “If it was going to work, it would have worked by now.” But how do you know? According to Dr. Lowell Ku, “The recommended maximum number of IUI tries, before considering IVF, is 3.” Dr. Roohi Jeelani from Vios Fertility in Chicago adds, “Each case is very unique and different. Depending on the cause of infertility, we typically allow up to six IUI – after 3 rounds the chance of success is lower.”

We moved forward with IVF, I knew nothing about IVF prior to starting the process. I knew that there were stomach shots, and ass shots, and no exaggeration, that is all I knew. I was able to make it through the IVF cycle and after retrieving 33 eggs, we were able to transfer one embryo, and that is my second daughter, Abby. This is not typical. Having IVF success is also an uphill battle. How do you know? Are you going to be like me and have a successful first round of IVF? Or do you need to genetically test your embryos? Here are some of those answers from experts. Dr. Ku says, “Studies suggest that women who are less than 35 may not have an improvement in pregnancy rates from PGT [preimplantation genetic testing] as much as women who are 35 years old or older. Thus, women who are older than 35 may want to consider PGT to try and improve their pregnancy chances with IVF.” Dr. Jeelani agrees, stating, “If you have more than two rounds of failed implantation then we recommend IVF with PGT. Also in women over the age of 37 studies have shown IVF with PGT increases chances significantly. In general, IVF with PGT decreases miscarriages and decreases the interval to successful pregnancy.” Dr. Temeka Zore, from Spring Fertility in California adds, “The addition of PGT-A should be individualized on the couple. Some may choose to start with genetic testing to bank embryos for future pregnancies and they want realistic expectations of numbers of normal embryos. Female age, number of children desired and desire to know the sex of the embryo are all factors that may go into whether someone elects to pursue PGT with their IVF cycle.”

When I asked these experts what happens after multiple failed cycles of IVF – how does a patient know to turn to egg/sperm donor or surrogacy – the answers were interesting. Dr. Shahine explains the science behind that decision, “This decision is very patient-dependent. If someone has a high risk of aneuploidy embryos (history of recurrent pregnancy loss with aneuploidy pregnancies or advanced reproductive age) then PGT-A may be a first line treatment.” Dr. Ku lets his patients know that it is a personal decision for each family, “This is a tough one. It’s like asking, “When is it time to give up?” But I tell patients that moving on to donor eggs/embryos does not mean that you have given up. It means that you are doing everything you can to grow your family. But if the couple does not desire donor eggs/embryos, that’s ok too! There is no right or wrong. It’s what is right for you and your family.”

While we have all shed many tears over our infertility, I hope we can also gain knowledge about the different tiers of treatments and when to advocate moving from one tier to the next. Dr. Licciardi summarizes it perfectly, “As I tell my patients, ‘You’ll know.’ Of course these are difficult questions but I try to tell my patients to try not to worry too much about decisions they need to make in the future. Go with what feels best now. You’re really not sure what you are up against until it’s right in front of you. Decisions get made themselves.”