A 41 y-o,
Unexplained infertility (age-related) and mild ovarian reserve (AFC= 9), second IUI cycle (doesn't want IVF).
Well stimulated with CC (100mg/day) + HMG 75/day until day 12 when she got 2 follicles: 21mm and 17mm.
Ovestrion on day 12 and IUI 40 hours after. She wants a second IUI. Should we start progesterone? How many hours after can we perform the second IUI? Should we give another Ovidrel shot?
Prof. Bartmann, Ana MD, PHD,
Answer by Gill Lockwood
Without knowing how long is the duration of unexplained infertility I would always recommend IVF over IUI in a 41 year old with low ovarian reserve. If the couple cannot consider IVF then she needs stronger stimulation, double insemination and luteal support. IVF would be much better!
Dr Gill Lockwood
Answer by Peter Brinsden
Dear Professor Bartmann
Thank you for your enquiry.
Firstly, I would confirm what you are already aware of, which is that IUI in the over 40 year olds is not at all successful. I am sure you have already counselled your patient to this effect. I estimate her chance of success at somewhere between 2-4% per cycle. below are the UK national figures for donor sperm IUI, and husband IUI invariably is not as good as these figures. In our Clinic, we do not recommend IUI over the age of 39 because of these poor success rates. She should be told, in my opinion and most UK practitioners, that she should go for IVF, even though her chances of success with this are also not that good. I appreciate, however, that she does not want IVF, but when our patients are informed of the advantage, many change their opinion. Below is a table of the UK data on Donor IUI for your interest:Year of treatment: 2009
18– 34 15.0%
35– 37 11.4%
38– 39 8.2%
40– 42 5.9%
43– 44 0.7%
If you do make another attempt at IUI, I believe that what you achieved with your last treatment was near an ideal cycle, as one does not want more than two oocytes really. I would stick to the same regimen, but give her luteal phase progesterone - a recent paper has shown some benefit, although we have not usually used it for straight IUI. Evidence also is that a second IUI 24 hours after the first insemination is of no benefit. In my opinion a second Ovitrel shot would not be useful. The timing of the insemination after the HCG injection is variable in the literature, but anywhere between 36 - 40 hours seems to be the normal timing; we usually do it between 38 and 40 hours - a single insemination.
I hope these few thoughts are of some help - these are always difficult cases and should, in my opinion, be steered away from IUI at this age towards IVF.
Peter R Brinsden MB BS FRCOG
Specialist in Reproductive Medicine
Group Medical Director, Bourn Hall International