Intrauterine insemination, in vitro fertilization: which method is more effective and what is available in the SUS?

Research released in 2019 by the IBGE (Brazilian Institute of Geography and Statistics) showed that the female participation rate in the workforce was already 54.5%. This indicates, in part, that women aim to fly higher and higher when it comes to a professional career. However, the biological clock does not wait and, after menopause, they are not always able to get pregnant without the help of science.

This is because, unlike men, who produce sperm all their lives, women do not produce eggs forever, as explained by Renato Fraietta, associate professor, deputy head of the Urology discipline and coordinator of the Integrated Human Reproduction Sector from Unifesp (Federal University of São Paulo).

“With each menstrual cycle, hundreds of eggs are prepared, but she ovulates only one, and the rest dies. We call this programmed cell death, which occurs until she enters menopause. And what happens is that this stock is not renewed with each ovulation, then, she just loses it”, summarizes Fraietta.

The specialist mentions that, biologically, the woman is at the peak of fertility, that is, with a huge ovarian reserve, from 18 to 28 years of age, on average. Between 32 and 35, she still has a good potential to get pregnant, but from that age until 37, there is a sharp drop in the quantity and quality of eggs.

“Up to 35, she still has between 17 and 20% chance of pregnancy per menstrual cycle. But between those 35 to 40 years old, the rate drops to just a 5% chance of getting pregnant without intervention”, says the coordinator of the Integrated Sector of Human Reproduction of the Federal University of São Paulo.

Already after the age of 45, the chances of a natural pregnancy revolve around less than 1% and from the age of 50 it is considered extremely rare. In this sense, it is worth remembering that women over 40 have high-risk pregnancies.

“They are at risk due to their greater propensity for miscarriages, gestational diabetes, pre-eclampsia, restriction of the baby’s growth, premature labor, among others”, warns specialist in human reproduction Mychelle Garcia, gynecologist and obstetrician at MEJC (Maternidade Escola Januário Cicco), linked to the Ebserh network, from UFRN (Federal University of Rio Grande do Norte).

On the other hand, Garcia, who is also coordinator of the Maternity Assisted Reproduction Center—says that it is possible to reduce these risks during pregnancy. “The first step is to be in good health before becoming pregnant: normal weight, practice physical activity, if you have chronic diseases that these are controlled and maintain all the care requested during prenatal care”, she emphasizes.

And, if there is difficulty, the woman can resort to some methods to achieve the long-awaited pregnancy. See below what they are and how they work:

intrauterine insemination

This is the oldest technique. In this case, the woman takes medication (injectable or oral) to stimulate ovulation and then goes through a follow-up of her menstrual cycle through ultrasound exams, therefore, insemination can only be done while she is still menstruating.

The next step is semen collection (through masturbation). Then, the best spermatozoa are selected and prepared, which are transferred directly into the woman’s uterus on the day of her ovulation.

“We shouldn’t call it artificial, because there’s nothing artificial about it. People call it that maybe because it’s not the woman’s natural cycle, but the DNA belongs to the couple. It will be the couple’s child and a pregnancy like any other”, guides Fraietta.

This is an outpatient procedure that does not require anesthesia or rest. According to experts interviewed by BBC News Brasil, the success rate is between 10 and 25% per attempt.

However, it is not indicated to make more than three insemination attempts, especially because of the cost-benefit ratio. On average, intrauterine insemination costs between R$ 5 and 10 thousand, depending on the clinic. Without success, the medical advice is to go for in vitro fertilization.

The main side effect of intrauterine insemination is swelling, due to hormonal drugs in high doses that retain fluid. Headaches are also common, and both can cause discomfort, but there are already well-established protocols and these symptoms tend to be temporary. Therefore, the risks of this procedure, in general, are minimal.

In vitro fertilization

This is considered the most effective treatment, especially if the woman had her eggs frozen before age 35. But it is worth mentioning that a pregnancy is not recommended from the age of 50.

Fertilization does not place the semen in the woman’s uterus. In this method, the woman receives a much larger load of hormonal drugs and the specialist, under anesthesia, aspirates (removes) her eggs and fertilizes them with the partner’s sperm in the laboratory, which, in turn, will promote the development of the embryo— uniting egg and sperm.

After formation, the embryos are implanted in the woman, which may or may not stick. According to Fraietta, the chances of success depend on age:

Women up to 35 years old have between 50 and 60% chance of pregnancy per attempt;
36 to 39 years is around 30 and 40%;
40 years, 20%;
42 years is between 8 and 10%;
43 years, 5%;
From 44 onwards, 1% to 0 to work.

In vitro fertilization has a few variants. For example, contrary to the intrauterine procedure, it is possible to perform it even after menopause, as the woman can receive eggs from an anonymous donor, whose procedure is called “donor egg”.

Everything is done anonymously — the donor will not know the identity of the recipient and vice versa. The donor’s eggs are prepared and collected to be fertilized with the semen of the recipient’s partner in the laboratory.

A CFM (Federal Council of Medicine) resolution, published in 2021, also allowed the donation of eggs and sperm between relatives of up to 4th degree for in vitro fertilization procedures.

“Women who don’t have a uterus can also use that of a “borrowed” relative of up to the 4th degree to just carry the child”, adds the coordinator of the Integrated Sector of Human Reproduction of the Federal University of São Paulo, remembering that the choices depend, individually , of each case.

All these procedures, therefore, are supported by law. “The child belongs to the woman who requested and performed the procedure. The DNA may belong to the donor, but the child is emotionally and legally hers”, clarifies Fraietta.

Although this procedure is considered the flagship for the success of many pregnancies, there is an obstacle: the price. It is estimated that in vitro fertilization in private clinics ranges between R$ 20,000 and 50,000 per attempt.

“When a patient undergoes in vitro fertilization, she will spend between BRL 4,000 and BRL 6,000 just on medication, included in the final amount”, estimates Caio Parente Barbosa, gynecologist and obstetrician at Instituto Ideia Fértil de Saúde Reprodutiva and pro- Dean of Graduate Studies, Research and Innovation at FMABC (Faculty of Medicine of ABC).

The side effects are similar to those of intrauterine insemination. And both methods increase the risk of twin pregnancy.

scheduled sex

This is another method in which the woman receives medication to stimulate egg production and, after a period, the couple is guided on the best days for sexual intercourse.

However, experts say this procedure often works for younger women, as the chances of getting pregnant naturally in their 40s are slim.

“And time goes by and the situation becomes increasingly difficult, so at that age the indication is to do in vitro fertilization, to have more chances in that short interval that she still has to get pregnant”, warns Fraietta.

What is available on SUS?

Here we come to a stumbling block. On the one hand, doctors claim that SUS does not provide funds for human reproduction treatments.

“There is no code in the SUS table that includes these assisted methods” says the coordinator of the Integrated Human Reproduction Sector at the Federal University of São Paulo.

However, Fraietta points out that, in Brazil, there are about 13 assisted human reproduction services in some public hospitals.

“SUS is national, so you can’t go to any public service hospital because it doesn’t offer it. But there are state hospitals that receive funds directly from the State Health Department for human reproduction. In São Paulo, for example, there is the Women’s Hospital (formerly Pérola Byington) and Hospital das Clínicas, which offer 100% free intrauterine insemination and in vitro fertilization services”, says the coordinator of the Integrated Human Reproduction Sector at the Federal University of São Paulo.

For the gynecologist and obstetrician at Instituto Ideia Fértil de Saúde Reprodutiva, in addition to the shortage of free treatment, there is another important point. “SUS does not cover treatments, nor fertility preservation. And this is a big problem, because there are cancer patients who are going to undergo chemotherapy and who need to preserve their eggs through freezing, but they cannot”, argues Barbosa.

In short, experts consider the number of public hospitals insufficient to meet the demand and believe that many women give up treatment due to bureaucracy or after years in a queue.

The Ministry of Health, in turn, claims to have these treatments subsidized by the folder. “The treatment for fertilization has been fully offered by the Unified Health System (SUS) since 2005, with the National Policy for Comprehensive Care in Assisted Human Reproduction”, says an excerpt from the note sent to the report.

The entity claims that the gateway to these procedures is primary care, that is, the health centers and UBSs (Basic Health Units). In these places, according to the Ministry, there is reception, general guidelines for women, physical examinations and evaluation of other situations that may interfere with a pregnancy.

“When necessary, women can be referred to specialized care”, says the folder. Regarding the demand for carrying out the procedures, she passes the baton to the state and municipal health departments which, according to her, are responsible for managing these services. “Bearing in mind that the SUS is decentralized”, he limited himself to saying.

Also according to the agency, the states that have free Assisted Human Reproduction Care services registered are: Federal District, Minas Gerais, Rio Grande do Sul, São Paulo, Pernambuco and Rio Grande do Norte.

When to seek help?

Even if the woman is new, if possible, she should see a specialist after a year of unsuccessful attempts. “Or, after the age of 35, if six months go by and she doesn’t get pregnant, she should see a doctor, precisely because of the drastic drop in eggs”, says Fraietta.

In addition, there are cases in which fertility is impaired, such as endometriosis in women, varicocele, testicular cancer, chemotherapy or radiotherapy treatment, in the case of men. In all these situations, help should be sought as soon as possible to treat the underlying problem and then try to get pregnant.

* This text was published at https://www.bbc.com/portuguese/brasil-63722144