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IUI or IVF? What to Consider
Intrauterine insemination (IUI) vs. in vitro fertilization (IVF)
is a question that gets asked of fertility doctors quite often. "Should we do IUI (also known as artificial insemination) or go straight to IVF?" Or, "How many cycles of IUI should we try before moving to IVF?"
The Cost of IUI
IUI is much less expensive than IVF and can be a cost-effective solution for infertile couples. Keith Blauer, M.D., a fertility doctor with Reproductive Care Center in Utah, says his fertility patients are most likely to request an IUI procedure first. "This is often a cost benefit issue," he says. "Our patients in Utah are very cost conscious and prefer to try less expensive options first even if the pregnancy rate is low."
IUI can cost anywhere from $300 to $2,000 per cycle depending on the fertility clinic, the type of fertility drugs used, and the type of monitoring and blood work that is performed.
Who May Benefit from IUI?
To understand why IUI may be helpful to a couple having trouble conceiving, it's important to understand how far sperm has to travel to fertilize an egg — from the vagina through the cervix (which limits the number of sperm that keep traveling), into the uterus and up into one of the fallopian tubes. With an IUI, the male partner's semen is collected, "washed" in a laboratory to concentrate the sperm and remove seminal fluid (which can cause severe cramping), and then slowly injected via a catheter into the woman's uterus. By putting the sperm directly into the uterus, they have much less distance to travel to the fallopian tubes.
A couple may benefit from IUI if:
- the female partner has an ovulation disorder and has been unable to get pregnant with only the ovulation-inducing fertility drugs
- the female partner has cervical factor infertility, such as scarring, or problems with the cervical mucus (which can be caused by fertility drugs such as Clomid)
- the male partner has a low sperm count, low sperm motility (movement) or poor morphology (shape)
- the male partner has ejaculation problems
- the male partner freezes his sperm to preserve fertility before a surgery or cancer treatment, such as that for testicular cancer
- the couple is using donor sperm in order to conceive
IUI may also be used as a first-line treatment for unexplained infertility or mild endometriosis. "For IUI, the woman must have at least one open fallopian tube, reasonable egg quality and the ability to induce ovulation if needed, and the male partner must have adequate semen parameters," Dr. Blauer says.
IVF is indicated as the course of treatment for patients with blocked fallopian tubes, advanced endometriosis, failed IUI cycles, very poor sperm parameters/severe male factor infertility or vasectomy. In these cases, patients will probably spend less per live birth than if they chose IUI-based treatment. The decision is really made on a case-by-case basis, and some studies have shown that bypassing IUI is more cost effective and pregnancy rates are higher.
IUI and Ovulation-Inducing Medications
IUI can be performed without fertility drugs, but the chances of success are greater if ovulation-inducing medications are used. However, there is also the very real risk of becoming pregnant with multiples when taking fertility drugs with IUI.
Typically, the female partner will take an oral fertility drug such as Clomid (clomiphene citrate) or Letrozole/Femara. Other times, gonadotropins — injections containing follicle stimulating hormone (FSH) may be used. In addition, hCG may be administered in order to trigger ovulation and optimally time the insemination. The procedure can be timed by ovulation predictor kits (OPK) which determine the most fertile time in a cycle by detecting the presence of luteinizing hormone (LH) in the urine. Or, the physician can monitor the growth of the ovarian follicles via ultrasound and confirming blood tests.
"Our most commonly used protocol is Clomid — 100 mg a day on days 3 through 7 with the IUI the day following a '+' on the OPK," Dr. Blauer says. However, he says the most successful protocol is IUI with a combination of Femara and injectable FSH plus ultrasound monitoring.
If IUI is performed in conjunction with injectable fertility drugs, the risk of multiples increases significantly. Therefore ultrasound monitoring of the follicles is very important in order to reduce this risk. If too many mature follicles develop, the IUI cycle can be canceled, or it can be converted to an IVF cycle.
IUI Success Rates
Typically, it is recommended that a couple move on from IUI after three to six failed cycles.
The success of IUI depends on many factors, with age being one of them. At the Reproductive Care Center, the positive pregnancy test per IUI cycle for 2009-2011 for all protocols (Clomid, Femara and Femara/FSH) range from 13 percent for ages 41-42 to 19 percent for women under 35.
According to the American Society for Reproductive Medicine (ASRM), if IUIs are performed monthly with fresh or frozen sperm, success rates can be as high as 20 percent per cycle. However, this depends on whether fertility drugs are used, the age of the female partner, the infertility diagnosis and other factors, such as how experienced the lab is in preparing and washing the sperm. In addition, the fertility team is important to the success of an IUI cycle, too, says Dr. Blauer.
"We have a great nurse practitioner team that focuses on optimizing each cycle."