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Deciding Between Intrauterine Insemination (IUI) and In Vitro Fertilization (IVF)

by Dr. Geoffrey Sher on November 5, 2017

Many infertile patients, are erroneously advised by their physicians to first try IUI several times before resorting to IVF. Additionally many misguided insurance providers often, purely for economic reasons, require that infertile female enrollees who have at least 1 patent Fallopian tube, first undergo several attempts at IUI before doing IVF. It is important for infertile women to be aware that such an approach is often ill-advised as there are circumstances where IUI is very unlikely to be successful and where IVF should be the primary approach.

While IUI is well indicated for women undergoing controlled ovarian stimulation for ovulation dysfunction, cervical mucus hostility, male impotence and when artificial insemination with pre-frozen sperm, there are several situations where in spite of tubal patency it is (in my opinion) relatively contraindicated:

  • Moderate or severe male Infertility:  Intrauterine insemination (IUI) and in-vitro fertilization (IVF) are both often touted as being equivalent treatments for male factor subfertility. This is a fallacy. The success rate with a single IVF treatment using intracytoplasmic sperm injection is actually 8-10 times greater than a single attempt at IUI. Thus when it comes to moderate or severe male infertility such patients will ultimately require IVF anyway. Those who argue that because a single cycle of IUI is much less expensive than a single attempt at IVF and for this reason, several attempts at the former should be tried before resorting to IVF. A recent study conducted by the Department of Public Health in the UK compared outcomes (live birth-producing pregnancy) and the cost-effectiveness of offering IVF as a primary approach as compared with first trying IUI and only resorting to IVF if this fails. The results confirmed that in cases of male factor infertility it is far less costly and much more cost-effective to go directly to IVF as the primary treatment than to start with IUI and then only resort to IVF, should this fail.
  • Older women and those with Diminished ovarian reserve (DOR):  For the vast majority of women, over 35y of age, an inevitable irreversible and accelerated advancement of the biological clock takes place, such that by age 40y there is only about a 2-3% per-cycle, chance of IUI success. Conversely IVF afford many such women a far greater opportunity to have a baby. Thus such women simply do not have the time to waste on ineffectual treatments such as IUI. Rather, they need (in my opinion) to “make hay while the sun still shines” and go directly to IVF.
  • Endometriosis: All women with endometriosis have toxins in their pelvic secretions. This compromises the ability of sperm to fertilize eggs that pass from the ovary (ies) to reach sperm in the fallopian tube(s).This dramatically reduces egg fertilization potential by a factor of 4-6 fold.  It in large part serves to explain why potentially all women with endometriosis have reduced fecundity (reproductive potential) and why tubal surgery, the use of fertility drugs and/or intrauterine insemination (IUI) does not improve fecundity over no treatment at all.  The only way to improve the chance of having a baby through extracting eggs before they are exposed to toxic pelvic secretions…i.e. through IVF. I am not suggesting that all women with endometriosis should go directly to IVF. In fact most ovulating younger women with early endometriosis have time and should consider trying to conceive on their own. Rather, what I am saying is that women over 35y, regardless of age, those who have DOR and those women who for whatever reason feel a compelling sense of urgency to conceive ASAP, should preferentially consider doing IVF.

I would now like to try and dispel the following misconceptions regarding IUI:

  1. The per-cycle cost of IUI is significantly lower than IVF and thus IUI represents a “cost saver”: Given the fact that IVF is at least 3-4 times more likely to be successful, when one looks at cost per baby (rather than cost per procedure) this turns out to be a fallacy. Moreover, cost also comes in the form of emotional currency and this needs to be measured in terms of the much lower chance of success with IUI.
  2. Success in ovulating women who undergo natural-cycle IUI and those women undergoing ovulation induction with clomiphene citrate is equivalent to success rates when gonadotropins are used:  Quite to the contrary….,with the exception of IUI performed using thawed sperm (usually donor sperm), spontaneously ovulating women undergoing natural-cycle IUI does not improve the chance of pregnancy over regular timed intercourse. Also, when compared with IUI performed following induction of ovulation with gonadotropins, the use of clomiphene citrate is associated with a 30% lower success rate.
  3. IUI is less invasive than IVF”… ….This is true, however aside from the surgical egg retrieval which (when done in the right setting) is a safe procedure, IUI with gonadotropins requires largely the same drugs, preparation and monitoring as does IVF and the success rate is several fold lower than for IVF.
  4. IUI is a viable option when at least one Fallopian tube is patent: Most tubal damage is due to prior pelvic inflammatory disease and this almost always affects both Fallopian tubes. What this means is that when only one tube is damaged or blocked the other (whether patent or not) is almost invariably affected as well. For a viable intrauterine pregnancy to occur following IUI, a healthy intra-tubal environment is an absolute necessity. This serves to explain why the chance of successful pregnancy following IUI is severely compromised in such cases. It also serves to explain why the chance of pregnancy is markedly reduced and why the risk of a tubal (ectopic) gestation is markedly increased in such cases. It is therefore my opinion, that IVF should be considered preferentially when one tube is damaged and this is deemed to be the likely consequence of tubal infection.
  5. The chance of a multiple pregnancy can be controlled with IUI: When compared with IVF, IUI has another major disadvantage. This is because in women with ovulation dysfunction (e.g.; those who have irregular or absent menstruation such as with PCOS) ovarian stimulation often results in the release of multiple eggs at a time and it is not possible to limit number of embryos that reach the uterus. This is why when, undergoing IUI, such women are very likely to have multiple pregnancies (triplets or greater) which is associated with serious perinatal and long term complications. It is only through IVF that by regulating the number of embryos transferred to the uterus that the risk of multiple pregnancies can be limited.

In my opinion, we as physicians need to rethink the basis upon which we recommend IUI as an alternative to IVF and educate our patients accordingly.

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  • Melissa - December 4, 2017 reply

    To my mind, such articles can help someone to understand their infertility problems better. And ways how they can fight with them. Together with my partner we have been trying to have a child for 4 years and there were no results. After multiple failed IVF cycles, one miscarriage we lost the last hope. But I must add that sometimes one IVF cycle can cost pretty much in my native country. You can’t even imagine how much money we spent here! After some time, we decided that we will do the last IVF try. But I thought that I can do this somewhere else. My husband agreed and said that his college got her child at the Ukrainian Center for Human Reproduction. Moreover, the IVF procedure costs there nearly 30k euros and that is much cheaper than in my country. We emailed to the clinic and sent all my medical documents there and soon we were in Kiev. Unfortunately, the doctors said that it was really low chances for me to carry baby by own. As a result, they suggested to me to use surrogacy service in their clinic. that was really unexpected suggestion so we are still thinking about it. I think that we have to use our last chance with IVF and then to think one more time.

    Dr. Geoffrey Sher

    Dr. Geoffrey Sher - December 4, 2017 reply

    Whenever a patient fails to achieve a viable pregnancy following embryo transfer (ET), the first question asked is why! Was it simply due to, bad luck?, How likely is the failure to recur in future attempts and what can be done differently, to avoid it happening next time?.
    It is an indisputable fact that any IVF procedure is at least as likely to fail as it is to succeed. Thus when it comes to outcome, luck is an undeniable factor. Notwithstanding, it is incumbent upon the treating physician to carefully consider and address the causes of IVF failure before proceeding to another attempt:
    1. Age: The chance of a woman under 35Y of age having a baby per embryo transfer is about 35-40%. From there it declines progressively to under 5% by the time she reaches her mid-forties. This is largely due to declining chromosomal integrity of the eggs with advancing age…”a wear and tear effect” on eggs that are in the ovaries from birth.
    2. Embryo Quality/”competency (capable of propagating a viable pregnancy)”. As stated, the woman’s age plays a big role in determining egg/embryo quality/”competency”. This having been said, aside from age the protocol used for controlled ovarian stimulation (COS) is the next most important factor. It is especially important when it comes to older women, and women with diminished ovarian reserve (DOR) where it becomes essential to be aggressive, and to customize and individualize the ovarian stimulation protocol.
    We used to believe that the uterine environment is more beneficial to embryo development than is the incubator/petri dish and that accordingly, the earlier on in development that embryos are transferred to the uterus, the better. To achieve this goal, we used to select embryos for transfer based upon their day two or microscopic appearance (“grade”). But we have since learned that the further an embryo has advanced in its development, the more likely it is to be “competent” and that embryos failing to reach the expanded blastocyst stage within 5-6 days of being fertilized are almost invariably “incompetent” and are unworthy of being transferred. Moreover, the introduction into clinical practice about a decade ago, (by Levent Keskintepe PhD and myself) of Preimplantation Genetic Sampling (PGS), which assesses for the presence of all the embryos chromosomes (complete chromosomal karyotyping), provides another tool by which to select the most “competent” embryos for transfer. This methodology has selective benefit when it comes to older women, women with DOR, cases of unexplained repeated IVF failure and women who experience recurrent pregnancy loss (RPL).
    3. The number of the embryos transferred: Most patients believe that the more embryos transferred the greater the chance of success. To some extent this might be true, but if the problem lies with the use of a suboptimal COS protocol, transferring more embryos at a time won’t improve the chance of success. Nor will the transfer of a greater number of embryos solve an underlying embryo implantation dysfunction (anatomical molecular or immunologic).Moreover, the transfer of multiple embryos, should they implant, can and all too often does result in triplets or greater (high order multiples) which increases the incidence of maternal pregnancy-induced complications and of premature delivery with its serious risks to the newborn. It is for this reason that I rarely recommend the transfer of more than 2 embryos at a time and am moving in the direction of advising single embryo transfers …especially when it comes to transferring embryos derived through the fertilization of eggs from young women.
    4. Implantation Dysfunction (ID): Implantation dysfunction is a very common (often overlooked) cause of “unexplained” IVF failure. This is especially the case in young ovulating women who have normal ovarian reserve and have fertile partners. Failure to identify, typify, and address such issues is, in my opinion, an unfortunate and relatively common cause of repeated IVF failure in such women. Common sense dictates that if ultrasound guided embryo transfer is performed competently and yet repeated IVF attempts fail to propagate a viable pregnancy, implantation dysfunction must be seriously considered. Yet ID is probably the most overlooked factor. The most common causes of implantation dysfunction are:
    a. A“ thin uterine lining”
    b. A uterus with surface lesions in the cavity (polyps, fibroids, scar tissue)
    c. Immunologic implantation dysfunction (IID)
    d. Endocrine/molecular endometrial receptivity issues
    Certain causes of infertility are repetitive and thus cannot readily be reversed. Examples include advanced age of the woman; severe male infertility; immunologic infertility associated with alloimmune implantation dysfunction (especially if it is a “complete DQ alpha genetic match between partners plus uterine natural killer cell activation (NKa).
    I strongly recommend that you visit http://www.DrGeoffreySherIVF.com. Then go to my Blog and access the “search bar”. Type in the titles of any/all of the articles listed below, one by one. “Click” and you will immediately be taken to those you select. Please also take the time to post any questions or comments with the full expectation that I will (as always) respond promptly.

    • The IVF Journey: The importance of “Planning the Trip” Before Taking the Ride”
    • Controlled Ovarian Stimulation (COS) for IVF: Selecting the ideal protocol
    • IVF: Factors Affecting Egg/Embryo “competency” during Controlled Ovarian Stimulation (COS)
    • The Fundamental Requirements for Achieving Optimal IVF Success
    • Use of GnRH Antagonists (Ganirelix/Cetrotide/Orgalutron) in IVF-Ovarian Stimulation Protocols.
    • Ovarian Stimulation in Women Who have Diminished Ovarian Reserve (DOR): Introducing the Agonist/Antagonist Conversion protocol
    • Anti Mullerian Hormone (AMH) Measurement to Assess Ovarian Reserve and Design the Optimal Protocol for Controlled Ovarian Stimulation (COS) in IVF.
    • Human Growth Hormone Administration in IVF: Does it Enhances Egg/Embryo Quality and Outcome?
    • The BCP: Does Launching a Cycle of Controlled Ovarian Stimulation (COS). Coming off the BCP Compromise Response?
    • Blastocyst Embryo Transfers should be the Standard of Care in IVF
    • IVF: How Many Attempts should be considered before Stopping?
    • “Unexplained” Infertility: Often a matter of the Diagnosis Being Overlooked!
    • IVF Failure and Implantation Dysfunction:
    • The Role of Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 1-Background
    • Immunologic Implantation Dysfunction (IID) & Infertility (IID): PART 2- Making a Diagnosis
    • Immunologic Dysfunction (IID) & Infertility (IID): PART 3-Treatment
    • Thyroid autoantibodies and Immunologic Implantation Dysfunction (IID)
    • Immunologic Implantation Dysfunction: Importance of Meticulous Evaluation and Strategic Management 🙁 Case Report)
    • Intralipid and IVIG therapy: Understanding the Basis for its use in the Treatment of Immunologic Implantation Dysfunction (IID)
    • Intralipid (IL) Administration in IVF: It’s Composition; how it Works; Administration; Side-effects; Reactions and Precautions
    • Natural Killer Cell Activation (NKa) and Immunologic Implantation Dysfunction in IVF: The Controversy!
    • Endometrial Thickness, Uterine Pathology and Immunologic Factors
    • Vaginally Administered Viagra is Often a Highly Effective Treatment to Help Thicken a Thin Uterine Lining
    • Treating Out-of-State and Out-of-Country Patients at Sher-IVF in Las Vegas:
    • A personalized, stepwise approach to IVF
    • How Many Embryos should be transferred: A Critical Decision in IVF?
    • The Role of Nutritional Supplements in Preparing for IVF

    If you are interested in seeking my advice or services, I urge you to contact my concierge, Julie Dahan ASAP to set up a Skype or an in-person consultation with me. You can also contact Julie by phone or via email at 702-533-2691/ Julied@sherivf.com You can also apply online at http://www.SherIVF.com .

    *FYI
    The 4th edition of my newest book ,”In Vitro Fertilization, the ART of Making Babies” is available as a down-load through http://www.Amazon.com or from most bookstores and public libraries.

    Geoffrey Sher MD

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