It is hard for me to believe that more than three decades have flown by since I first introduced intrauterine insemination into the clinical arena (Journal of Fertility & Sterility, April, 1984). At that time and for more than 2 decades thereafter, I held the strong belief that IUI would provide a less expensive, safe and equally successful alternative to IVF in cases where the woman had at least one patent Fallopian tube… How wrong I was! In my defense however, let me say that in the 1980’s and 90’s the reported National IVF success rate was under 15% while IVF success rates are now often 4 or even 5 times higher.
Today I believe that IUI is being over-used, is not nearly as beneficial as I once thought and that there are (often ignored) serious down-sides to its use. Here is one important example: Women who fail to ovulate or ovulate dysfunctionally, often respond to controlled ovarian stimulation (COS) by the releasing (ovulating) of several eggs at a time. Unless IVF is used, it is not possible to control/regulate the number of embryos reaching the uterus, therefore the risk of high-order multiple pregnancies (triplets or greater) is far greater with IUI. And, multiple pregnancies (especially triplets or greater) carry a very high maternal and neonatal risk.
Here are a few of the misperceptions about the use of IUI:
- IUI is a “cost saver”. However, 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. But 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.
- “IUI is less invasive than IVF”… ….True! However aside from the surgical egg retrieval (which is a very safe procedure in the right hands/setting), IUI with gonadotropins requires largely the same drugs, preparation and monitoring as does IVF and the success rate is several fold lower than IVF.
- The use of oral Clomiphene Citrate for IUI- COS provides the same success rates as does Gonadotropin- This is absolutely incorrect. In fact, the IUI success rate with clomiphene is about 30% lower than when gonadotropins are used.
- Natural cycle IUI has benefit: This is only true when frozen donor sperm is used for inseminations and in the isolated cases where there is non-immunologic cervical hostility to sperm. In all other cases, COS is needed to improve success.
- IUI can be used in cases of Embryo Implantation Dysfunction: Given the complexity of treatment is in cases where a thin uterine lining, significant uterine anatomical disease or immunologic implantation dysfunction (IID) prevents a healthy pregnancy, it is my opinion that IVF is the preferred primary approach.
- IUI can supplant or replace IVF in all cases where there is patency of at least 1 Fallopian tube. However, contrary to popular belief, there is no evidence that IUI improves pregnancy potential in cases of:
- Moderate or severe male factor infertility
- Endometriosis with patent Fallopian tubes. Since inseminating sperm does not overcome the main impediment to fertility, i.e., a “toxic” peritoneal factor that compromises sperm penetrating the egg envelopment).
- Older women (over 40y) where the IUI pregnancy yield is only about 2% per treatment cycle.
Upon Honest Reflection:
Unfortunately, too many physicians who should (and alas often do) know better, still liberally recommend IUI preferentially in cases of moderate or severe male infertility, older infertile women or those with diminished ovarian reserve (DOR), cases of endometriosis or where there is clear evidence of an anatomical or immunologic implantation issue. Such women would be much better advised to go directly to IVF but find themselves attracted to what they erroneously consider to be a much lower cost alternative.
Then there is the fact that many infertile patients, erroneously believing that IUI is less risky that IVF, provides an equivalent chance of success, and comes at a much lower price tag, put undue pressure on their physicians to first try the former several times before resorting to the latter.
To make matters worse, many misguided insurance providers (purely for economic reasons) demand that their female clients who have at least 1 patent Fallopian tube, first undergo several unsuccessful attempts at IUI before becoming eligible for IVF. And they often take this position regardless of cast iron indications that IVF should be the primary treatment of choice.
In summary, it is my opinion that IUI is presently an over-prescribed treatment. As such, we as physicians need to rethink the basis upon which we recommend IUI and educate our patients appropriately.