Dr. Jamie Grifo said because "IVF is more involved, more invasive and more expensive," he usually recommends that infertile couples try intrauterine insemination (IUI) first.

by Laura Shin

Trying to conceive a baby can be a challenging time for some couples, and when it comes to understanding the different fertility treatments that are available, it can be even more stressful.

In vitro fertilization (IVF) is an effective and well-known procedure. It involves removing eggs from the woman’s body, fertilizing the egg or eggs outside of the body and then placing the embryo in the uterus to establish pregnancy.

Though IVF has become much more common since it was first done in the late 1970s, it is still costly and invasive. Because of this, most patients begin with intrauterine insemination (IUI), also known as artificial insemination, said Dr. Jamie Grifo, director of the Division of Reproductive Endocrinology at NYU Langone Medical Center.

IUI is a simple, less expensive procedure that involves injecting sperm into the uterus with a catheter. Grifo explained the benefits and risks of both procedures.

In what situations are intrauterine insemination and in vitro fertilization used?

It’s highly individualized and it depends on a lot of things, including patient age and diagnosis. In general, for patients who have unexplained infertility, IVF is a last resort option, not a first resort option. Depending on the kind of male factor infertility—how low the sperm count, how low the mobility—we offer IUI before IVF.

In general, IUI is done in addition to fertility medicine to improve the odds. The first round of IUI therapy usually involves Clomid, which is a fertility medicine that stimulates ovaries. We usually do Clomid with IUI three to six tries before moving on to IVF.

What is the risk of multiple births with IUI and IVF?

The risk of multiple births comes from the stimulation you use for the ovaries. Clomid, the oral medication used with initial IUI attempts, has a very low multiple pregnancy rate—it has an 8 percent multiple pregnancy rate, and the majority are twins.

Most of the high order multiple pregnancies these days don’t come from IVF, they come from the injectable medications—the stronger fertility medicines—that we use for IVF and with IUI. In those cases, patients make multiple follicles, multiple eggs, and are more at risk.
There was a study done to see what was more cost-effective after three failed Clomid IUI cycles. The question is, do you go right to IVF or to injectable IUI? The conclusion was that it was cheaper and safer, with less risk of multiples, if you went to IVF. Even though IVF is more involved, more invasive and more expensive, the actual cost was lower, and part of the reason was that the multiple pregnancies that occur from injectable IUI eat up a lot of health care dollars, taking care of triplets and quadruplets and beyond. You don’t get those with IVF because you can manage which embryos you put back. I think multiple births will be less and less of a problem as we shift away from injectable IUI cycles and go straight to IVF.

Does insurance typically cover both IUI and IVF?

It depends on the policy. It varies so much, and it often influences patients’ decisions about what to do. A lot of policies cover IUI but don’t cover IVF. Some cover none of it and some cover all of it. But those that cover all of it often require three to six cycles of IUI before covering IVF.

What are the success rates for these procedures?

All of it is age dependent. But in general, if X is the at-home, in-bed pregnancy rate, Clomid IUI is 2X [twice as likely], injectable IUI is 2.1X and IVF is 5X.

Are there any negative effects of trying IUI multiple times?

No. IUI is really simple. It’s like a pap smear in terms of what you experience as a patient. You may feel more cramps when you push the sperm into the uterus, but basically you use a speculum, put a little plastic tube in the cervix and inject the sperm. Injection implies needle, but there’s no needle, just a small tube that goes in the natural opening of the cervix and the sperm is then inserted. It usually takes a few minutes and you’re done.

In what situations might a patient skip IUI altogether and go to IVF?

I think most patients don’t skip IUI. A patient over 40 might, but still, a few months of IUI is usually done because a few months wouldn’t change the outcome. Patients don’t choose IVF right away. If they did, people would get pregnant a lot faster, but there’s always the cost barrier. IVF is much more expensive, usually around $10,000, whereas IUI might be around $2,000, so it’s five times less, but it’s also two and half times less efficient. It’s highly individual. It depends on the patients; that’s why you really need to have a good dialogue with your doctor and talk about the pros and cons of the different options.

Infertility is a disease or condition of the reproductive system and can be present in the woman, the man or both. Certain health conditions and factors, such as age, can affect a woman’s ability to conceive. A healthy 30-year-old woman has about a 20 percent chance of getting pregnant every month, but that percentage drops by age 40, when her chances are about 5 percent each month. Infertility can affect women regardless of age and background.

When you look at the process of conception, it is remarkable that pregnancy happens at all. When a man ejaculates, 200 million sperm are mixed with semen. In most men, only 15 to 45 million of those sperm will be healthy enough to fertilize an egg, and only 400 of those will survive after a man ejaculates. Traveling up the vagina, which is hostile to sperm as well as the toxic environment of the semen, only around 40 of the 400 will reach the vicinity of the egg. Then, only one sperm will be able to drill through the tough layer of the egg to fertilize it, and voilà, a baby is on the way—well, maybe. There are other circumstances that can end the pregnancy.

For sperm to make it to the end goal, three factors come into play: quantity, quality and movement. Conception is a numbers game, so the more semen discharged in an ejaculation, the better. The quality of the sperm—with an oval head and long tail—is important, as is the ability to move quickly through a hostile environment.

Certain factors can create problems for sperm, with the No. 1 problem being temperature. Increased scrotal temperature can interfere with sperm production. If you are trying for a family, avoid hot tubs, saunas and steam baths. Even though exercise is important, bike riding or remaining seated for long periods at a time can interfere with sperm production. Tight-fitting clothes such as briefs or athletic shorts will increase your body temperature, so switch to boxers.

Sperm movement and shape can be altered by smoking and marijuana, cocaine and heroin use. Excessive alcohol consumption can reduce the quantity and quality of the sperm produced. Lubricants, such as KY and skin lotions, will slow down the movement of sperm so they never reach the egg. Certain medications can also contribute to infertility issues, such as calcium channel blockers, tricyclic antidepressants, steroids, chemotherapy and radiation treatment.

For women, infertility issues are more likely structural or age-related problems. Damage or blockage in the fallopian tube caused by inflammation can prevent the egg from moving down to the uterus. The most common cause of this is chlamydia, a sexually transmitted infection that can affect both men and women. Uterine fibroids, tumors in the uterus, and endometriosis, uterine tissue implants growing outside of the uterus, can affect the function of the egg, ovaries, uterus and fallopian tubes.

Another cause of infertility is polycystic ovarian syndrome, in which the body produces too much androgen, a hormone that in turn causes ovulation problems. Pelvic adhesions secondary to pelvic infections, appendicitis, pelvic and abdominal surgery can also impair fertility.

Medications, thyroid problems and cancer treatments can also affect fertility.

Fertility for women starts to decline after age 30, whereas men can maintain their fertility well past 40. For both sexes, it is important to maintain a healthy body. Stop smoking and use alcohol in moderation. A healthy weight is important, but too much exercise can be associated with ovulation problems. A sedentary lifestyle, which can contribute to obesity, can also be a contributing factor to infertility.
For those couples who are infertile, there is still hope. Through in vitro fertilization (IVF), many couples have gone on to have successful pregnancies. Another option that may help that many specialists now recognize is acupuncture.

Mary Sabo, one of the clinical directors at the Yinova Center on 11th Street and Broadway, uses acupuncture to support IVF. “When couples come in to us, we look at their entire bodies and see how they are functioning,” she said. “If they have a diagnosis from their gynecologist or endocrinologist, we can help. If the uterine lining is too thin or if the blood flow to the uterus or ovaries is not ideal, we can increase the blood flow, relax the uterus before transfer in an IVF and help balance the hormones to improve fertility. The leading reproductive endocrinologists in the city are now recognizing the importance of acupuncture.”

If you are experiencing problems with infertility, don’t despair: Reproductive medicine has advanced over the years and it is still possible for you to have a child or, sometimes with fertility clinics, multiple children. Then you can buy one of those double-wide buggies and get a nice house in Brooklyn.

There is perhaps nobody with more questions—and the need for support—than a pregnant woman or new mother. To help, we’ve compiled a list of some of New York City’s best classes, venues and experts for maternal health and well-being.

Mind: Education, Information & Advice 

A group of trained HypnoBirthing practitioners based in Brooklyn, A Mother’s Instinct specializes in HypnoBirthing, doula services, fertility hypnosis and belly casting. Birthing while under hypnosis is taught in a series of five weekly classes; groups are limited to eight couples. Classes are taught in Brooklyn, Manhattan, Queens and North Jersey. amothersinstinct.com

Founded by two trained doulas and Lamaze educators, Birth Day Presence has a bit of everything on offer, including childbirth education, breastfeeding and newborn care instruction, belly basics, CPR and even prenatal belly dance and photography services in their Park Slope and SoHo studios. birthdaypresence.net

BklynBirth classes, led by local midwives, promote positive, safe birth experiences by informing women and their partners of all available options. Recognizing that the transition to becoming a parent is always unique, BklynBirth combines various schools of thought with professional and life experience to provide comprehensive guidance. Group and private classes available. bklynbirth.com

Caribou Baby in Brooklyn sells baby supplies and toys focused on simple, healthy living, in addition to hosting events and expert-led classes like breastfeeding support, prenatal yoga, prenatal and post-pregnancy Pilates and postpartum support groups. Check out the store’s very full calendar online. cariboubaby.com

From pregnancy through childbirth and parenting, Ellen Krug’s Choiceful Birth and Parenting offers information-seeking parents advice on how to make the most informed choices. Individualized counseling and psychotherapy offers parents the chance to explore various topics in a nurturing environment. choicefulbirth.com

Choices in Childbirth is an education, outreach and advocacy organization that assists mothers-to-be in considering their prenatal options, choosing a provider and creating a birth philosophy and support team. Alongside comprehensive childbirth education and workshops, postpartum services are also available. choicesinchildbirth.org

Destination Maternity on the Upper East Side has more than just great clothes. Classes in prenatal yoga, Pilates, breastfeeding and childbirth are held on a daily basis, as well as mom support groups. destinationmaternity.com

In small evening classes limited to eight couples, Ellen Chuse Childbirth provides moms and dads with the necessary information on labor, birth, breastfeeding and newborn care. Mother’s Meetings are a great place to share experiences and gain insights. Classes are held in Manhattan and Brooklyn; private classes also available. ellenchusechildbirth.com

The Tribeca Parenting education center offers a variety of classes like Expecting Reassurance, Preparation for Childbirth, Essential Baby Care and Breastfeeding Preparation. New parent classes include a Meeting Other Mothers series and Raise a Good Sleeper. Locations in Manhattan, Brooklyn and Jersey City. tribecaparenting.com

Twiniversity has (you guessed it!) classes for parents of multiples. Courses like Twins Prep 101 and the follow-up 201 Intro to Twins offer plenty of tips and tricks on how to prepare and adjust for multiple bundles of joy. Private Skype sessions and home visits are also available. twiniversity.com

The Upper East Side’s Yummy Mummy is a one-stop destination for information, products, services and classes devoted to the breastfeeding experience. Daily and weekly pre- and postnatal classes, including yoga, are offered for moms seeking support and guidance. yummymummystore.com

Body: Exercise & Fitness

In addition to classes focused on transitioning into parenthood, baby safety and caring for a newborn, 92Y hosts New Dad Boot Camp, prenatal Pilates and prenatal yoga. 92y.org

An eight-week weightless, water-based workout may be just the ticket for expectant mamas at AquaMom. These prenatal pool sessions promote strength, endurance, flexibility, better sleep and weight control. Small group classes are offered at private pools in the Midtown Sheraton Hotel and Léman Preparatory School in the Tribeca/Wall Street area. aquamom.com

An experienced fitness instructor, Pamela Keefer founded Baby Body Boot Camp for full-body conditioning targeted at moms and moms-to-be at all fitness levels. Classes are held outdoors in Battery Park City and personal training consultations are available. b3nyc.com

In its 10th year, Core Pilates NYC is conveniently located near Union Square and is open seven days a week. With classes in prenatal tower and prenatal props mat, pregnant women can focus on targeted muscles and challenge their bodies in new ways. All students can pay per class or buy packages. corepilatesnyc.com

Spearheaded by Julie Tupler, Diastasis Rehab offers the famous Tupler Technique for losing the mummy tummy after baby. Her maternal fitness offerings are conveniently packaged in books and DVDs. You can also attend local seminars in Manhattan or Brooklyn or take part in online sessions from the privacy of your own home. Individual consultations are also available. diastasisrehab.com

The first yoga center of its kind in NYC, the Prenatal Yoga Center’s schedule includes Pre- and Postnatal Yoga, New Mother’s Support Groups, Childbirth Education and a Breastfeeding Support Circle, all conducted in a calm, peaceful environment. Locations in Manhattan and Brooklyn. prenatalyogacenter.com

The great outdoors becomes a parent’s perfect playground at Strollercize classes in all five boroughs. Founded over 20 years ago by retired ballerina Elizabeth Trindade, Strollercize has a calendar full of postnatal exercise classes, as well as a prenatal fitness program called Preparing to Push. Classes are membership based. strollercize.com

Use your stroller to get a total body workout while spending time with your baby at Stroller Strides. If you’re expecting, try the Fit4Baby class to get in shape while pregnant, while Body Back offers high-intensity workouts for women at any stage of motherhood. Classes are held in the morning and on Saturdays in Manhattan and Brooklyn. strollerstrides.com

And don’t miss our New York Baby Show on the weekend of May 19 and 20 in New York City. For event news and ticket sales, visit newyorkbabyshow.com or email newyorkbabyshow@manhattanmedia.com.