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.
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