Intrauterine Insemination: A Reality Check
Thirty years ago when I first introduced IUI in its present form (Journal of Fertility & Sterility, April 1984), I held the strong belief that it would provide a less expensive, safe and viable alternative to IVF in cases where the woman had at least one patent Fallopian tube….How wrong I was! In my defense, however, is the fact that at that time, the reported National IVF success rate was under 10%. By comparison, current IVF success rates are often 4-6 times greater than this (> 50% in some cases) for certain types of IVF.
I now strongly believe that the only legitimate indications for IUI are in cases of cervical mucus hostility, male impotence and artificial insemination where frozen sperm is used. Herewith, the traditional arguments in favor of IUI, and my analysis of their merits:
1) The erroneous belief that IUI is 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. But cost also comes in the form of emotional strain as well as the effect of wasted time on the biological clock. These need to be measured in terms of the much lower chance of success with IUI.
2) “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.
3) IUI can supplant or replace IVF in all cases where there is patency of at least 1 Fallopian tube. 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 the sperm’s ability to penetrate the egg envelopment).
- – Older women (over 40 years) where the IUI pregnancy yield is about 2% per cycle
- – Where clomiphene citrate (rather than gonadotropins) is used – here the success rate is likely to be about 20-30% lower.
Against this background, the indiscriminate performance of IUI in normally ovulating women is, in my opinion, redundant and the fact that many insurance companies, in the presence of tubal patency, require that several IUI cycles be completed before the patient becomes eligible for IVF insurance coverage is regrettable.
IUI and the risk of Multiple Pregnancy: Finally, when compared to IVF, IUI has another major downside: in women who tend to release multiple eggs at a time (abnormally ovulating or non-ovulating women undergoing COH), it is not possible to regulate the number of embryos reaching the uterus unless IVF is done. Thus the risk of high-order multiple pregnancies in such women undergoing COH and/or IUI cannot be controlled and is enormously increased. On the other hand, with IVF it is possible to control this by transferring no more than 2 “competent” embryos (the most viable ones). At most SIRM centers, the use of Comparative Genomic Hybridization (CGH) now allows us to select embryos with far greater reliability.
As physicians we really need to seriously rethink the basis upon which we recommend IUI!