Intrauterine Insemination: A Reality Check

14 Jan
Ask Dr. Sher A Question

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!

22 Comments

  • Loraine says:

    Hi Dr. Sher

    I am 43 my AMH level is 7.83pmol/L (this month). FSH level on day 21 3.5 iu/l, serum LH level day 21 3.3 iu/l, serum progesterone level 28.5 nmol/L. I have regular cycles and according to a fertility monitor and ov. stick appear to be ovulating. I have had a scan in my January cycle (when the FSH, LH levels were taken), the scan showed at least one maturing follicle, no follicles could be seen on one side (when the fsh, lh levels were taken). I have tried AI many times and recently IUI (both frozen donor sperm), it didn’t work last month but am waiting to see if it has worked this month. What would you recommend, I realise I am far from my biological peak as far as age is concerned. I am a healthy weight, don’t have pcos, and my tubes are clear. I would appreciate any advice you feel able to offer. I did want to avoid ivf if possible but I know there are only som many things possible. Thank you L

    • Geoffrey Sher says:

      Loraine…With diminished ovarian reserve and being 43Y of age, trying on your own or using AI, in my opinion is wasting PRECIOUS TIME). You in actuality need IVF with egg donation because at 43, less than one out of 10 embryos will be chromosomally normal. The only rational secondary alternative would be Embryo Banking with Staggered IVF and CGH embryo selection (see below).

      Please go to the home page of this blog, http://www.IVFauthority.com . When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.
      1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

      2. Ovarian Stimulation for IVF: The most important determinant of IVF Outcome” (Nov. 2103)

      3. “Agonist/Antagonist Conversion Protocol”

      4. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

      5. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

      6.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

      7. “IVF success: Factors that influence outcome”

      8. “Use of the Birth Control Pill in IVF”

      9.”Staggered IVF”

      10.“Embryo Banking”

      11.“Array CGH versus metaphase CGH in IVF patients….’

      12.“Egg Donation”

      13. “Intrauterine Insemination (IUI): Setting the Record Straight on when it is to be considered”.

      Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype with me so we can discuss your case in detail.

      Finally, perhaps you would be interested in accessing my new book (recently released). It is the 4th edition (and a re-write) of “In Vitro Fertilization, the ART of Making Babies”. The book is available through “Amazon.com” as a down-load or in book form. It can also be obtained from most bookstores.

      Geoff Sher

      P.S: Please go to http://www.youtube.com/watch?v=Vp3GYuqn2eM&feature=youtu.be
      To view a video-tutorial by Linda Vignapiano RN, Clinical Manager at SIRM-Las Vegas.

  • Eirlis says:

    Hi Dr. Sher,

    I’m 37 and am in the process of miscarrying my 8th pregnancy. After the first 2 losses (both with heartbeats but fatally small chorionic sacs) we were referred to a RE who tested my day 3 FSH at 12.9 (5 years ago now). We did 3 cycles of Follistim IUIs and I became pregnant each time, but miscarried within the first few weeks. Our RE wanted to move on to IVF without further testing, so we got a second opinion, did recurrent pregnancy loss testing, and discovered that I tested positive for anticardiolipin syndrome (IgM of 46). We did an IVF cycle with that doctor and I went on blood thinners. Despite a vanished twin and multiple SCHs, our son was born healthy in 2011.

    We started trying for a second child in 2012 and after an ectopic and a failed IUI, I became pregnant naturally with our second son. However I had bleeding and multiple SCHs from the start and developed low fluid in the second trimester. Sadly our son died at 24 weeks and chromosomal testing and autopsy showed no abnormalities. Afterward I saw a rheumatologist to do more testing and see if we could find answers. Surprisingly, all of my labs came back normal — including the test for anticardiolipin antibodies. So now are we back to square one for finding an explanation for all of my losses? Should I still take blood thinners anyway when pregnant? I also have ulcerative colitis which was flaring badly during my pregnancy with my second son and was treated with prednisone. None of my doctors feel that it was a factor in his death, however.

    We would still love to have a second child, but are at a loss for what to do now. We can’t afford a surrogate. Thank you so much for your insight.

    • Geoffrey Sher says:

      Hi Eirlis,

      You certainly have been through a lot.I suggest we talk. Please go to the home page of this blog, http://www.IVFauthority.com. When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.

      1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

      2. “Recurrent Pregnancy Loss (RPL)”

      3. “Thrombophilia”

      4. “Immunologic Implantation Dysfunction” (2 articles, posted on May, 10th and on May 16th respectively).

      5. “Thyroid Autoimmunity and IVF”

      6. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

      Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype with me so we can discuss your case in detail.

      Finally, perhaps you would be interested in accessing my new book (recently released). It is the 4th edition (and a re-write) of “In Vitro Fertilization, the ART of Making Babies”. The book is available through “Amazon.com” as a down-load or in book form. It can also be obtained from most bookstores.

      Geoff Sher

      Please go to http://www.youtube.com/watch?v=Vp3GYuqn2eM&feature=youtu.be
      To view a video-tutorial by Linda Vignapiano RN, Clinical Manager at SIRM-Las Vegas.

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