In vitro fertilization (IVF) and intrauterine insemination (IUI) are two commonly used fertility procedures. There are pros and cons to each. This article is designed to help you compare and contrast the procedures and, together with your doctor, arrive at a decision of which one is the right fertility procedure for you.
IN VITRO FERTILIZATION
In vitro fertilization, also known as IVF, is a common infertility treatment that involves using fertility drugs to stimulate the development of multiple eggs. The eggs are retrieved from the ovaries using a small needle. They are then fertilized with sperm in a specialized lab. The embryos grow for 3 to 5 days before one or more is placed into the uterus.
Who is a good candidate for in vitro fertilization?
IVF is the most successful infertility treatment for almost all patients, including those with the following:
- ovulation problems
- fallopian tube damage/obstruction
- pelvic adhesions
- poor semen quality
- unexplained infertility
- prolonged infertility.
It can also be used to enable preimplantation genetic testing (PGT) of embryos.
However, IVF does not make new eggs for patients, and if the uterus is incapable of implanting and carrying a pregnancy, IVF cannot solve that problem.
Assisted reproductive technologies (ART), which include IVF, include the use of donor egg, donor sperm and gestational carrier (surrogate) which can overcome almost all biological infertility limitations. It can also be used for single people and other non-traditional family building.
IVF Success Rates
Age is the primary factor that most affects IVF success rates. Women younger than age 35 have approximately a 50/50 chance of having a baby with their first IVF egg retrieval and subsequent embryo transfer(s). Women who don’t get pregnant following the first IVF cycle still have a very good chance of getting pregnant on second, third and even more cycles of IVF.
According to the Society for Assisted Reproductive Technology (SART) Clinic Report, the average cumulative live birth percentage chance of live birth from IVF by age are:
- 55% for women under age 35
- 40% for women age 35-37
- 26% for women age 38-40
- 13% for women age 40-42
- 4% for women over the age of 42
The cumulative success rate for a live birth increases with additional IVF cycles for all women. Success rates also depend on:
- patient selection,
- diagnosis, protocols used,
- amount of ovarian stimulation,
- laboratory quality,
- use of add-on techniques,
- number of embryos transferred,
- and other factors.
It is very difficult to compare live birth rates from clinic to clinic. However, you should discuss pregnancy rates with your clinic.
The major factor limiting success with IVF is female age which results in diminished ovarian reserve. This problem can also occur but less often in younger women. Using donor eggs is sometimes the only option in such situations.
How Much Does IVF Cost?
The cost of an IVF cycle ranges from $10,000 – $15,000 with an average of $12,000; While about half of the patients have a baby on their first cycle, the others need to try a second, third or even more times. The average number of cycles per patient is approximately two.
This dollar amount does not include fertility medications which can range from $1,500 to $6,000 per cycle. The total cost will be higher if donor eggs or sperm are used and if embryos are frozen and stored. An additional cost of $5,000 may be incurred if genetic testing is needed.
Insurance coverage for IVF in the US varies widely and remains inadequate. Even with coverage, restrictions on procedures and other limitations often result in significant out-of-pocket costs for patients.
Many fertility clinics offer IVF treatment packages that bundle services such as multiple IVF cycles or offer discounts on fertility medications to make treatment more affordable. A successful and popular national program can be found at www.arcfertility.com (with which I am affiliated).
What are the Advantages, Disadvantages, and Risks of IVF?
IVF is much more successful than intrauterine insemination (IUI), another commonly used fertility procedure. Unlike IUI, it can help treat almost any type of infertility problem. It can also provide access to genetic testing of embryos. Further, IVF has much more capability to prevent multiple births by the use of single embryo transfer (SET). It is also generally a faster way to get pregnant because success rates are higher.
IVF can also be beneficial for people wanting more than one child. Often additional frozen embryos that are not used to get the first pregnancy can be used in the future to attempt to have additional children.
The disadvantages are that it is a more demanding process than IUI. IUI involves only mild ovarian stimulation, a small amount of monitoring and an office-based IUI.
IVF requires much stronger ovarian stimulation, frequent daily monitoring, an egg retrieval procedure with conscious sedation anesthesia, laboratory fertilization and embryo growth, usually cryopreservation (freezing) and storage of embryos, and embryo transfer followed by progesterone injections or suppositories.
Decisions to make
Patient factors such as age, fertility diagnosis and family medical history will help women and men decide if the chances are good enough to try IVF. If chances are very poor, it may be appropriate to consider the use of donor eggs or sperm. Your fertility clinic can refer you to agencies and other sources to obtain these.
Other decisions include:
- consideration of pre-treatment genetic testing of women and men
- preimplantation genetic testing (PGT) of the embryo
- type of treatment cycle, number of embryos to transfer
- number of embryos to freeze
When should someone go straight to IVF?
Patients should go straight to IVF when the chances of pregnancy with IUI are low but relatively higher with IVF. These include fallopian tube damage, moderate to severe endometriosis, pelvic adhesions and more than mild male infertility factor.
Women should also go straight to IVF when they have a short time to try to get pregnant because of age, diminished ovarian reserve or other factors when they can afford IVF, when there is a need for PGT, and when there is a need for donor eggs or a gestational carrier.
The choice of IUI or IVF should be made by each patient in consultation with their fertility specialist. It is best if your doctor is an experienced reproductive endocrinologist who can provide all types of treatments:
- ovarian stimulation
That way you are more likely to get a balanced opinion.
Other Articles by Author:
The Unique Challenges of Secondary Infertility
Infertility Coverage is Becoming an Important Employee Benefit
Deciding whether to pursue fertility treatment and if so, which ones, can be challenging and complex. But deciding to invest your time and money in trying to have a baby simply offers no greater reward.
Everyone’s heard of IVF, but what is IUI? It’s “intrauterine insemination” a type of insemination that has been performed for decades. For some women, it may also be a better option to try before IVF.
In vitro fertilization (IVF) is the most effective, and usually final, infertility treatment. While commonly performed, it is used far less than some other simpler treatments. Since many factors determine the best treatment for any given patient, it is important to consider all options.
While age and fertility diagnosis may be the major considerations for selecting a treatment, there are other factors to consider including demands of treatment and cost. It’s worth comparing IUI and IVF to see which might be best for you and your partner.
What is intrauterine insemination?
Intrauterine Insemination (IUI) is a fertility procedure in which sperm that have been washed in a laboratory to concentrate the most active sperm are placed directly into the uterus using a catheter passed through the cervix. While historically also called “artificial insemination,” the term “artificial” is no longer used because it is inaccurate and pejorative.
The insemination is performed at or just before a woman is ovulating. This may be either during a natural cycle or one in which oral or injectable ovarian stimulation fertility medications are used.
IUI is often suggested by doctors as one of the first fertility treatments. This is because it is relatively simple, cheaper and increases pregnancy rates when performed with ovarian stimulation.
Who is a good candidate for IUI?
Different factors affecting both women and men make IUI a good first option.
IUI is often the first treatment considered for polycystic ovarian syndrome (PCOS) or other ovulation problems because fertility medications make cycles more regular. IUI can also increase pregnancies in women with mild endometriosis or unexplained infertility.
IUI is also a good option for women with cervical abnormalities including scarring from prior surgery or abnormal development of the cervix or vagina. These abnormalities can impair passage of sperm from the vagina to the uterus.
IUI is often recommended for overweight or obese women. Some fertility clinics have a BMI limit for performing IVF because of surgical and other risks.
Along with the conditions described, IUI is a good option for women who have:
- At least one unblocked and reasonably normal fallopian tube
- A normal uterine cavity
- Regular ovulation with or without the help of fertility medication
- A healthy ovarian reserve, that is, a reasonable number of healthy eggs
IUI is not recommended for women with:
- Moderate to severe endometriosis
- Severe disease of the fallopian tubes
- A history of pelvic infections
- Longstanding (>4 years) infertility
IUI is a good option if a partner has normal sperm or mild male infertility factor including a below-average sperm count, motility problems or mildly abnormal sperm morphology. It is also helpful if there are ejaculation problems. IUI is not usually successful with severe male infertility.
IUI is also a good option after male fertility preservation for men who have frozen their sperm before cancer treatment or surgery that might affect their fertility. This only applies, however, if their female partner is a good candidate for IUI. And, if there’s a sufficient quantity of frozen sperm available to use for IUI with enough left for IVF if IUI is unsuccessful.
And, IUI is often used by couples where the male has a genetic defect that is managed by using donor sperm
For Women and Men:
IUI is often tried first – along with medications to stimulate the development of 2 or 3 mature eggs – for those with unexplained infertility. This diagnosis affects one out of every five couples with fertility issues.
IUI is a good option and commonly used by those without fertility problems, including same-sex couples and single women, who need to use donor sperm. Lesbian couples often use IUI with donor sperm. Male couples may use their own sperm and have their gestational carrier (surrogate) use IUI. And single women who use donor sperm most often use IUI.
Related content: Gestational Carrier 101: What You Need to Know
What is the success rate for IUI?
Success rates with IUI depend on age, the reason for infertility, whether fertility drugs are used and how many cycles are performed.
IUI pregnancy rate in women less than age 35 is about 8% to 10% per cycle. The cumulative pregnancy rate (total pregnant) after two cycles is about 18% and with 3 cycles about 25%.
Pregnancy rates decrease after 3 unsuccessful cycles. After 6 cycles of ovarian stimulation and IUI, the cumulative or the total number of women pregnant is about 35%. By age 38 or older, pregnancy rates per cycle are usually 5% or less.
For couples with unexplained infertility, IUI is double the success rate of no treatment.
How much does intrauterine insemination cost?
IUI costs range from $500 – $4,000 depending on what’s included and where you live.
Total costs vary by the following factors:
- whether fertility drugs are used (clomiphene is cheaper than gonadotropins)
- if monitoring is used ($500-1,000)
- whether donor sperm is needed
- if a second IUI will be performed on successive days.
A patient will also need ultrasounds, lab tests, and semen analysis.
Insurance may or may not cover some or all IUI costs. Some insurance policies require several unsuccessful IUI cycles before they will cover IVF. Check with your employer to learn about your specific coverage including whether there are any state mandates that require some form of coverage.
Also, some fertility clinics may offer IUI packages for one or multiple cycles using different fertility drug options – oral or injectable. That may also include the necessary office visits, ultrasounds, and blood work.
Related Content: Health Insurance for Infertility: What You Need to Know
What are the advantages, disadvantages, and risks of IUI?
The IUI procedure is relatively safe, easy and non-invasive. It is also much faster and less costly than IVF.
The major disadvantage of IUI is the significantly lower live birth rate than IVF.
Also, while taking fertility drugs is safe, there can be side effects – clomiphene can cause:
- hot flashes,
- fluid swings and
- mood swings in some women.
However, most women tolerate clomiphene quite well.
The primary risk of IUI when done with ovarian stimulation is multiple pregnancies. Multiples carry risks for mother and babies including premature birth, disability, infant mortality and health issues for the mother.
Twins can occur in up to 30% of pregnancies with gonadotropins which is why gonadotropins and IUI are rarely done together now. However, this risk can be substantially reduced if only 2 – or at the most, 3 – mature follicles are created during ovarian stimulation.
When limited to 2 or 3 eggs ovulated the twin rate is about 8% to 10%. And the triplet rate is 1 in 200. It is important to note that the multiple pregnancy risk comes primarily from the ovarian stimulation of multiple follicles, not the IUI itself.
Decisions to make if selecting intrauterine insemination
As with most medical treatments, there are decisions to make along the way. With IUI these include, but are not limited to:
- Whether to use fertility drugs and if so, which ones?
- Whether to have monitoring
If monitoring is selected, one must choose either a fertility clinic or ob-gyn to provide the services.
A fertility clinic is considered the best option for monitoring for several reasons:
- better daily monitoring to track and adapt cycle treatment as needed;
- the ability to perform insemination on the weekend if ovulation occurs;
- and better expertise in washing sperm.
Fertility clinics can also treat with gonadotropins if needed, but this is rarely done now.
To learn more, contact Creating a Family – the National Infertility Education and Support nonprofit. To learn more about whether IUI or IVF is right for you, click here to listen to a radio show with an expert (one hour).
When to stop IUI and try IVF
Before you begin IUI, it’s a good idea to have a conversation with your partner and doctor about how many cycles you want to attempt. Many physicians place a limit of three failed IUI cycles, but others may try up to six before moving on.
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This post was published in two parts in July 2019. They were reviewed and combined into one article on March 7, 2020, in order to make it easier for readers to compare and contrast these two important fertility procedures.
David Adamson, M.D.
G. David Adamson, BSc, MD, FRCSC, FACOG, FACS is a reproductive endocrinologist and surgeon, Clinical Professor ACF at Stanford University, and Associate Clinical Professor at University of California San Francisco.
His undergraduate, medical school, and obstetrics/gynecology residency training were at the University of Toronto, and his Reproductive Endocrinology and Infertility fellowship training at Stanford University. Currently, he is Director of Equal3 Fertility, APC, and CEO of ARC® Fertility.
Dr. Adamson has over 300 peer-reviewed and scientific/medical publications and has lectured extensively for more than 30 years nationally and globally on assisted reproductive technologies, endometriosis, reproductive surgery, infertility, and access to quality reproductive health care. Dr. Adamson led the committee that created The FIGO Fertility Toolbox and the organization that created the global Endometriosis Phenome and Biobanking Harmonization Project (EPHect). He created the Endometriosis Fertility Index, all digital tools used globally to improve health care for reproductive-age women.
He is Chair of the International Committee Monitoring ART (ICMART), which is a non-State actor (NSA/NGO) in official relations with the World Health Organization (WHO) and President of the World Endometriosis Research Foundation (WERF). Dr. Adamson is on the Board of the International Federation of Fertility Societies (IFFS) and FIGO Committee on Reproductive Medicine of which he is Past Chair. He is the Founder, Chairman, and Chief Executive Officer of Advanced Reproductive Care (ARC® Fertility), the largest United States network fertility company.
Dr. Adamson is Past President of the American Society for Reproductive Medicine (ASRM), Society for Assisted Reproductive Technology (SART), AAGL, and several other major gynecological societies. He has been recognized as one of the best 400 physicians for women in America. He has received many awards, including the Outstanding Achievement in Medicine award from the Santa Clara County Medical Society, a Certificate of Special Congressional Recognition for contributions to the community, Distinguished Surgeon award from the Society of Reproductive Surgeons, Honorary Life Membership from the Canadian Association of Internes and Residents, the Barbara Eck Founders Award from RESOLVE, numerous honorary memberships and professorships, and the ASRM Distinguished Service award for his outstanding achievements in advancing the practice of reproductive medicine.
Dr. Adamson enjoys spending time with his family, reading, hiking, traveling, and ice hockey.
In addition to being a contributing author for The Doctor Weighs In, Dr. Adamson also serves on the TDWI Editorial Board, where he medically reviews articles submitted for publication.