About 1 in 8 couples in the United States experiences infertility. This number might seem high, but considering how many things need to go perfectly suitable to conceive, it’s not surprising.
There are many reasons why an individual or couple might have a hard time becoming pregnant, including factors related to ovarian health and egg quality, sperm quality (concentration, motility, shape), uterine health, and more.
For those having trouble conceiving, there are various options to seek or utilize that can help you get pregnant, some of which you can even begin to pursue on your own, like making changes to your diet and lifestyle to optimize your body for pregnancy. You can also work with your current OB/GYN or Primary Care Physician (PCP) to start with preliminary testing, such as basic ovarian reserve testing and a referral for a semen analysis.
For many looking into fertility treatments, two options become top choices to consider pursuing: intrauterine insemination (or IUI) and in vitro fertilization (or IVF).
For people struggling to conceive, an initial evaluation with a fertility specialist can help identify the root cause of infertility and factors that may be creating challenges. Reproductive Endocrinologists have extensive training and experience in evaluating problems that can interfere with conception — such as egg, sperm, uterine, or implantation issues — and are therefore best able to guide patients in choosing which treatments are best for them.
IUIs should be performed by a medical professional trained to do them. In most cases, IUIs are used in conjunction with medicated (oral pills) treatment cycles. IVF is a more involved treatment and should only be managed by an experienced reproductive endocrinologist (REI).
Below we’ll look at what IUI and IVF entail, the pros and cons of both treatments, and knowing which one is the right option for you.
What Is IUI?
IUI stands for intrauterine insemination. It involves having sperm injected into the uterus around the time of ovulation. This is done to bypass any potential cervical issues and decrease the sperm’s travel time to the egg and increase the likelihood of fertilization happening.
For whom is IUI a good option? It’s typically one of the first fertility treatments recommended for patients who have not gotten pregnant on their own within about six months to one year of trying depending on age. It’s a great option for those dealing with hormonal and fertility issues such as:
- Anovulation (lack of ovulation without help from medication)
- Cervical mucus problems
- Sperm quality issues
- It can also help same-sex couples using donor sperm, single mothers using donor sperm, and sometimes couples with unexplained infertility.
You might also hear IUI referred to as artificial insemination. IUI involves the sperm first being “washed” to increase its potency, then being delivered directly to the uterus.
“Washing” sperm means that a sperm sample is first collected, and then the sperm are separated to sort healthy, motile (swimming) sperm from the less healthy sperm and seminal fluid. Only the best quality sperm is used during an IUI; this way, there’s the greatest chance of the sperm being able to reach and penetrate the egg.
It’s essential that the individual is ovulating or just about to ovulate when IUI is performed because this is the only time that a person can get pregnant. Ovulation is when a mature egg is released from an ovary to begin its journey down the fallopian tubes, at which point it can be fertilized.
Before an IUI is performed, a doctor monitors the individual to track the timing of their cycle and ensure they are ovulating. Monitoring can be done using an ultrasound, which looks at egg follicles within ovaries, and sometimes with bloodwork.
Here are the basic steps involved in an IUI cycle:
- The IUI cycle begins on the first day of a person’s period and the egg(s) mature inside the ovaries for about the next two weeks leading to ovulation.
- Some people will take medications to encourage ovulation during this period. For example, medications (such as oral meds like Clomid or Letrozole or injectable hormone medications called gonadotropins) can be used to stimulate more eggs to mature and be released.
- In most cases, the IUI will take place on the day of ovulation or sometimes the day prior. This is determined using monitoring. A “trigger shot” might also be used to time ovulation since this medication induces ovulation within about 36 hours.
- A sperm sample from either a partner or a donor will be provided to the doctor’s office, then washed.
- The doctor/practitioner will insert the washed sperm sample into the uterus using a thin catheter. This is primarily painless and only takes a couple of minutes.
- After the IUI, the person will lay down and relax for about 10 minutes, and then they are free to leave the doctor’s office and go about their day. Hopefully, at this point, fertilization takes place.
What are the advantages of IUI?
Below are some of the main advantages of IUI:
- Less invasive and less expensive compared to IVF. A typical IUI cycle can cost about $1000 (depending on your insurance), while IVF can cost $20,000 per cycle.
- IUI Deposits the best quality sperm possible close to where the egg is waiting, which increases the chances of becoming pregnant in comparison to conceiving through intercourse.
- Uses monitoring to ensure that insemination happens at the time of ovulation.
- IUI cycles can either use medications or not, depending on the specific situation. Those who have difficulties ovulating, such as those with irregular periods or PCOS, can use medications to help release more mature eggs.
- Not using ovulation medication can help lower the cost. This is a good approach for those who ovulate regularly or who are using donor sperm.
Who performs IUIs?
IUIs cannot be performed at home without proper processing and washing of seminal fluid; however, some people may try intravaginal or intracervical inseminations at home, with significantly less success. Most often, people choose to see a medical professional for the procedure. OB/GYNs can perform IUI, which means patients may be able to work with their previous provider if they prefer (only reproductive endocrinologists can perform IVF, however).
That being said, patients often choose to work with a fertility specialist or an REI for an IUI because an REI can perform thorough tests prior to an IUI in order to gain more advanced knowledge of a patient’s fertility status and obstacles.
Specialists typically have cutting-edge technology and equipment and are capable of uncovering a great deal of information about the quality of one’s sperm, eggs, anatomy, menstrual patterns, and so on, which can help increase success with IUI.
How successful is IUI?
IUI is said to have “modest results” in terms of success, meaning it isn’t guaranteed to work and isn’t necessarily more successful than two healthy people having intercourse.
In best-case scenarios, it’s successful about 7% to 20% of the time per IUI cycle, depending on the woman’s age. If a couple tries IUI several times and does not have severe damage to fallopian tubes and has decent quality sperm, they may have a 50% chance of getting pregnant with up to six rounds of IUI.
Overall, success rates depend on the couple’s age, the timing of the procedure, and the health of the eggs and sperm. Individuals younger than 35 tend to have more success with IUI than those over 35 to 40 years old.
Are there any side effects of IUI?
IUI typically doesn’t hurt, although it may feel a bit uncomfortable. Some people experience mild cramping during the procedure. Afterward, it’s okay for the person to resume normal activities, as they’re unlikely to feel any significant side effects.
Side effects can be more noticeable if medications are being taken. For example, ovulation medications can sometimes cause temporary bloating, cramping, water retention, and breast pain.
There’s also a higher likelihood of having multiples (twins or triplets) if using gonadotropin medications with IUI since these drugs can cause multiple eggs to be released and potentially fertilized.
What Is IVF?
IVF stands for in vitro fertilization. It’s a fertility treatment that fertilizes eggs with sperm in a lab (“in vitro” refers to a process performed in a laboratory culture dish instead of inside the body).
IVF is one type of artificial reproductive technology (or ART). IVF aims to stimulate the ovaries to mature as many healthy eggs as possible in a given cycle in order to create embryos. In the majority of cases patients pursuing IVF choose to utilize genetic testing, which entails a few cells being removed from the embryos for testing prior to freezing. Through genetic testing, your REI physician will be able to dramatically increase the likelihood that the embryo being transferred into the uterus is genetically healthy and increase the liklihood of getting pregnant. There are many reasons individuals or couples choose to pursue IVF when growing their family, including various causes of infertility, wanting to utilize genetic testing on embryos, or moving on from other fertility treatments that have been unsuccessful.
The entire IVF process can usually occur within three months. Medications are first used to help eggs inside the ovaries mature, then as many eggs as possible are removed from the body with help from an egg retrieval procedure. The mature eggs are then mixed with a sperm sample in a lab (called insemination), hopefully facilitating fertilization and embryo formation. In frozen embryo cycles, embryos are then frozen to allow for the woman’s body to return to normal after stimulation within a few weeks. The final step is the frozen embryo transfer which occurs after the uterus is primed with estrogen and progesterone for approximately three weeks. In this minor painless procedure, an embryo is released inside the uterus with the aid of ultrasound guidance.
To summarize the steps above, a cycle of IVF includes several steps:
- Ovarian stimulation using injectable medications.
- Egg retrieval from the ovaries.
- Fertilization of retrieved eggs using a semen sample within a laboratory.
- Optional but recommended preimplantation genetic testing of embryos prior to freezing them.
- Uterine lining preparation.
- Transfer of the fertilized embryo back into the uterus using a thin tube through the cervix under ultrasound guidance
- Then hopefully, pregnancy occurs!
There are several additional treatment options available with IVF, including using intracytoplasmic sperm injection (or ICSI), Preimplantation Genetic Testing (PGT), or using donor eggs, donor sperm, or a gestational carrier (surrogate). Including any of these options into your treatment plan will all depend on the couple’s specific needs.
Who is IVF best suited for? Depending on the factors contributing to infertility, IVF may be the best choice and recommended as the primary treatment plan due to its significantly higher success rates than IUI. However, less aggressive initial attempts with IUI cycles would also be appropriate in many situations due to its less invasive and costly nature. In general, IVF would be a good first choice for those with the following conditions:
- Damaged, blocked, or absent fallopian tubes (the procedure bypasses the fallopian tubes, where ovulation typically takes place).
- Poor sperm quality (it can be successful even with very little healthy sperm, as explained more below).
- Prolonged unexplained fertility.
- Problems with ovulation that are not being solved with other treatments.
- Severe endometriosis
- A genetic disorder that can be passed down to offspring.
IVF With ICSI:
ICSI is a procedure only available during IVF and cannot be performed with an IUI. It involves having a single healthy sperm be injected into a mature, retrieved egg. Research shows ICSI typically fertilizes between 50% to 80% of eggs. ICSI is often recommended as a good option when undergoing IVF treatment if:
- The partner produces too few sperm to do IUI or traditional IVF (in which 50,000 sperm are used to inseminate a retrieved egg).
- Sperm aren’t motile, or sperm have trouble attaching to or penetrating the thick outer layer of the egg.
- There’s a blockage in the reproductive tract that is preventing sperm from exiting.
- Traditional IVF fertilization has not worked for unknown reasons.
- Eggs that were previously frozen are being used.
What are the advantages of IVF?
Below are some of the main advantages of IVF:
- Considered the most potent fertility treatment, it can help couples get pregnant when other options cannot.
- It can help address reproductive issues related to both egg and sperm providers, including egg and sperm health and problems with the cervix and fallopian tubes.
- It can help treat age-related infertility and prolonged unexplained infertility, which often lead to unsuccessful treatment with IUI.
- It offers the option of using ICSI, which IUI does not.
- It offers the option of using genetic testing, which IUI does not. This reduces concerns regarding certain genetic disorders since embryos can be tested before being implanted to identify genetic disorders or chromosomal abnormalities.
- It offers the option of storing embryos to be used and transferred at another time.
Preimplantation Genetic Testing:
One of the significant advantages of IVF is that it allows for genetic testing of embryos, including for inherited familial diseases, which IUI and other fertility options do not.
Called Preimplantation Genetic Testing (or PGT), this type of testing is performed to identify if embryos have a specific genetic or chromosomal condition. This way, those embryos are not transferred to the uterus, and the defect is not passed onto the offspring. The goal is to ensure that healthy embryos are transferred to the uterus in order to sustain a pregnancy and result in a healthy baby.
PGT also helps address the fact that one of the most common reasons embryos do not transfer and result in pregnancies is because of abnormal embryo genetic factors.
PGT may be recommended for couples or patients with a history of single-gene disorders, such as cystic fibrosis or sickle cell anemia, or sex-linked disorders, such as Duchenne muscular dystrophy and Fragile X syndrome.
How successful is IVF?
IVF now accounts for up to 4.5% of all live births in the United States and Europe.
The chances of getting pregnant with help from IVF ultimately depend on a number of factors, including age and overall health status, the underlying reason for infertility, and how many healthy embryos were created.
Like with IUI, IVF is most successful when the person providing eggs is younger than 35 to 40 years old and generally healthy. Overall, women between 30 and 40 have about a 40% to 50% chance of IVF working depending on several factors, and however, with the advent of PGT testing, a genetically normal embryo would have an approximately 70% chance of resulting in a healthy pregnancy in a high-quality fertility clinic.
Are there any side effects?
IVF involves using medications that can cause side effects, such as bloating, nausea, water retention, headaches, and mood swings. These are temporary and usually last about one week or so.
The egg retrieval procedure is performed under anesthesia and takes approximately 15-20 minutes. After the process, there may be some mild discomfort, including cramping, swollen ovaries, light bleeding, and tenderness. Following IVF, patients should avoid anything too strenuous, or that involves twisting of the ovaries.
Depending on the medications used in the IVF stimulation, there may also exist a minimal risk of ovarian hyperstimulation, which is a condition that can cause the ovaries to become temporarily swollen and painful, and in very rare circumstances, requires fluid to be removed from the abdomen.
IUI Vs. IVF: Which Is Right For You?
There’s a lot to consider when deciding between IUI and IVF, including the cost, invasiveness, time commitment, use of medications, potential side effects, and success rates.
An IVF cycle is more involved, invasive, and expensive than an IUI cycle; however, it can also be significantly more successful when IUI and medications are not.
If you’re dealing with infertility, your provider will help guide you through the process.
Your fertility provider will run tests to determine things like your egg and sperm quality and then be able to advise you on options that are most likely to be successful. Because every infertility situation is unique and complex, it’s best to listen to your provider’s recommendations regarding your treatment plan.
Is it worth trying IUI before IVF?
You and your doctor together can review your current health status and the specific conditions you’re facing to determine if IUI should be performed first or if it is in your best interest to move directly to IVF as your first-line treatment choice.
In many cases, if appropriate, your physician may recommend trying up to three cycles (sometimes up to six) of medicated IUI before moving onto IVF, assuming there are no significant obstacles that can interfere with IUI being successful. Sometimes certain insurance companies will require this before paying for IVF.
Some doctors may suggest that women in their 40s only try IUI once or twice before going to IVF, or even that they go straight to IVF to not waste time.
How do you know if you should do IUI first or go straight to IVF?
According to fertility experts, here is when to consider IUI before moving on to IVF:
- Try IUI first if your infertility is mainly related to ovulation issues. This includes individuals with PCOS or other forms of anovulation, plus cervical mucus problems.
- If the partner providing sperm has moderate sperm health issues but is still producing healthy amounts of sperm, try IUI first.
- Same-sex couples and single parents trying to conceive with donor sperm can also try IUI first.
- If the egg provider is under 35 or between 35 and 40 with no significant known fertility issues, IUI is typically done before IVF.
IVF may be a better option if 3-6 IUI cycles have been unsuccessful, or if the individual providing eggs or carrying the pregnancy is in their 40s, there is very little good quality sperm, or if there are known problems with uterine or fallopian tube function.
Family planning is another crucial element to consider when deciding where to start. If more than one child is desired, and advanced female age is one of the issues, IVF may be the best option in order to provide ample opportunity for fertility preservation through embryo creation. This future planning can allow individuals and couples to build the family of their dreams instead of enduring a long fertility journey that results in a significant decrease in the chance of additional successful cycles and future children.
Don’t forget to discuss these issues with your trusted REI so they can guide you appropriately.