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Optimizing Infertility Treatment: Does IUI Make Sense?

Article originally sponsored by Optum.

The goal of infertility treatment is to have a healthy baby, a healthy pregnancy, and to do it in a timely and affordable manner. While the risks of a high order multiples (triplets or more) pregnancy are well recognized and understood, there is still a perception that twins are an acceptable – and even desirable – outcome of infertility treatments. Contrary to the belief that twins have minimal risk, according to the March of Dimes, 60% of all twins are born prematurely. Prematurity, which is defined as birth before 37 weeks of completed pregnancy, is associated with many adverse health consequences, among them being a higher risk for cerebral palsy, infection, chronic lung disease, and other medical conditions.

The infertility treatments that are associated with a higher chance for twins (or triplets or more) include ovulation induction (OI), controlled ovarian stimulation (COS), and assisted reproductive technologies (ART) such as in vitro fertilization (IVF).

  • OI is when a woman takes a medication – or hormone therapy – in order to stimulate ovulation.  OI is primarily used in women who do not ovulate.
  • COS also entails ovarian stimulation in women but generally involves different medications such as injectables and may be given as part of an Intrauterine Insemination (IUI) cycle.  
  • 99% of all ART treatments in the U.S. are IVF. 

Interestingly, OI and COS account for close to 50% of all triplet and higher births, much higher than that associated with ART. Indeed, the triplet rate from ART has fallen to below 2% in recent years. The reason for the higher rates of multiples with OI and COS is that the number of eggs developing and ultimately released cannot be precisely determined. While it is prudent to stop an ovarian stimulation cycle when there are more than three to four mature follicles (the structure containing the egg), this does not always happen. Furthermore, while the chance of having more than one baby when there are only two or three mature follicles may not be overly high, it is still possible to have all the eggs released and fertilized resulting in a multiple pregnancy. OI, in cases where there is a history of a lack of regular ovulation, is usually successful within six ovulatory cycles. COS, particularly when used in conjunction with an IUI cycle, typically results in a successful pregnancy within four IUI cycles. In either case, if a pregnancy has not occurred, it is wise to move to an ART cycle.

There is increasing evidence that skipping COS/IUI altogether is prudent for women over the age of 35, and limiting such cycles to three for women 35 and younger should be considered. Indeed, given the success rates with IVF, an argument can be made that skipping COS/IUI makes sense from a time and pregnancy outcome perspective. Conception may occur far more rapidly as one takes into account the number of cycles and the pregnancy rate per cycle of each treatment option. While a Clomid/IUI cycle is less expensive than an ART cycle, four cycles – each with a lower chance for success compared to ART – that do not result in a pregnancy actually ends up costing as much as an ART cycle. So staying with COS/IUI may actually cost you more in terms of dollars and time than moving more quickly to IVF.

ART cycles have the advantage of bypassing many of the issues that are causing the infertility problem and allowing a controlled number of embryos to be placed into the womb. In the proper clinical setting, the elective transfer of a single blastocyst yields a pregnancy rate that is as good as transferring two or more embryos but with a minimal risk for twins or more (spontaneous twinning may still occur in 2% of cases).

Talk to your doctor about your specific diagnosis and ask in advance if OI, COS, or IVF is right for you.  Discuss your perspective on multiple births with your doctor and how to ensure the healthiest outcome for the mother and her child or children. 

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