Natural Cycles with IUI
Natural cycles with IUI have the least amount of monitoring, In these cases, either over the counter LH predictor kits are used to determine when ovulation occurs and the IUI is timed accordingly. Alternatively, an ultrasound can be performed between cycle days 11-14 to determine if a mature follicle has developed and subsequently, HCG is administered which will cause ovulation to occur within 36-44 hours. Then the insemination(s) are scheduled. Progesterone vaginal supplementation is then started one day after the IUI and continued for 12-14 days until the pregnancy test. If the pregnancy test is negative, the progesterone must be stopped in order to allow for the period to occur.
Clomiphene citratre (Clomid) cycles have slightly more monitoring. An ultrasound is performed on cycle days 2, 3, or 4 in order to confirm that no ovarian cysts are present prior to starting the Clomid. Taking Clomid in the presence of cysts can lead to an abnormal response and the enlargement of already present cysts. The woman then takes clomid either 50 to 150 mg daily for five days. A mid-cycle (days 11-14) ultrasound is performed to determine if and how many mature follicles (measuring 20-24mm) are present and also evaluate the endometrial lining. In 10% of women, the anti-estrogen effect of clomid can cause unexpected thinning of the endometrial lining which is detrimental to implantation of an embryo. If this persists over two or more attempts, clomid may not be an appropriate treatment option. Once mature follicles are present, HCG is administered and the IUI(s) will follow within 24-48 hours, once again followed by the use of vaginal progesterone. The risk of multiples pregnancies with Clomid is approximately 8% with the majority being twins.
Gonadotropin Cycles (Fertility Shots)
Gonadotropin cycles (fertility shots) increase both medication costs and the necessity of ultrasounds and bloodwork. In these cycles, a baseline is once again performed between cycle days 2 through 4 to confirm no cysts being present. At this point, the injectable medication is started. Multiple days of ultrasounds and blood hormone levels will follow in order to closely follow the growth of the follicles and assure that the ovaries do not over-stimulate (ovarian hyperstimulation syndrome) and that too many follicles are not present. One of the risks for this type of stimulation is that of higher order multiples. If multiple follicles are developing, the risk of higher order multiples (triplets and above) increases. The overall risk of multiples with gonadotropins is approximately 20% and the presence of too many follicles (greater than 4-5) may prompt cancellation of the cycle. Many people are unaware that the majority of higher order births (triplets and above) are a result of gonadotropin/IUI treatments that are not managed and cancelled appropriately. It is a misconception that these higher order births are a result of IVF; IVF provides a much more controlled treatment limited to the number of embryos being transferred. Once a reasonable number of mature follicles are noted (between 1 to 4), the HCG trigger shot is given followed by the insemination(s). Once again this is followed by progesterone vaginal support.
Should one or two inseminations be done per cycle?
Any insemination should be carefully timed to occur at or a little before the time of ovulation. We know that in some couples, sperm can remain viable in the female reproductive tract and result in fertilization of an egg for five days (after having sex). However, eggs are fertilizable for only about 12-24 hours (maximum) after ovulation during the time they are moving through the fallopian tubes. Therefore, IUIs must be properly timed so that sperm are present in the fallopian tubes at the same time as the egg.
There are many published studies that address whether one or two inseminations should be performed in order to facilitate the egg and sperm meeting in the fallopian tube. Some studies show no improvement in pregnancy success rates with two inseminations done on sequential days as compared to one well-timed insemination. Other studies show higher pregnancy rates when two inseminations are done on back to back days. One possible explanation for the different findings is that if single inseminations are not properly timed for ovulation, success rates would improve with a double insemination protocol. At least one of the 2 inseminations might be timed correctly. However, most fertility experts believe that one well-timed IUI is sufficient.
At Advanced Fertility Care we perform both single and double inseminations based mostly on the development of the follicle and endometrial lining as well as logistical considerations. For patients using donor sperm purchased through a sperm cryobank, the doctor will recommend a single well-timed IUI in order to minimize the cost to the patient for multiple vials of sperm which can run between $300 to $500 per vial. The cost of the actual cycle varies depending on the medication used and the amount of ultrasound and blood monitoring being done. Click here to see pricing.
How many attempts should be made with artificial insemination?
In general, IUI is a reasonable initial treatment that can be attempted for a maximum of about 3-4 months in women who are ovulating (releasing eggs) on their own. It is reasonable to try IUI for longer (up to 6 months) in women with polycystic ovaries (PCOS) and lack of ovulation that have been given drugs to ovulate.
85-90% of women who will successfully conceive using ovulation induction with IUI will do so within 4-6 cycles (months of treatment).
If superovulation (i.e. Clomid) with IUI is unsuccessful options for more aggressive treatment include ovulation induction (with injectable gonadotropins) with IUI versus proceeding directly to IVF. In many cases, given that the success rates with ovulation induction/IUI are not that much better when compared to clomid/IUI, the most successful path towards success may be to pursue IVF directly.