If you have been struggling to get pregnant, two of the most popular infertility treatment options often discussed are artificial insemination (I.U.I.) and in-vitro fertilization (I.V.F.). What are the differences between these two methods of assisted reproductive technology (A.R.T.) and which one is best for you? Every couple’s infertility journey is unique, so ultimately it is important to speak to your doctor during your fertility evaluation to assess your options and the reasons for your infertility. Let’s explore the differences between I.U.I. and I.V.F. and the reasons why couples might choose one over the other.
When Do Couples Seek I.U.I. or I.V.F. Treatments?
According to the Centers for Disease Control, couples who have not been able to get pregnant after one year of trying (having unprotected sex) are considered infertile. Because fertility is known to decline as women age, if the woman is over 35, the couple would be considered infertile after 6 months of having unprotected sex. At this point, many couples make an appointment with their doctor for a fertility evaluation. During the evaluation, your doctor will try to assess the reasons for your infertility, and offer you a range of treatment options. There are many different treatment options for infertility, and I.U.I. and I.V.F. might not be your first or only choice. However, when assisted reproductive technology options are needed, I.V.F. and I.U.I. are often considered.
What is I.U.I.?
With I.U.I., sperm is placed directly into the uterus when the woman is ovulating, where it is closer to the egg, thus increasing the chances of fertilization. Semen is collected either at the doctor’s office or at the patient’s home. According to Planned Parenthood, women may take fertility medicines to help them ovulate before the procedure is performed. When the sperm is collected from the male partner, doctors may put it through a process known as to remove chemicals that could prevent pregnancy and to create a more concentrated sample of healthy sperm.
Both partners undergo a thorough fertility evaluation to ensure that the male partner has healthy sperm counts and motile sperm, and to ensure that the woman is ovulating. Doctors will also check to make sure that there are no obstructions in the uterus that could interfere with pregnancy. The procedure itself is relatively quick. It can be performed in a doctor’s office in under 10 minutes. During the procedure, a thin flexible tube is slid through the cervix and into the uterus, and the sperm is injected directly into the uterus. The average cost of I.U.I. ranges from $300 to $1,000 without insurance. Because of its relatively low cost and low invasiveness, for couples without a medical reason to use I.V.F. first, I.U.I. is often the first assisted reproductive technology method used.
What is I.V.F.?
I.V.F. is a much more involved procedure than I.U.I. and it is more costly. I.V.F. involves 5 steps:
- Preparation for the First I.V.F. Cycle. During this preparation period, some women will be put on birth control and take a GnRH antagonist to prevent ovulation. It might seem counterintuitive to go on birth control before I.V.F., but research published in the International Journal of Clinical and Experimental Medicine showed that taking these drugs could reduce the risk of ovarian hyperstimulation syndrome, without interfering with I.V.F. outcomes. Women who develop ovarian hyperstimulation syndrome, a condition in which the ovaries swell up and become painful, run the risk of having their I.V.F. cycle stopped. You’ll also take wellness supplements (prenatal vitamins) to prepare your body for a healthy pregnancy.
- Ovarian Stimulation with Fertility Drugs (Gonadotropins). After your period, blood work and an ultrasound is performed. Then, if all is well, ovarian stimulation with fertility drugs (gonadotropins) begin. Your doctor will determine the right amount of fertility injections you’ll need. Finally, when the follicles have matured, you’ll take a single shot of hCG (human chorionic gonadotropin). The timing of this shot is essential. Your doctor will monitor the size of the follicles and when they are the right size (12-19 mm according to a study in Frontiers of Endocrinology), the shot of hCG will be administered. According to Very Well Family, the shot is timed to the precise hour it needs to be taken. Taking it too early could result in the follicles not being mature enough to produce a mature egg and taking it too late can result in follicles being too mature and therefore produce eggs unable to be fertilized. While you are taking these drugs, follicle development is closely monitored by your doctor. This week is one of the most involved weeks in your I.V.F. cycle.
- Egg Retrieval. According to the Society for Assisted Reproductive Technology, egg retrieval typically takes place 34 to 36 hours after the hCG shot is administered. Before the procedure, women are often administered pain medication and sedatives to keep them comfortable. A needle is guided up the vagina and into the ovaries where the follicles are accessed and the eggs are retrieved through suction from the follicles. The eggs are analyzed in the lab and the mature eggs are then fertilized after retrieval using sperm that your partner provided or sperm that has been donated. During the egg retrieval, the male partner will provide sperm, usually through ejaculation into a sterile jar, but sometimes surgical procedures may be used and sometimes donor sperm is used. The sperm and egg are both placed in a culture medium where the sperm can fertilize the egg, or individual sperm might be injected directly into the egg. Doctors closely watch the eggs, sperm, and resulting embryos for development. 3-5 days later, the embryologist looks for the healthiest embryos. Other procedures may be performed on the embryos, such as genetic testing or assisted hatching before the embryo transfer takes place.
- Embryo Transfer. A few days after the egg retrieval, if embryos have successfully developed, the embryo transfer will take place. According to the Society for Assisted Reproductive Technology, a catheter is guided through the cervix into the uterus, where the embryos are directly placed. This procedure doesn’t usually require pain medication or sedatives.
- Waiting Period, Hormones, and Pregnancy Test. After the egg retrieval, you’ll be taking progesterone to prepare your uterus for embryo implantation. About 9 to 12 days after the embryo transfer, you’ll take a pregnancy test. If you are pregnant, your doctors will closely monitor the pregnancy. If the I.V.F. cycle fails, you and your partner will need to consider next steps. Many couples need more than one I.V.F. cycle to get pregnant.
I.V.F. can be physically invasive, stressful for couples, and it can be costly. According to the National Conference of State Legislatures, a single cycle of I.V.F. (not including drugs and medications) can cost anywhere from $12,000 to $17,000. Because of the cost and invasiveness of I.V.F., many couples are advised to try I.U.I. first. However, there are certain situations where I.V.F. may still be a couple’s first choice. Let’s explore.
Whether you’ll use I.U.I. first or I.V.F. first will depend on the causes of your infertility. Some infertility causes, like menstrual irregularities, might be better treated with changing your lifestyle or through hormones, and other infertility causes may be remedied through surgery. If you suffer from a thyroid condition, autoimmune disorder, or infection whose symptoms include infertility or low fertility, your doctor may treat this condition first before you undergo any type of assisted reproductive technology procedure. In some cases, treating the underlying causes of your infertility can lead to pregnancy without the need for either I.V.F. or I.U.I.
Additionally, it is important to check the man’s sperm count, sperm motility, and testicular health because this can also have an impact on whether I.U.I. or I.V.F. is the first choice, and whether the man needs to undergo treatments before any procedure begins. In some cases, addressing lifestyle factors, surgical interventions for blockages, or treatments of underlying conditions can also result in pregnancy without the need for either I.V.F. or I.U.I.
When time is of the essence, patients will want to use the best possible fertility method, while also taking costs, invasiveness, and risks into account. In many cases, I.U.I. can be just as effective as I.V.F., especially if the woman was not suffering from a blockage of the fallopian tubes, doesn’t have severe endometriosis, and when there was no significant male factor infertility involved.
One study published in the journal of Fertility and Sterility found that I.U.I. was just as effective as I.V.F. However, it is important to note that the study excluded some patients. Patients who had been infertile for more than 18 months, had a significant male factor in infertility (very low sperm counts, very low motility), had a female partner with severe endometriosis, or where the female partner had blocked fallopian tubes were not considered, and in these cases, patients might want to consult with their doctors about whether I.V.F. is the best first choice. According to Human Reproduction, patients suffering from unexplained fertility or mild male partner infertility should use I.U.I. as the first-line of treatment. I.U.I. is preferred because it is the less invasive and less expensive treatment option. Finally, research published in Fertility and Sterility found that candidates who saw the best results with I.U.I. were women under 30 with cervical or anovulatory infertility and a man with total motile sperm count more than 5 million. Ultimately, the decision of whether to use I.U.I. or I.V.F. first should rest with patients and their doctors.
Older Women: I.V.F. vs. I.U.I.
When it comes to deciding whether to start your assisted reproductive technology treatment with I.V.F. or I.U.I., age matters. According to Reproductive BioMedicine Online, the chances of success with I.U.I. are very low for women over age 40. The authors recommend that after a short course of I.U.I. with gonadotropins, women should be referred to I.V.F. right away (though success rates for I.V.F. in women over age 40 is also low). According to the Society for Assisted Reproductive Technology, women between the ages of 41 and 42, saw an 11.6% success rate for embryo transfers with I.V.F., while women over age 42 saw a success rate of only 4.1%. Women who tried I.V.F. between the ages of 38 and 40 saw far greater success rates. Women in this age rate saw success rates at 23%.
Women who are seeking assisted reproductive technology in their late 30s may need to carefully weigh the statistics and time considerations when deciding whether to go with I.V.F. or I.U.I. While I.U.I. is less costly and less invasive than I.V.F., it takes time, and women may need more than one cycle to see success. According to Fertility and Sterility I.U.I success rates among women between the ages of 36 and 39 years of age was 9.5% per I.U.I. treatment. The percentage of women who see success goes up with multiple treatments. I.V.F. success rates in this same age group ranged from 35.9% among women between 35 and 37 years of age and 23% among women between 38 and 40 years of age.
Women in their late 30s looking for assisted reproductive technology options will need to weigh whether they are willing to risk several months of their fertility trying I.U.I. or want to try I.V.F. earlier, when the chances of success may be higher per cycle. Of course, statistics only tell you the story of many women trying collectively. Your individual story is unique. So, if you are in your late 30s or early 40s, a discussion with your fertility doctor is the best place to start.
When Might I.V.F. Be the Best First Choice?
There are situations where I.V.F. might be a couple’s first choice for assisted reproductive technology. According to Very Well Family, I.V.F. is used as a first-line treatment for infertility when there is a blockage of the fallopian tubes, when a gestational carrier is needed, where an egg donor is needed, or where male infertility is severe. Couples who are concerned about birth defects of passing on certain illnesses to their children may also choose I.V.F. as a first-line treatment.
When you go in for your infertility evaluation, your doctor will determine the causes for your infertility. If the woman is suffering from a blockage or if the woman is older, I.V.F. may be the best first line treatment for infertility. I.V.F. may be a slightly more successful treatment option for women suffering from polycystic ovaries according to the Journal of Human Reproductive Services. Of PCOS patients who underwent treatment for the condition, 44.77% saw pregnancy success with timed intercourse, 17.09% saw successful pregnancy with I.U.I., and 29.82% saw successful pregnancy with I.V.F. So, IVF may be more effective, but because I.U.I. is cheaper and less invasive, some women with PCOS may elect to use this as a first option before trying I.V.F.
For many couples, I.U.I. will be the first line of treatment, but ultimately, whether you’ll try I.U.I. or I.V.F. first will depend on your medical needs, age, and personal choice. Some insurance providers may require that you try I.U.I. as your first-line treatment before covering I.V.F., so your insurance provider may play a role in the decision-making process. If you have been struggling with infertility, your first step will be to visit your doctor for an assessment. From there, you and your doctor can chart a course forward.