IUI vs IVF: When it makes sense to skip IUI and go straight to IVF

If you're working with a fertility clinic and gotten your fertility test results back, you've likely had a consultation with your fertility doctor and they have likely explained what your infertility diagnosis is that is affecting your ability to get pregnant and what treatment they recommend to help you have a baby.

Often times, doctors will recommend that people start with a less invasive and less expensive treatment called intrauterine insemination, known as IUI.

In some cases, doctors will recommend for you to skip IUI and go straight to in vitro fertilization.

And then sometimes your doctor will lay our your treatment options and give you the choice: IUI vs IVF. 

But how do you know whether you should do IUI or IVF?

No, you do not have to IUI before moving on to IVF.

It is a decision you need to think through and make with your fertility doctor on whether it makes sense for you to start with IUIs or skip them and begin IVF treatment.

However, is you are using insurance to cover your infertility treatment you should checked with your insurance company on your coverage terms.

Some insurance companies require you to do a certain number of IUIs under your insurance coverage before the plan will cover an IVF cycle.

If you are paying for fertility treatment yourself, you may have slightly more freedom in selecting which infertility treatment to pursue.

Based on the current research, most infertility doctors will recommend their patients to try 3 rounds of IUI before considering moving to IVF. 

The reason that 3 IUI cycle are recommended is that the research has shown an increase in cumulative success rates after 3-4 cycles.

But after that, few patients get pregnant with the procedure, so moving on to IVF is recommended, as success rates with IVF are much higher per cycle than with IUI. 

IUI is about a tenth of the cost of an IVF cycle.

If you are paying for infertility treatment yourself, this is a big one to consider.

IUI can cost around $1,000-$2,000 per cycle while IVF can cost $20,000-$25,000 per cycle. Big difference! Sometimes that difference is worth it.

Some people may consider the cost and want to try a more affordable option first to see whether an IUI is all they need to get pregnant and avoid the large financial costs of an IVF cycle if possible.

But there are cases when your infertility diagnosis could affect your chances with IUI in a way where IVF would actually end up being more cost-effective than doing multiple IUIs.

IUI cycles have a lower average success rate than an IVF cycle but they are much less invasive and more affordable. So for certain diagnoses, doctors will recommend women to try about 3 cycles of IUI before considering moving on to IVF.

For women younger than 35, IUI has a 14% average success rate.

Women with PCOS tend to do well with IUI compared to other types of infertility, so it can be a good first line of treatment in this case.

When looking at women younger than 35, women with ovulatory dysfunction, such as PCOS, tend to do the best with infertility treatment in general.

The diagnosis that has the poorest IUI success rates is tubal factor, meaning there is an issue with the fallopian tubes. A review of IUI factors that predict success noted that a study found that women with tubal factor only benefit from a maximum of 2 IUI cycles before the results show that they should move to IVF.

It was also noted that women with stage III/IV endometriosis have poor outcomes with IUI, showing about 5.6% per IUI cycle.

However, women with endometriosis did well with IVF treatment with one study finding women with endometriosis had an IUI success rates of 11% per cycle and an IVF success rate of 47% per cycle.

The success rate of IUI decreases with female age, so as women get older IUI becomes less effective as a treatment option. Women older than 38 years old see less success with IUI.

Your fertility doctor may decide based on your medical history or your infertility diagnosis that IUI would be much less effective than going straight to IVF instead.

Dr. Matrika Johnson who is a reproductive endocrinologist at Reproductive Specialists of the Carolinas walked us through when she recommends someone go straight to IVF and skip IUI.

Dr. Johnson recommends going straight to IVF for:
☑️ women aged 38-42
☑️ blocked fallopian tubes
☑️ diminished ovarian reserve
☑️ male infertility

Dr. Johnson mentions the FORT-T trial when it comes to whether IUI or IVF makes sense for older women. In this study, women aged 38-40 who were diagnosed with infertility after trying to conceive naturally for at least 6 months were randomized to either IUI with clomid, IUI with gonadotropins, or went directly to IVF.

They found that after looking at all live births, 84.2% of all live born babies resulted from the group of women who did IVF. 

Furthermore, this group had to do fewer treatment cycles to get pregnant, meaning that they got pregnant faster. 

The two IUI groups after 2 IUI cycles had cumulative pregnancy rates of 22% and 17% while the IVF group after just one cycle had a pregnancy rate of 49%. 

Blocked fallopian tubes often call for IVF because IUI relies on the fact that the sperm will be able to make their way through the uterus into the fallopian tube to fertilize an egg. 

If the fallopian tubes are blocked, IVF is often needed as the fallopian tubes are bypassed during this process.

Women with diminished ovarian reserve have also been shown to do poorly with IUI but have improved success rates with IVF.

However, when it comes to diminished ovarian reserve, how a woman is classified as having poor ovarian reserve may make a difference in whether IUI is beneficial.

Young women with diminished ovarian reserve (AMH <1ng/mL) were found in a large study to have comparable IUI success rates to women of the same age that had a higher ovarian reserve (≥1ng/mL).

Some women are classified as diminished ovarian reserve due to their age. As women age, their ovarian reserve declines and egg quality decline with age as well.

So for this group of women with diminished ovarian reserve, it is more their age that makes IUI less effective and less about their AMH level.

Male infertility has been shown to significantly affect IUI success rates.

Men with poor sperm quality have lower success rates with IUI as often, the lack of a large number of sperm, poor motility, poor sperm morphology hinders the sperms ability to travel through the uterus and fertilize an egg.

Fertility specialists are still trying to assess an exact threshold for wen sperm count seems to significantly affect IUI. Thus far, it seems that at least 10 million total motile sperm is a good aim.

One large study found that men with less than 10 million total motile sperm had just a 1.5% pregnancy rate with IUI while men with 10-30 million total motile sperm had 10.5% pregnancy rate and those with 30 million or more had a 12% pregnancy rate.

IVF can overcome a lot of these hurdles by placing the sperm very close to the egg or by directly injecting a sperm into each egg in order to maximize the chances of success.

Here's a look at the IUI timeline showing a typical IUI treatment calendar.

You can follow the IVF timeline day-by-day here to learn more about the treatment timeline for in vitro fertilization.