Many infertile patients, are erroneously advised by their physicians to first try IUI several times before resorting to IVF. Additionally many misguided insurance providers often, purely for economic reasons, require that infertile female enrollees who have at least 1 patent Fallopian tube, first undergo several attempts at IUI before doing IVF. It is important for infertile women to be aware that such an approach is often ill-advised as there are circumstances where IUI is very unlikely to be successful and where IVF should be the primary approach. While IUI is well indicated for women undergoing controlled ovarian stimulation for ovulation dysfunction, cervical mucus hostility, male impotence and when artificial insemination with pre-frozen sperm, there are several situations where in spite of tubal patency it is (in my opinion) relatively contraindicated:

• Moderate or severe male Infertility:  Intrauterine insemination (IUI) and in-vitro fertilization (IVF) are both often touted as being equivalent treatments for male factor subfertility. This is a fallacy. The success rate with a single IVF treatment using intracytoplasmic sperm injection is actually 8-10 times greater than a single attempt at IUI. Thus when it comes to moderate or severe male infertility such patients will ultimately require IVF anyway. Those who argue that because a single cycle of IUI is much less expensive than a single attempt at IVF and for this reason, several attempts at the former should be tried before resorting to IVF. A recent study conducted by the Department of Public Health in the UK compared outcomes (live birth-producing pregnancy) and the cost-effectiveness of offering IVF as a primary approach as compared with first trying IUI and only resorting to IVF if this fails. The results confirmed that in cases of male factor infertility it is far less costly and much more cost-effective to go directly to IVF as the primary treatment than to start with IUI and then only resort to IVF, should this fail.
• Older women and those with Diminished ovarian reserve (DOR):  For the vast majority of women, over 35y of age, an inevitable irreversible and accelerated advancement of the biological clock takes place, such that by age 40y there is only about a 2-3% per-cycle, chance of IUI success. Conversely IVF afford many such women a far greater opportunity to have a baby. Thus such women simply do not have the time to waste on ineffectual treatments such as IUI. Rather, they need (in my opinion) to “make hay while the sun still shines” and go directly to IVF.
• Endometriosis: All women with endometriosis have toxins in their pelvic secretions. This compromises the ability of sperm to fertilize eggs that pass from the ovary (ies) to reach sperm in the fallopian tube(s).This dramatically reduces egg fertilization potential by a factor of 4-6 fold.  It in large part serves to explain why potentially all women with endometriosis have reduced fecundity (reproductive potential) and why tubal surgery, the use of fertility drugs and/or intrauterine insemination (IUI) does not improve fecundity over no treatment at all.  The only way to improve the chance of having a baby through extracting eggs before they are exposed to toxic pelvic secretions…i.e. through IVF. I am not suggesting that all women with endometriosis should go directly to IVF. In fact most ovulating younger women with early endometriosis have time and should consider trying to conceive on their own. Rather, what I am saying is that women over 35y, regardless of age, those who have DOR and those women who for whatever reason feel a compelling sense of urgency to conceive ASAP, should preferentially consider doing IVF.

I would now like to try and dispel the following misconceptions regarding IUI:

1. The per-cycle cost of IUI is significantly lower than IVF and thus IUI represents a “cost saver”: Given the fact that IVF is at least 3-4 times more likely to be successful, when one looks at cost per baby (rather than cost per procedure) this turns out to be a fallacy. Moreover, cost also comes in the form of emotional currency and this needs to be measured in terms of the much lower chance of success with IUI.
2. Success in ovulating women who undergo natural-cycle IUI and those women undergoing ovulation induction with clomiphene citrate is equivalent to success rates when gonadotropins are used:  Quite to the contrary….,with the exception of IUI performed using thawed sperm (usually donor sperm), spontaneously ovulating women undergoing natural-cycle IUI does not improve the chance of pregnancy over regular timed intercourse. Also, when compared with IUI performed following induction of ovulation with gonadotropins, the use of clomiphene citrate is associated with a 30% lower success rate.
3. “IUI is less invasive than IVF”… ….This is true, however aside from the surgical egg retrieval which (when done in the right setting) is a safe procedure, IUI with gonadotropins requires largely the same drugs, preparation and monitoring as does IVF and the success rate is several fold lower than for IVF.
4. IUI is a viable option when at least one Fallopian tube is patent: Most tubal damage is due to prior pelvic inflammatory disease and this almost always affects both Fallopian tubes. What this means is that when only one tube is damaged or blocked the other (whether patent or not) is almost invariably affected as well. For a viable intrauterine pregnancy to occur following IUI, a healthy intra-tubal environment is an absolute necessity. This serves to explain why the chance of successful pregnancy following IUI is severely compromised in such cases. It also serves to explain why the chance of pregnancy is markedly reduced and why the risk of a tubal (ectopic) gestation is markedly increased in such cases. It is therefore my opinion, that IVF should be considered preferentially when one tube is damaged and this is deemed to be the likely consequence of tubal infection.
5. The chance of a multiple pregnancy can be controlled with IUI: When compared with IVF, IUI has another major disadvantage. This is because in women with ovulation dysfunction (e.g.; those who have irregular or absent menstruation such as with PCOS) ovarian stimulation often results in the release of multiple eggs at a time and it is not possible to limit number of embryos that reach the uterus. This is why when, undergoing IUI, such women are very likely to have multiple pregnancies (triplets or greater) which is associated with serious perinatal and long term complications. It is only through IVF that by regulating the number of embryos transferred to the uterus that the risk of multiple pregnancies can be limited.

In my opinion, we as physicians need to rethink the basis upon which we recommend IUI as an alternative to IVF and educate our patients accordingly.