IUI, artificial insemination and ovarian stimulationOral and injectable medications are the mainstay of treatment for ovulation disorders.  Occasionally we are able to correct underlying hormonal issues causing anovulation (ie, thyroid or prolactin), but more frequently we will use medications to stimulate the ovary to produce one or more eggs. These medications can also be used in combination with intrauterine insemination (IUI) to treat other causes of infertility including mild male factor infertility, endometriosis and unexplained infertility. To perform an IUI, sperm are collected, washed and concentrated, and placed directly into the uterus.

The oral agents used for ovulation induction are Clomid (Clomiphene) and Femara (Letrozole). These are inexpensive, easy to take and have few side effects (i.e., hot flushes, irritability, headaches) for most people. Each of these medications is taken daily for 5 days at the beginning of the menstrual cycle. When IUI is also performed at the time of ovulation, monthly pregnancy rates vary between 8-32% depending on the specific infertility etiology (see table below). Multiple pregnancy rates are approximately 8%.

When oral medications fail or are not indicated, injectable gonadotropins (FSH, hMG) can be used to stimulate the ovaries to produce several eggs per cycle. IUI is frequently performed when injectable hormones are given. The medications are self-administered at home for approximately 7-9 days after which an injection of hCG is given to cause the eggs to ovulate, or be released. Monthly pregnancy rates with gonadotropins and IUI are routinely quoted as between 10-18%, but we have seen better rates, closer to 25-30%. Multiple pregnancy rates are higher than with oral medications, ranging from 15-30%. Side effects using gonadotropins are also increased, and include bloating, emotional lability, injection site reactions and rarely, hyperstimulation syndrome.

Intra-uterine Insemination (IUI)

IUI is often used as a first step for fertility treatments. It can be performed with a partner’s sperm or a donor’s sperm. The cycle can be run as a natural cycle (no medications) or as a medicated cycle.

Clomiphene citrate (CC) and letrozole (LET) are two medications that are used to help women ovulate if they have trouble ovulating on their own. These can be combined with insemination if a male factor is present along with anovulation. In cases of anovulation, where pregnancy does not occur despite ovulation on medications, IUI is sometimes added as an adjunct to treatment with the medications.

Superovulation with medication combined with IUI is often used as a treatment for unexplained infertility, male factor infertility, and age related infertility prior to the more invasive treatment of IVF. Clomiphene and letrozole can be used in combination with injectable medications for controlled ovarian stimulation and this can markedly reduce the cost of the cycle while maintaining good pregnancy rates. This also reduces the rates of the serious complication of ovarian hyperstimulation.

IUI Success Rates 2012

IUI Success Rates by Woman’s Age

Woman’s Age <36 36-37 38-39 40-42 >42
Number of Cycles 29 3 20 30 8
Number of Pregnancies 11 2 4 7 0
IUI Success Rate 38% 66% 25% 23% 0%

IUI Success Rates by Protocol

Type of Cycle Natural IUI Clomid IUI Let IUI Clomid/ COH IUI Let/ COH IUI COH IUI All Combined
Number of Cycles 25 17 3 23 22 4 90
Pregnancies 4 3 1 6 7 2 24
Success Rates 8 18% 33% 26% 32% 50% 27%

IUI Success Rates by Woman’s Age and Protocol

Woman’s Age <36 36-37 38-39 40-42 >42
Natural IUI 2/3 (66%) 2/9 (22%) 1/13 (7.8%) 0/3
Clomid IUI 2/11 (18%) 1/1 1/1 0/4
Let IUI 1/3 (33%)
Clomid/ COH IUI 2/9 (22%) 0/1 0/4 4/8 (50%) 0/1
Let/ COH IUI 4/8 (50%) 1/1 (100%) 2/5 (40%) 0/3 0/4
COH IUI 0/1 2/3 (66%)

Let: Letrozole

COH: Injectable gonadotropins (Follistim, Gonal F, Bravelle, Menopur)

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