Scholarly Series No. 2: IUI - An Ineffective Treatment

In continuation of my nerdy pursuit of professional articles addressing topics related to infertility, I will be running a small section on the current debate over the whether or not IUI is worthwhile. This spawned from C and I needed to make a decision between Time Intercourse or IUI and me happening on the article I reviewed in my initial Scholarly Series post. In this book, two back-back-back chapters discuss each side of the argument and will be topics for my next two posts in this series.  

Johnstone, E.B. & Dorias, J. (2013). Intrauterine Insemination: An Ineffective Treatment. Biennial Review of Infertility: Volume 3. Eds Schlegal et. al., 173-183

Summary

These authors take a very pointed stance by clearly stating at the end of the first page that "IUI should no longer be a standard part of infertility treatment" based on several compelling arguments. The article begins by explaining how IUI performed and a little bit about its history (first published article on this was in 1962!) and the rationale for treatment, but then quickly veers into the arguments against its continued use. 

The first argument is that IUI is not significantly more effective than timed intercourse and/or controlled ovarian hyperstimulation (i.e. use of Clomid, Letrozole, Gonadotropins, etc.) and much less effective than IVF. They cited numerous studies, including many meta-analysis studies that analyze aggregated data from all previously published studies, finding that IUI was not more effective than these other approaches in both unexplained infertility and male factor infertility. Compared with IVF, IUI is becoming less beneficial over time as IVF success rates are continuing to increase but IUI success rates have remained stagnant. 

The second argument was made regarding cost effectiveness. They discussed two studies that compared the costs of "expectant management" (e.g. using OPKs, CM checks, etc.), Clomid, and IUI and found that the costs of IUI were significantly greater than the other two treatment options but without a significant increase in chance of live births. One really interesting study they discussed (which I may have to review separately at a later date), called that FASTT trial, compared unexplained infertility couples randomized to either three cycles of CC/IUI followed by three cycles of FSH/IUI followed by IVF (as necessary) to an accelerated track of three cycles of CC/IUI followed by IVF. The study found that not only were pregnancy rates increased with the "accelerated track" but there was also a cost savings of $2624 on average! They discussed several other studies that have concluded that cost-effectiveness data favors immediate IVF over IUI. 

The third argument proposed by the authors is that IUI is much riskier than other procedures and has more adverse events (e.g. discomfort of the patient and potential risk for infection). Infections were found in 1.83/1,000 women undergoing IUI. The biggest "adverse event" discussed was the risk for multiples. While most of the blame for multiples falls on ovarian stimulation (either oral or injectable meds), the issue with IUI over IVF is that you have much less control over how many eggs are mature, fertilized, and implanted. Multifetal gestations carry increased risk of numerous complications for both the mother (e.g. anemia, diabetes, preecplampsia, etc.) and the children (e.g. prematurity, cerebral palsy, visual and hearing deficits, learning difficulties, etc.). These risks are often minimized with IVF, especially with a single embryo transfer.

Review

This was clearly an argumentative style paper. I was surprised by how strongly worded the article was but I am also surprised that this was one of my first times coming across any negative thoughts or opinions on IUI. With both REs that I've consulted with with others that I have talked to, it seems like it is still the standard protocol to go through IUIs before moving on to IVF, especially in those "milder" cases. The idea that this was even up for debate in the medical community was a complete surprise to me. This makes me wonder if either A) the general medical community is slow to change their thinking with new scientific advances or B) these authors are a little extremist and making the mistake of throwing the baby out with the bathwater.

I do have to say that the arguments were very compelling. I would definitely recommend people read the whole article if you're trying to make related decisions. What I took away from it is that, for many couples, IUI does not add much and puts additional cost and time in the fertility journey so that it can be advantageous to just jump straight to IVF. For some couples, taking the gamble of trying IUIs first will pay off and you won't need to move to IVF, but this does't seem to be a statistical norm. I'm sure that there are some psychology studies related to the gambling mentality with all of this.

I purposely did not read the next chapter, the counter-argument that IUI is an affordable and effective treatment, but now I can't wait to see what the others are saying. Until then, I leave you in suspense.