Scholarly Series No. 3: IUI is Valuable and Cost Effective

Continuing on with the medical community's debate on whether or not IUI is worthwhile, I now take on the counter-argument. For previous articles that initially sparked my interest in this topic, check HERE and HERE. In my last Scholarly Series post, I discussed the first of two chapters debating the merits of IUI and, frankly, it made a very strong argument against this approach. Now I take a look at the other side.

Moolenaar, L.B., Van Voorhis, B.J., van der Veen, F. (2013). IUI is a Valuable and Cost-Effective Therapy for Most Couples. in Biennial Review of Infertility: Volume 3. Eds Schlegal et. al., 185 - 188. 

Summary

Compared with the last article, these authors take a more moderate approach and begin by acknowledging that IUI is not the best approach for some diagnoses. They state that, unfortunately, many fertility decisions are made based purely on financial considerations rather than cost-effectiveness, a subtle but distinct difference. The authors do discuss a randomized control trial that compared 6 months of "expectant management" versus hMG and IUI that showed no difference in pregnancy rates and argued that that expectant management should be the "first line" treatment approach for most couples. 

They also discuss several studies comparing the cost-effectiveness of IUI to IVF. While some of these studies did conclude that jumping straight to IVF was more cost-favorable overall, the authors argue some key problems with the research methods in each of the studies. As for the FAST trial, that the previous article I reviewed spent a lot of time discussing, these authors point out that while the median time difference to pregnancy between the two groups was approximately 3 months, there was an equivalent rate of multiple pregnancies and that, ultimately, by 1 year, the pregnancy rate in both groups was equal. The other interesting finding that the authors point out is that, in each of these studies, 14-32% of the pregnancies were "treatment independent", meaning the pregnancies occurred during a break cycle. 

The authors conclude that current evidence show that expectant management for 6 months, followed by IUI is still more cost-effective, but that the duration of treatment with IUI before proceeding to IVF and the additional value of ovarian stimulation to IUI are still unclear. There is an upcoming study that compares IUI to IVF eSET to modified natural IVF, which the authors are hopeful will further clarify this issue. 

Review

The writing style of this article was definitely less compelling than the last article. To be honest, I found some of their arguments more confusing and harder to follow. But I think that might just be the point. Infertility is not a one-size-fits-all diagnosis and it is likely impossible that one, or even a handful, of studies can adequately capture each of the nuances that affect healthy conception and ultimately a healthy birth. There are too many different factors that cannot all possibly be controlled in a research lab, and if they were, would definitely not be generalizable to real-life.

The take-home point from this article that I gathered is that IUI can definitely be valuable to some couples, but trying this approach over and over will begin likely offset its value. Which is probably true with most other approaches/treatments if you think about it. So in other words, for many couples, it is definitely worth a try but not something to spend an excessive amount of time/money on.