After trying to conceive with Clomid or letrozole, for many patients the next step is to try intrauterine insemination. Intrauterine insemination (IUI), sometimes referred to as “artificial insemination,” is the process of placing sperm directly into a woman’s uterus. This procedure delivers a prepared sample of motile sperm past the vagina and cervix, both potential barriers for sperm, and into the uterus near the fallopian tubes, thereby raising the chances sperm will fertilize a woman’s egg.

While IUI is less invasive than options like IVF (which we’ll cover momentarily), IUI can still require a fair amount of time at a doctor’s office, and the costs can add up. For example, in the United States, the cost of an IUI cycle can range from $500 to $4,000 and depends on which, if any, medications are taken in the lead-up to the insemination (more on that in a moment). In India, IUI costs often range from Rs. 15000—25000.

We have an incredibly detailed course on IUI here that we suggest you look at if this becomes an option you want to consider.

However, IUI success rates are highly dependent on age. As you can see from the data below, success rates go down significantly from ages 35 up, and that is true in most every country where IUI success rates have been published. Below are examples country-wide or from major clinics in the U.S., China, and Japan.

This trend holds true for clinics in India. Below is pregnancy rate data from a single center treating 800+ patients across 2,100+ IUI cycles. As you can see, there was an inverse correlation between odds-of-success and female age.

Yet, even for a woman under the age of 35, the odds are likely that any given IUI will not work. This can be a devastating surprise, and so it’s important to get familiar with the odds of success for IUI.

Given the single-cycle failure rate for IUI, it’s common for women to try multiple inseminations in back-to-back months. Our detailed chapter on IUI vs IVF addresses the costs associated with undergoing multiple cycles of IUI in comparison to IVF.

Generally speaking, IUI doesn't help or isn't an option for patients with severely low motile sperm counts, two blocked fallopian tubes, or gay couples pursuing surrogacy.

IUI Medication Options

IUI success rates and costs vary depending on which, if any, medications are used leading up to an insemination.

The chart below incorporates study data from both China and the United States and shows the correlation of increasingly intensive drugs, higher success rates, but also higher risks (in the form of multiple gestation pregnancies—which can be dangerous both to the mother and child).

To illustrate, if a woman does IUI with no drugs, she may have a 1%–10% chance of delivering a child and if so, a <1% chance that delivery will result in twins. On the other hand, if a woman takes gonadotropin (injectable hormones) leading up to her IUI, there’s a nearly 15% chance of live birth, and an (extremely high) 30% chance it will be with twins.

Unmedicated or "Natural" IUI

There’s the option to do a “natural” IUI cycle, and use no drugs at all, in which case you’ll merely do monitoring to understand when ovulation is likely and have the insemination performed just before ovulation. This may be a good option for women with vaginismus who are unable to have penetrative intercourse, or for same sex couples using donor sperm.

The best candidates for this are women with “regular cycles”, meaning they have no ovulatory disorders.

In the data above, these natural cycles had the lowest chances of working, but also the lowest risk of resulting in a multiple gestation pregnancy like twins, triplets, or more.

Clomid or Letrozole

The next level up are the medications most commonly used with IUI. These are oral medications like Clomid (clomiphene) or Femara (letrozole). These medications are fairly easy to take, inexpensive, and they do boost success rates per cycle into the low teens.

However, the chances that a resulting pregnancy is a multiple gestation pregnancy also rise.

Finally, taking these medications will probably step up the logistics involved in a cycle, because it’s more likely that your doctor will have you come in for monitoring appointments to ensure the medications are working properly—this is more time consuming and also adds some cost.

Generally speaking, many doctors are comfortable performing an IUI with these drugs: they feel the improved odds of success compensate for the increased (but still “tolerable”) risk, cost, and inconvenience.

Gonadotropins

Finally, the most intensive medications are gonadotropins—these are injections that are expensive (around $2,000 per cycle in some countries like the U.S. and far less in many other regions).

They moderately increase success rates above letrozole (Femara) or Clomid, but in many countries, it’s rare that they would be recommended for IUI, because they are often more costly, and some studies show they drive up the risk of a multiple gestation delivery.

However, we should point out many clinics in India still routinely combine IUI with gonadotropin, and indeed, some report far lower "multiple gestation" pregnancy rates than is recorded in the literature elsewhere. Those doctors suggest to us the reason might be because they put their patients on gonadotropin for a brief 3—5 day window, and may use lower doses. Before starting an IUI cycle with gonadotropin, it's important to have a detailed discussion with your doctor about the heightened risks involved.

What Is IVF & Who Benefits?

IVF, or in vitro fertilization, is a more intensive and expensive treatment option than IUI—it requires that eggs are surgically removed from the ovaries, that those eggs are inseminated with sperm in a laboratory, and that a resulting embryo is placed in a woman’s uterus with the hopes that it implants and leads to a healthy baby.

A person or couple might strongly consider IVF if:

• They are mostly focused on getting pregnant as fast as possible (though by no means is IVF likely to work quickly)

• IUI has not previously worked in the first 3–6 attempts

• There is a medical condition (like blocked fallopian tubes) that renders IUI ineffective

• Presence of “male factor infertility” and upon semen analysis, produces a “total motile count” (number of moving sperm) below 5—10 million

• Fertility treatment or preservation is needed and the hope is to have multiple children, across multiple pregnancies. IVF may allow patients to create and freeze multiple embryos for future use

• A woman has already frozen her eggs, and thus, completed the most expensive and intensive portion of the IVF process

• There is a known genetic condition and a desire to minimize the risk of transmission to future children

• There have been multiple pregnancy losses due to genetic abnormalities

• They plan on using donor egg and/or gestational carrier

• They are a same-sex female couple interested in co-maternity

IVF Success Rates

IVF tends to be performed differently in each country but one universal truth is that, generally speaking, success rates tend to correlate closely with female age. To illustrate, below is data from regions where some clinics report or publish their success rates (we'll note capturing peer-reviewed data from South Asia on an age & cycle-start basis has been difficult). Within each region, IVF success rates coincide with female age.

When British investigators looked at historical data, they noted more than half of women under age 40 delivered a child after three IVF cycles, whereas for women over the age of 40, rates of IVF success tended to be much lower.

As you’ll see below, when “donor eggs” are incorporated into the process, success rates climb quickly.

The U.K. data reflects the reality for egg donor recipients in India as well. According to nationally collected NARI data, the rate of pregnancies per transfer has hovered between 50%—60% on a regular basis.

While in the United States it can be immensely difficult to find donors of South Asian heritage, in India, the number of annual donor-egg IVF cycles is in the thousands and has historically grown each year. That said, the regulations around donor egg use is likely to remain fluid.

When a male partner has an underlying fertility issue, “donor sperm” tends to improve success rates, as you can see in the U.K. data below. Unlike in the United States, both egg and sperm donation arrangements in India are required to be anonymous.

If a female partner has difficulty conceiving or carrying with embryos that appear to be of good quality, having a gestational carrier or surrogate also dramatically raises the odds of success, as you can see in the Indian data below. However, we should highlight the legality of using a gestational carrier in many countries (e.g. India) can be a fluid situation and requires continual monitoring.

The Process of IVF

As we mentioned, IVF is practiced differently in many parts of the world, but generally speaking, there are a handful of basic steps (and decisions) involved. We’ll summarize those below, but if you want the full set of details, head to our comprehensive guide to IVF here.

Ovarian Stimulation

A woman is usually given injectable hormones to make her ovaries develop as many eggs as they can (say, 8–20) instead of the usual one egg that would be matured each month. This continues for an average of 10 days, until a “trigger shot” is taken to start the ovulation process where eggs become mature.

Egg Retrieval

Eggs are surgically retrieved from the ovaries, and typically anesthesia is used during the procedure. A doctor uses a vaginal ultrasound to guide a needle that suctions out each egg.

Growing Embryos

Over the next 3–7 days, a fertility clinic’s laboratory will take all of the collected, mature eggs and try to grow them into healthy embryos.

First, they fertilize the eggs with sperm either by surrounding an egg with sperm in a petri dish, or using ICSI, a micro-procedure where a single sperm is injected into an egg.

Then the laboratory will try to grow the embryos into either Day 3 “cleavage stage” embryos or heartier Day 5, 6, or 7 “blastocyst stage” embryos. Growing embryos to “blastocyst stage” is challenging, and depending upon the region, it can be more common (e.g. United States, Singapore, urban regions of India) or less common (e.g. rural parts of India, China, Europe) to find clinics able to do so.

Optional Genetic Screening

Once embryos have reached the blastocyst stage, there is an option to remove a few cells and have them sent out for genetic testing, sometimes referred to as PGT-A, PGT, or PGS screening. This platform can either test for chromosomal abnormalities associated with miscarriage and birth defects, or single gene defects that cause specific genetic disorders.

As you can see, implantation rates per embryo transfer are higher with PGT-A tested embryos that are shown to be euploid (i.e. chromosomally normal) than they are with untested embryos and are less likely to lead to a miscarriage.

PGT-A is still the exception in IVF procedures given its cost and, to a lesser degree, the local shipping infrastructure required (samples of the embryo need to be frozen and then shipped from the clinic to a "reference laboratory").

Credible experts disagree on the utility of PGT-A screening. For instance, below is data collected from clinics on three continents that reflects PGT-A has less value in younger patients. Where there is more agreement is the value of PGT-A to screen out embryos that carry a specific genetic disorder. We go into more detail on the topic to help you make your decision in our dedicated course here.

Option to Freeze

After developing embryos, whether or not genetic screening has been done, more clinics and patients are using the option to "freeze all" of their embryos and transfer them into the uterus at a later date.

As you’ll see, according to a small amount of data from the United States, when women of South Asian heritage opt to freeze their embryos and wait (a month or so) to transfer, disparities in success rates may dissipate between women of South Asian and European heritage. This is compared to fresh embryo transfers (taking place days after the egg retrieval), where success rates appear to be much lower in women of South Asian heritage compared to their Caucasian counterparts.

However, there are drawbacks to freezing all embryos. Some experts believe it's still preferable to try a "fresh" embryo transfer first. That said, amongst women of South Asian heritage, rates of success tend to be higher with frozen embryo transfers rather than fresh embryo transfers. You can see more data and context here.

Transfer

An embryo will be transferred into the uterus with the hopes that it “implants” and leads to a healthy pregnancy. The safest option is to transfer one embryo at a time. As you can see in the data below, multiple gestation pregnancies raise the risk to both the person carrying the pregnancy and to the offspring.

For this reason, in most every country there is a push to reduce the number of embryos transferred per transfer. We have a detailed lesson on the subject here, and patients should have a thorough discussion with their doctor of the risks and tradeoffs if the plan is to transfer more than one embryo at a time.

Option to Freeze Any Additional Embryos

Any embryos of reasonable quality that were not transferred will be frozen and can be used later, either in the event that the first transfer doesn’t work, or if it does work, for more children in the future.

Thinking of IVF as a Funnel

In some senses, you can think of IVF like a funnel. Unfortunately, not every developed ovarian follicle will contain a mature egg, and not every mature egg will lead to a healthy embryo or a baby. At each stage throughout the process, you’ll lose something. That’s why the goal is to have a high number of eggs to start off with. Below is a sample summary of this funnel based on outcomes for a typical 32 year old IVF patient. These numbers will vary based on age; for example, the percent of embryos that are chromosomally normal rapidly decreases as age increases.

Costs of IVF

IVF prices vary dramatically by region and whether a local government or insurer covers some of the cost. In regions where patients pay for IVF “out of pocket”, costs can stretch from a few thousand dollars (e.g. in Thailand, Vietnam) to upwards of $20,000 in the United States.

In India, costs typically come in at roughly INR 2,50,000 to 4,00,000 per IVF cycle. Prices can be lower if recombinant gonadotropin is substituted out for urinary gonadotropin. Prices will rise if PGT-A is used.

It’s common for patients to pay significantly more for treatment than the figures quoted by a fertility clinic. Often these quoted prices exclude the prices for required drugs (which can be significant) or “add-ons” (e.g. ICSI or embryo testing) the clinic may later recommend.

To showcase in an American context how drugs and add-ons can change the total cost for each cycle, below is a chart of what patients pay in a handful of U.S. cities.

Insurance

In countries like India and the U.S., it's rare to have health insurers cover the cost of IVF. If coverage does exist, a woman or couple may be asked to try a progression of timed intercourse, oral medication, and IUIs before receiving coverage for IVF.

Generally speaking, IVF costs and coverage vary. In many countries, a woman or couple will be asked to try multiple (less expensive) IUIs before IVF can be covered. Even if IVF is covered, certain aspects of the process (e.g. drugs, fertilization techniques, tests, ability to transfer multiple embryos at once) may not be. Finally, in many countries where IVF is covered, there can be lengthy delays to receive treatment, and oftentimes, a cap on female age, often 40–45, whereafter treatment won’t be covered.

Where to Start: IUI or IVF?

We think there are a handful of criteria in determining whether one should start with IUI or IVF. We elucidate the factors below, though of course prioritizing those factors is a personal choice. We provide more detail in our chapter on IUI vs IVF.