Ep 336: Decoding IUI: Answering Patient Questions About IUI Cycles, Timing, Trigger Shots and More

0:00Dr. Carrie Bedient: You're listening to the Fertility Docs Uncensored Podcast, featuring insight on all things fertility from some of the top-rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

0:21Dr. Susan Hudson: This episode is brought to you by Receptiva DX. What if unexplained infertility isn't actually unexplained? For many women, hidden inflammation associated with endometriosis and other uterine conditions can go undetected for years, even when everything else appears normal. For more than a decade, fertility specialists have trusted Receptiva DX to provide deeper insight into the uterine environment, helping women and their physicians uncover answers and make more informed treatment decisions.

0:52Dr. Carrie Bedient: Hello, and welcome to another episode of Fertility Docs Uncensored. I am joined by my absolutely marvelously meticulous co-host, Dr. Susan Hudson from Texas Fertility Center.

1:03Dr. Susan Hudson: Hey, Keri. How are you doing today? Good.

1:06Dr. Carrie Bedient: How are you?

1:07Dr. Susan Hudson: I am good. It's a wonderful weekend, and I have been doing editing, and I've been to our local little market to get some gifts for some people, and it's been a very productive morning. What kind of gifts did you find? well I found they have like like wood carving stuff and one of my friends she does knitting and it's this fancy little bowl that has holes in all the right places for the yarn to go through and not get jumbled up and I was like that's like the perfect gift for a perfect person

1:46Dr. Carrie Bedient: that's amazingly specific and clever and functional well it was one of those I was

1:52Dr. Susan Hudson: like, I need to go find presents for a couple of people and I want to find something neat and unique. And I found that. And then for her brother, there was another booth that had a wooden shallow bowl that has felt at the bottom, but it has this fancy little dice. Scrambler is the best way for me to describe it. You drop the dice in it and it has little things where the dice bump around. So you don't have to shake to get your dice to do random things. You drop them in the thing and they come out the end into the fancy ball. Huh.

2:25Dr. Carrie Bedient: Do you think there's a way to rig it so that if you drop it with, say, sixes coming up, that it'll be sixes coming up on the bottom?

2:33Dr. Susan Hudson: I don't think so. I mean, it's meant to kind of shake up the dice. I thought it was neat, though. That is cool.

2:41Dr. Carrie Bedient: But yeah, I am curious if you can manipulate the system. Can you rig it so that the next time you're playing Yahtzee, you can go, okay, well, I'm just holding the dice randomly in my hand and then kind of randomly convert everything to a full house or a Yahtzee and then drop them in. And can you totally rig the game?

3:02Dr. Susan Hudson: I don't know. I would hope not. Yahtzee is one of my favorite games from my childhood, so it's very near and dear to my heart.

3:10Dr. Carrie Bedient: I'll have to bring it the next time we go to a conference together and we can play in between meetings.

3:16Dr. Susan Hudson: My Oma and I spent many an hour playing Yahtzee. Yeah.

3:20Dr. Carrie Bedient: Yeah. There's way more logic and strategy than you would ever think in a dice game.

3:26Dr. Susan Hudson: My goodness. Yes. People who are like, oh, it's so boring. I'm like, you just have not figured out the strategy of how to play this game. Yes.

3:34Dr. Carrie Bedient: Yes. You're not thinking about it at all. All right. Well, do we have any questions today?

3:40Dr. Susan Hudson: We do have a question for today. So our question today is age 41, AMH between 0.15 and 0.4, did one stem cycle with estrogen priming, Menopur and Follastem with a pregnail trigger. Got three eggs, two mature, one day five blast, but low quality and couldn't be tested. The next stem is coming up soon. Doctor has asked if I'm interested in Omnitrope, human growth hormone. Studies inconclusive. They've seen some good outcomes in patients my age. A bit expensive, but does it improve the number of eggs retrieved or quality? Why not? Do you have any advice on HGH?

4:22Dr. Carrie Bedient: What do you think? Are you a believer and are you a user?

4:26Dr. Susan Hudson: I am a believer, but I also believe it doesn't work in everybody. but I think it works in more people, if appropriately selected, than it doesn't work. And I do use it. I use it on people who have elevated FSH levels, which is a marker of kind of more ovarian quality than quantity. I use it on people who are over 40 or people that I've had poor outcomes in the past.

4:58Dr. Carrie Bedient: So this isn't something that you would default blanket to absolutely everybody who's coming through?

5:03Dr. Susan Hudson: No, no, I wouldn't. It's a little expensive, but it depends on how it's also being used. I typically use three vials. Each vial I get four doses out of, and I do it for the first 12 days of stem, regardless of how long the stem ends up being. I know there's some people who do it for months prior to, but they maybe do it two, three times a week. There's a lot of voodoo in this piece of magic. What do you use, Carrie? You use it some, right?

5:32Dr. Carrie Bedient: I do, yeah. And I use it, I have the same opinion in that I think it does work for a subgroup of patients. I just think we don't know exactly who that subgroup is because even when they separate out, if we just do the study with older patients, if we just do low responders. Some of the studies are really favorable and show it's the next best thing since sliced bread, and others show that it doesn't really make a difference. I'm of the same opinion. I think it works. I just don't think we know exactly who it works in, and it's a bit pricey to just give to everybody. I typically use it for about four to six weeks total, and so I will have somebody start it roughly two to three weeks before they begin their full stim cycle.

6:13Dr. Carrie Bedient: And they'll take in that time, they'll take it during stim, and then they stop with the trigger. And I would say that my results match what we see in the studies, where some of those cycles are fantastic and we're really pleased with what we got relative to what we thought we were going to get. And others, it doesn't make a darn bit of difference. I have a couple patients who want really big families and have struggled with their fertility. We've ended up doing a ton of cycles. And there's one in particular where I'm thinking of where we ended up doing five cycles. And she gets a ton of eggs each time.

6:46Dr. Carrie Bedient: But the quality of embryos is highly variable. She ended up being her own control. And we did some with growth hormone and some without. And for her, it didn't seem to really make a difference at all. But I've got other patients where it seems like it's the magic solution.

7:02Dr. Susan Hudson: It's one of those things that I think it is helpful. I don't think we know exactly who to target it. And it's on some like microbiologic level that it's acting and not something that's completely obvious because we haven't been able to pinpoint that quite yet. But neat things going on. And if you don't mind paying for it, nothing is no risk, but it's relatively low risk. It's a good complement to the stimulation.

7:30Dr. Carrie Bedient: Have you ever had anybody have side effects from it, from taking it?

7:33Dr. Susan Hudson: I think I can remember one person complaining about side effects, but that's one out of many. Really not anything more than they're already not feeling great because of the stress of the stimulation and their ovaries getting big and higher estrogen levels and that type of thing. So nothing that I think is hugely out of the norm. What about you? Yeah.

7:56Dr. Carrie Bedient: Same. I have had maybe one or two over the years who they've said they've had some symptom when they start. And because I start before stim, it's a little easier to isolate and have them stop. But even then, it's not been something that I've been really convinced, oh, this is totally from the growth hormone. It's just you're on this extra medication. You don't have to be. So let's stop it in hopes that that helps you feel better. And sometimes it does. And sometimes it doesn't. Like you said, there's an awful lot going on when somebody is in that position, because if we're considering growth hormone, usually it is not an easy case and it's not a slam dunk.

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9:42Dr. Carrie Bedient: Today, we are going to talk about when to consider doing an IUI. And this is always a hot topic with patients because there are a lot of appeals to IUIs. When you've got someone who comes in who's asking about doing an IUI, what is the draw to it? Why is that something that people come in asking about in particular?

10:06Dr. Susan Hudson: I think the number one reason why people like starting off with IUI is it's less expensive by a lot compared to IVF. When you're looking at IUI cycles, you're generally looking at the cost of some medications, which I would say most of us are not using full injectable medications with IUI very much at all. So it's either oral medicines or oral plus injectables. So moderately low cost there. usually a couple of ultrasounds and then the cost of the IUI or intrauterine insemination itself. I would say regionally, it's going to range from somewhere between$1 ,000 to$5 ,000 depending on where you live, but that's a whole heck of a lot less expensive than$20,$30,$40 ,000 for IVF depending on where you are and what you're needing.

10:57Dr. Susan Hudson: I think that's the number one reason. And then the number two reason is it's, quote, more natural. We are doing things within the body. The woman is still having to ovulate. Egg and sperm are still needing to come together in the fallopian tube, create the embryo. The embryo has to go its little five-day journey until it implants into the endometrium. And then we wait for those two weeks until we have the positive, ideally, pregnancy test.

11:26Dr. Carrie Bedient: If you are going to tell your patient about all of the options for fertility treatment and they're trying to make their decision, what are the symptoms or the conditions or the diagnoses that make you say you're a really good candidate for IUI?

11:50Dr. Susan Hudson: Well, first of all, you need to have open fallopian tubes. So IUI is not going to work if your tubes are blocked for any reason. Number two, you need to have sperm from some sperm source that is relatively good quality and quantity. We ideally like to have between 5 to 10 million total modal sperm cells in the sample after preparation. That's really important. Carrie, why is after preparation an important caveat there?

12:21Dr. Carrie Bedient: Because when you come in to do an IUI and your partner, donor, whomever gives you the sample, you can't just put the whole sample in. It's not like we can draw it up from the cup, put it in a syringe, and immediately put it in. Because if we did, you would be incredibly cranky with us. It would hurt like hell. It would hurt like hell. And potentially cause a very severe allergic reaction. because what is in the seminal fluid, which is the fluid surrounding the sperm, was never designed to be in the uterus. The sperm, when it gets delivered, it's kind of in that gel-like fluid, and that allows it to very efficiently go from the penis into the vagina.

13:02Dr. Carrie Bedient: And over time, usually maybe half an hour to an hour, that gel dissolves and the sperm is able to swim out in the vagina, go into the cervix and have a shot at conceiving. Well, that liquid, that material is never meant to be inside the uterus. So what happens is when we get a sperm sample in preparation for IUI, we spin it down or separate it. That allows all of the sperm to separate out from the liquid. And we can then resuspend the sperm in a very small amount that is a much easier amount to tolerate for your uterus. and in a type of liquid, it's essentially a phosphate buffer, really, that your uterus can handle without having that massive reaction to it.

13:45Dr. Carrie Bedient: When we do that separation, it separates out the Olympians from the kiddie pool. And when we're doing a semen analysis, especially depending on where you get the semen analysis done, you don't always get detailed information. In looking at a semen analysis, they give you the concentration and the percent moving. Sometimes they'll divide it into progressive motility and non-progressive motility because you can have somebody sitting on the couch wiggling a foot and that's considered modal because it's moving, but that's not progressive motility. We don't want someone on a Sunday afternoon stroll through the park either.

14:23Dr. Carrie Bedient: We want the Olympians who are hauling ass all the way down to be the sperm that makes it there. And And so a lot of semen analyses don't really delineate what those numbers are. And what we're looking for is a good progressive motility number. And when we spin it out, we separate out those sperm, resuspend them in the fluid. And that allows us to see, okay, how many are truly swimming forward and how many do we have to count on? And that can easily take a sperm count that was 50 million and drop it down to about 5, 7, 10 million.

14:57Dr. Susan Hudson: It's definitely more of a drop than most people expect. And so people are always like, oh, my goodness, what happened to all of them? And I mean, there's a reason that guys produce millions and millions and millions of sperm. They do not stop and ask for directions.

15:11Dr. Carrie Bedient: And there is no inbound EGPS either. And those things make a huge difference. If you stop and put this in perspective, a normal sperm count is about 40 million sperm per ejaculate. Not per day, not per week, not per month, not per year. Per ejaculate. If it took 40 million of any of us to do anything, we would all be fired. But that is considered completely normal for sperm. It puts it into perspective, really, how many it takes to get there. And part of the reason for that is because many of them are not going to be swimming with the vigor that we would like. Or they don't have the right shape.

15:49Dr. Carrie Bedient: Their heads are little pinheads or they're big globular heads or they've got two heads and two tails, whatever it may be. All those are going to get separated out as well because we really just want the ones that are swimming and able to potentially compete in the Olympics. So you've got somebody who's got tubes. You've got somebody who's got a decent sperm count. What else do you need to consider about, is this person a good candidate for IUI? Or even though they could technically do IUI, maybe we shouldn't.

16:16Dr. Susan Hudson: Another thing to consider is what your ideal family size is going to be. So if we are only wanting to have one and done, IUI, regardless of age, can possibly be a reasonable thing to do. Now, as you get older, realize your risk of miscarriage gets higher and higher. And every time we have a miscarriage due to chromosomal abnormalities, that's going to take more time off the list. It's a balance of time and goals. If you come to us and you're 35, 38, and you say, I want to have four children, then thinking about things like IVF to bank embryos to use in the future is a very wise thing to consider.

17:04Dr. Susan Hudson: It is not something you have to do. You may say, I want to have four children, but I'm just going to do one at a time and whatever happens, happens. That's completely fine. But if you want to stack your odds to improve the likelihood that you're going to have the family size that you ideally want, doing something now to preserve your fertility is very, very important. Because no matter how hard it is to get pregnant now, getting pregnant in two, four, six years from now, regardless of your age, is going to be more challenging. Absolutely. Starting a family is one of life's greatest adventures, but sometimes the path to parenthood isn't as straightforward as expected.

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18:16Dr. Carrie Bedient: So what beyond family size and family planning can have an influence?

18:23Dr. Susan Hudson: Some of it also has to do with what your diagnosis is. One thing I think of is recurrent pregnancy loss. Getting pregnant with ovulation, induction, IUI can help you get pregnant faster. But as the most common cause of recurrent pregnancy loss, as I mentioned, is chromosomal abnormalities. We're not actually addressing that specific part with IUI. We're speeding things up, but we may not actually be addressing the problem. That's something to consider if you have some sort of genetic abnormality that you're wanting to not pass on. or you and your partner are both carriers for something like cystic fibrosis, spinal muscular atrophy, sickle cell, pick your recessive disease or X-linked recessive disease, and you wanted to minimize the risk of having a child in the future with that condition, IUI is not a great thing to do because you're essentially rolling the dice just like when you're having intercourse.

19:22Dr. Carrie Bedient: Can you do genetic testing in advance in IUIs?

19:27Dr. Susan Hudson: You can do genetic testing on you and your partner. You cannot do genetic testing on an embryo. So you're only going to be able to do testing once you are actively pregnant. And the earliest testing would be cryonic villus sampling, which I believe happens somewhere between 9 to 12 weeks. That is significant to a lot of people. And if you don't mind that, then that can be an acceptable risk. But if having a pregnancy and then finding out that it is abnormal is not in your best interest, then considering things like IVF can help avoid some of those unpleasantries.

20:06Dr. Carrie Bedient: I actually just found out about NIPT testing, the non-invasive prenatal testing, can be done as early as eight weeks. It's not necessarily designed for the really advanced type of genetic screening if you're looking for cystic fibrosis or sickle cell anemia. But if you are looking for some of the big chromosomal abnormalities like 21 or XY abnormalities, 18, 13, they're getting better at doing it earlier and earlier. So I just found that out yesterday. Very cool.

20:39Dr. Susan Hudson: I didn't know it was as early as eight weeks.

20:40Dr. Carrie Bedient: Yeah, but I don't think that they're expanding it out yet to every single chromosome, which is what IVF with PGTA is going to do. And that means that many of the conditions that are survivable, like Down syndrome, Edwards, Pitot's, where survivable means different things depending on the diagnosis. Sometimes survival just means you are breathing and it doesn't have the capacity to really go into more depth at this point. But if they're this close now, my guess is they're well on their way to figuring out how to do more and get more information so you can get it early. But it still brings up the point of if you're having losses, if you are older than 35, 40 and you have a child with a chromosomal abnormality through IUI, you're not going to know that until you're already pregnant.

21:29Dr. Carrie Bedient: And then at that point, the decision making is a very different ballgame because you are already pregnant and you have to decide, are you going to keep that pregnancy or not? When you have somebody going through IUI and you do the first one and let's say everything works perfectly, the lining's good, the follicles grow, the sperm count was good, and you get a negative test and you call that patient, what's almost always the first question out of their mouths once they register what you're saying?

21:59Dr. Susan Hudson: Why didn't it work?

22:02Dr. Carrie Bedient: So why didn't it?

22:04Dr. Susan Hudson: Well, that's a great question. So first of all, humans are very, very inefficient when it comes to reproduction. At the very best, when you're trying to get pregnant in your early to mid-20s and you haven't been trying to get pregnant in the past, the highest success rate that you're going to see is about 25%. There's so many things that have to happen within the body for IUI to work. So the sperm have to go up to the fallopian tube. You have to ovulate. That egg has to get picked up by the fembrae of the fallopian tube. Egg and sperm have to have their little date night. And then after fertilization happens, they have to travel and actually implant into the endometrium.

22:51Dr. Susan Hudson: And there are things along the entire process that can go wrong. And unfortunately, most of the time, we can't tell you where that process failed. And the example I always like to give is people like, well, did the embryo implant? I'm like, well, unless you have a positive pregnancy test, no one on this planet can tell you if you're embryo implanted or not. It's just not within our non-invasive testing that we have available. And with time and technology, I'm sure we're going to grow leaps and bounds. But unfortunately, even in 2026, when we can chat GPT and grok everything you can think of, there's a lot of things that happen within the body with an IUI cycle that we don't know if it happened or even have control to make it happen.

23:43Dr. Carrie Bedient: What does the timing work with an IUI? So there's a couple of aspects to that question. So the first place is just basic timing. If someone's about to start an IUI cycle, what are they waiting for?

23:56Dr. Susan Hudson: This is one of those things that may vary from clinic to clinic. Most of the time, you're going to give your clinic a call with the onset of your period. Now, most of us consider your first day of full flow to be cycle day one. So you give them a call usually between cycle day one and three, and they will bring you in for an ultrasound. Now, this is something that is a bit different than if you're having a cycle perhaps done with a general OB-GYN. An OB-GYN usually is not going to do all the ultrasound monitoring you're going to see at an REI office. We are control freaks, and we are really good at what we do because we are control freaks.

24:39Dr. Susan Hudson: And part of that is the ultrasound. So the ultrasound is there to let us make sure your uterus looks good, lining is nice and thin, ovaries are nice and quiet, we don't have any big cysts that we would be concerned about interfering with the hormonal cycle that we're going to do. If there are cysts, sometimes we might get estrogen levels to see if that has prematurely developed. And hey, this might not be a great cycle for you to invest in. You can still try on your own, but probably wouldn't pay extra money to do it in a cycle. And if everything looks good, then we give you medicine. Now, the most common medications are going to be Clomid or Clomiphene, Letrozole or Femara.

25:24Dr. Susan Hudson: These are brand names and generics. for injectable medications like Gonal F, Follistim, Menopur. That decision is going to be based on lots of things. What is your primary diagnosis? How old you are? All those types of things. So there can be all kinds of combinations done in there. And that can vary not only from clinic to clinic, but physician to physician. If you're going to use some of the oral medicines, usually you take those oral medications for about five days. A few days later, you come back in for another ultrasound. We look at your lining. We want to start seeing your lining thicken.

26:00Dr. Susan Hudson: We love to see what's called a trilaminar stripe, where we have three lines. It kind of looks like a little hamburger within the uterus. And then we look at the follicle size. Again, the follicles are the houses of the eggs on the ovaries. And the reason why that follicle size is important is follicles have to get big. ideally probably around 18 to 22 millimeters for an IUI cycle for the egg to start undergoing its teenage years without a better term of being able to have the potential to become mature. We look at the size and then based on that size and based on your lining you'll often use a trigger shot.

26:44Dr. Susan Hudson: Sometimes doctors have you just do ovulation predictor kits. Again that's a physician to physician decision. And then you'll ovulate and ideally you'll come in for your insemination. The sample from your partner, if you have one and you're not using donor sperm, often can be collected either at home or in the private collection room of your andrology lab. If you are collecting it at home, generally it needs to be there within an hour. Don't put it on the hot cold air conditioner either. And if you do have to have a longer transport time, there are sometimes new cups called Protex that can be used to protect the sperm for longer transportation.

27:30Dr. Susan Hudson: You'll bring in the sperm. That sperm will then be processed, as Carrie mentioned earlier. And then for the actual insemination, you'll go into the exam room. You'll get in the stirrups just like you always do. We'll place a speculum, and then we place a tiny little catheter just inside the uterus, gently inject the sperm, and then we have you lay there for a certain amount of time at our clinic. It's about 10 minutes, and then you go on your way back to work or whatever else you're going to need to do. Sometimes, depending, again, on your diagnosis, past history, you may start some progesterone a few days later, and pregnancy test is about two weeks after that.

28:12Dr. Carrie Bedient: If someone is doing IUI because of timing reasons, and we see this a lot where a partner is traveling for work or any other reason, or one person works day shift, the other one works night shift, or if you've got someone who's called out of town at the last minute, what are their options for being able to continue on with that cycle? If they're called out either in advance where they know it or at the last minute where the day of the insemination, they've got to leave before they can give a sample.

28:43Dr. Susan Hudson: These are some very tricky situations and some of it depends on the timing. If you know ahead of time and you have a high enough sperm count, then we can sometimes have you go give a sample in advance and cryopreserve the sperm. And the reason why I say you have to have enough is when we freeze sperm, at least half of that sperm generally is not going to survive. If you're sitting there and your normal semen analysis is 12 million sperm, I'm not going to be too excited about you freezing your sperm. Sometimes just substituting planal intercourse at the right time is going to be the best thing we can do in that situation.

29:23Dr. Susan Hudson: If we don't know until the last moment, andrology staff may or may not be available to free sperm. And not everywhere that you can give sperm, so not all andrology labs are set up to actually be able to cryopreserve. So it's not available at all places and at all times, weekends, holidays, those types of things. The more in advance we know something may happen, the more likely we're able to be more intentional on our intervention. but worse comes to worse, having sex sometimes works just as well too.

29:57Dr. Carrie Bedient: Sometimes we'll collect the day before and just put it in media and let it sit overnight. And yes, you will lose some sperm, but it still can be a very viable option, especially if freezing is not available because of the financial, because of the logistics, of personnel available to do it, equipment, whatever it may be. That, especially with a decent sperm sample, is oftentimes a very viable option where you just prepare it the day before, let it sit overnight, and then work with that sample in the morning.

30:28Dr. Susan Hudson: There's also a lot more flexibility and timing of IUIs than what we realized even 5, 10 years ago. There was a pretty good study, I think it was probably 2, 3 years ago now, that came out that said there was really very little difference in success rates at between 12 and 40 hours. The important thing is we get good sperm into the uterus. And the reason why that's important is because good sperm in the uterus can survive up to 72 hours. It's one of those things that it does give us some wiggle room. Carrie, what are some other things that logistically sometimes make IUIs more complicated?

31:08Dr. Carrie Bedient: When we've got a patient who has to travel a significant distance to get to us. So both Susan and I have patients who come to see us from across the country, across the world. And that makes sense to do in an IVF cycle much of the time because we can better control your cycle. There's more going on. So it's a little bit more worth it in the sense of there's a lot that we can do at our clinics that make it worthwhile for someone to come and stay here for two weeks. Alternatively, with those types of cycles, it's relatively easy to get monitoring someplace else if another IVF center will work with you for remote monitoring.

31:48Dr. Carrie Bedient: For IUIs, that calculus is all different because you're no longer talking about an ideal success rate in the 60 to 70 percent range. You're talking about maybe 15-ish percent, best case scenario. and all of a sudden it doesn't make as much sense to fly across the country at a moment's notice in order to do something that's got such a low success rate. It's unlikely that any clinic is going to have some protocol, technique, magic, voodoo, whatever you want to call it, that is going to make it worthwhile to really travel a significant distance to get there as compared to just working with a local center.

32:30Dr. Carrie Bedient: If we've got someone who lives out in a much further distance area, but that doesn't require air travel, that also can be challenging because if you've got to drive two, three, four hours to come get to us in order to do the IUI, it's a last minute notice, and that's not always possible. And we can plan for those things a little bit better in an IVF cycle compared to an IUI cycle.

32:55Dr. Susan Hudson: Kind of a segue into that, another two groups of people that I think of that logistically it's often challenging are our military couples where the gentleman may be getting deployed and the lady would like to work on conceiving while he's away. It's a whole lot easier to do IVF and us have one, two, or three samples of sperm in case we need to do multiple cycles than if he's getting deployed for a year, having enough frozen sperm to be able to do IUI cycle after IUI cycle after IUI cycle. And then also our couples where the guys go offshore. So some of our oil and gas people, because they're offshore and who knows when they're going offshore and who knows when they're actually coming back.

33:42Dr. Susan Hudson: And unfortunately for IUIs, we are literally at the mercy of the ovaries because people come in on day one. They're like, what day is going to be my IUI? And I'm like, ask your ovaries because we're not the ones in control. We're helping things happen in a timely fashion, but we're telling you when the shots are getting called, but we're not actually calling the shots.

34:03Dr. Carrie Bedient: Exactly. Another group of people that the timing can really play in are cancer patients. And usually if someone comes in with an active diagnosis of cancer, we're talking about egg freezing because they're not in a position where they want to get pregnant right at that moment. And that's not something that IUI is terribly helpful with because unlike IVF, where you could do an egg retrieval and then 10 years later do the embryo creation and transfer, with an IUI, it's all done within the same cycle. What we will have is patients who come in who have a diagnosis of oftentimes endometrial cancer, or they maybe carry one of the BRCA genes but don't have cancer.

34:40Dr. Carrie Bedient: And their goal is to get pregnant as soon as possible, deliver, and then go through a more definitive treatment like a hysterectomy or a mastectomy, hormone restriction, whatever it may be. And for those patients, IUI may be helpful to do once or twice to get them on their way, but we're usually under the gun and have a time clock there where we don't spend as much time on IUI because we need to do something that's going to be more effective more quickly so you can get the treatment you need.

35:09Dr. Susan Hudson: You mentioned doing a couple of cycles. Now, in somebody who is not facing the clock for some other medical indication, how many IUI cycles are generally recommended if things are going well?

35:24Dr. Carrie Bedient: This varies by center and by doc as to how many that particular person or location will do. In general, most people do somewhere between three and six IUIs and then move to something more aggressive, usually IVF. You can go up to 12. And what they found is that after you've done six, the success rate tends to drop off. Although there was a relatively recent study that showed that you could go out to, I believe it was seven or eight, especially in same-sex female couples. But even when you go out further, you're still looking at those low success rates. And after you hit roughly six months, those success rates start to drop.

36:06Dr. Carrie Bedient: And doing cycles 6, 7, 8, 9 don't add a whole lot to your overall success rate. And there is a cost to IUI. Even if your insurance is covering absolutely everything, there is a physical, mental, and emotional cost to doing it. And fertility is a marathon. It's not a sprint. We need you to have some gas in the tank. If we do need to go to something more aggressive, we can without having you have to tap out for a year or two because you are just fried from fertility treatment.

36:35Dr. Susan Hudson: Now, in reality, Carrie, do you have a lot of your patients go to six cycles or what is your norm? Because I'm betting you don't go out to six cycles very often.

36:45Dr. Carrie Bedient: Nope. By the time we hit three, maybe four, we are actively making plans for something else. I have an awful lot of patients where we'll do two to three and then call it and move on to something more aggressive. because so many of my patients do want two kids or they really do want sex selection or they're worried about the genetics or all of these other pieces that come into play that are soft calls. It's not a hard call like your tubes are blocked. You have to have IVF. But they're the soft calls that say, if we can get something, if we can get a pregnancy easily with an IUI, great, let's do it.

37:22But if it's not coming within the first couple cycles, fish or cut bait, let's go on to IVF so

37:28Dr. Carrie Bedient: that we've got more control and we can really get a better big picture.

37:31Dr. Susan Hudson: So if we wanted to kick it up a notch, and I'm specifically asking you this question because I know you have a bit more experience in it than I do, there's a newer technology called intratubal insemination or ITI. Who is that intended for?

37:48Dr. Carrie Bedient: ITI is really intended for patients who are otherwise good candidates for inseminations, but they need a slightly higher success rate, particularly people who are working with more restricted sperm counts. So that can apply to people using donor sperm, where you're having to pay$1 ,000 or more per vial. It can also apply to someone who, when they do their sperm collection and it's washed, instead of getting that$5 to$10 million or more total modal count, you're getting under$5 million. Because an ITI can make better use of that under 1 million sperm count by putting it directly at the opening of the tube rather than making it swim further starting from the middle of the uterus, which is what an IUI does.

38:34Dr. Carrie Bedient: ITIs are better at directing the sperm right to the tubal opening so that it can swim through and theoretically you've got a better chance of pregnancy with that. Usually the pregnancy success rates with an ITI are between about 18 and 25 percent, but they haven't found any improvement after two cycles. So if you do your first and then maybe a second cycle of ITI and it's not working, it's more of a bridge to IVF and more aggressive treatment than it is a replacement for it.

39:04Dr. Susan Hudson: Why doesn't everybody do ITI instead of IUI?

39:08Dr. Carrie Bedient: A couple reasons. It is a more expensive catheter. A normal IUI catheter is a slightly more dolled up cocktail swivel stick straw, those little tiny ones that they have at the cheapo coffee bars in the mechanics waiting room. It's a little more glorified than that, but not by much. Compared to the ITI catheter, the femiseed has a long stylet through the middle of it to help you get in straight. And then it's got this little arm that's itty bitty teeny tiny that extends that allows it to position the sperm right at the opening of the tube. And there's a tiny little balloon at the end of it. And what that does is it traps the sperm in that corner of the uterus so that it really has no place to go besides where you want it to go.

39:51Dr. Carrie Bedient: And it is a much more complex device. Usually you're doing it under ultrasound guidance at the same time. There may or may not be additional medications that are given to help make it more comfortable. And it's a more expensive process. The other thing is that there are some people who just don't tolerate it. And anyone who's ever had a baby before and is coming back for secondary infertility, they're fantastic candidates. People who've had other intrauterine procedures, they can be very good candidates. But someone who's really skittish during a pelvic exam who doesn't tolerate cramping and discomfort very easily, this may not be the right procedure for you because it is a bit more uncomfortable than an IUI.

40:31Dr. Susan Hudson: If you had an HSG and it was the most excruciating thing in your life, would ITI probably not be a great idea?

40:38Dr. Carrie Bedient: Probably wouldn't be real excited about doing that on you. Now, we can do many things, but none of us have the goal of traumatizing you and needing to put you in therapy. You come first in everything. Can you do an IUI if you've had an ectopic pregnancy?

40:54Dr. Susan Hudson: You can do an IUI if you've had an ectopic pregnancy. I can say that your doctor's probably not going to be super excited about it because if you've had an ectopic pregnancy and if that tube remains that tube is damaged and whatever damaged that tube to begin with the other tube was probably also exposed to and when we do HSGs or chromopertubation if you have a laparoscopy realize that the only things that we can really test are do your tubes visually look normal and are they open? We have no functional test for the fallopian tubes. We are always going to be hesitant about IUIs and using your fallopian tubes after you've had an ectopic pregnancy.

41:47Dr. Susan Hudson: We still do it all the time, but we're not going to be super excited about it and we're going to be watching you very, very, very closely when you get pregnant to make sure that pregnancy is in the right place.

42:00Dr. Carrie Bedient: Absolutely. And one last question. How do you feel about people who really either want to have twins and want to do an IUI or they have something where they absolutely cannot have or should not have twins, whether it's a medical condition or just sheer and utter terror at the thought of two babies at the same time?

42:19Dr. Susan Hudson: I would like to say with IUI, my goal is never for you to have multiples, IUI is really intended for you to get pregnant with one child at a time. Now, with that being said, you still probably have somewhere between a 7 % to 10 % chance of multiples. For most people, that's a reasonable risk. Now, if you have a medical condition, whether it's a unicorn uterus or some other uterine abnormality, you have a health condition that being pregnant at baseline is a little on the more dangerous side, but this puts you way more on the dangerous side, we're never going to aim for that. In some cases, doing IVF where we intentionally put one embryo in your uterus at a time may be a better option.

43:13Dr. Susan Hudson: It doesn't mean you can't, but there is going to be discussion on how much do we need to control that risk. And for most people out there, that 7 % to 10 % chance risk is fine. But there is a segment of the population that getting pregnant with multiples could very much put mom and baby's lives on the line. And that's a risk not worth taking. Absolutely agree.

43:40Dr. Carrie Bedient: All right. Anything else? Last minute words, thoughts that you have about

43:44Dr. Susan Hudson: IUIs? IUIs work wonderfully in a lot of people, but if for some reason IUIs don't work for you or you're not a candidate for IUI, know that it doesn't have to be the end of your road. There's lots of other options available and talk to your doctor to figure out what's going to be the best path for you.

44:03Dr. Carrie Bedient: All right. Well, thank you so much for spending a part of your day with us.

44:07Dr. Susan Hudson: If you enjoyed this episode, subscribe, leave a review, and send us your questions at fertilitydocsuncensored.com.

44:13Dr. Carrie Bedient: And if you want even more fertility information, pick up a copy of the IVF Blueprint, which is our practical guide to understanding fertility treatment, IVF, and the decisions you'll face along the way.

44:23Dr. Susan Hudson: Before you go, remember this podcast is for education and entertainment only.

44:28Dr. Carrie Bedient: While we are fertility doctors, we are not your doctors.

44:31Dr. Susan Hudson: Nothing we discuss should replace medical advice from your own physician who knows your individual history and circumstances.

44:38Dr. Carrie Bedient: Thank you for listening. We'll see you soon.

44:41Dr. Susan Hudson: Bye!