Rescripted S2E03_Timed Intercourse + IUI: Audio automatically transcribed by Sonix

Rescripted S2E03_Timed Intercourse + IUI: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi! I'm Kristyn Hodgdon, an IVF mom, current IVF patient, and co-founder of Rescripted.

Lucky Sekhon:
And I'm Dr. Lucky Sekhon, a board-certified reproductive endocrinologist at RMA of New York.

Kristyn Hodgdon:
Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for the millions of people globally who have trouble conceiving.

Lucky Sekhon:
We're here to answer real questions from real fertility patients about what to expect during each stage of the fertility journey and to provide you with the patient-centric advice and guidance you need to be your own advocate when trying becomes trying.

Kristyn Hodgdon:
Now, let's dive in and help you feel more empowered during this overwhelming process.

Kristyn Hodgdon:
Hi, everyone. Kristyn here, your host, and I am joined by Dr. Lucky Sekhon. Hi, Lucky!

Lucky Sekhon:
Hi. How's it going?

Kristyn Hodgdon:
I'm doing well. How are you?

Lucky Sekhon:
I'm doing great. Thanks for having me back!

Kristyn Hodgdon:
Absolutely. I'm so excited to talk today about timed intercourse and IUI. I went through many cycles of timed intercourse and IUI prior to doing IVF, and I love the idea of kind of setting people up for success before they start, because I felt like I wasn't really equipped with the knowledge that I needed to sort of know what to expect and how to advocate for myself during the process. So we received lots of great questions from our community, and I'm excited to jump in.

Lucky Sekhon:
Me too. And I love this topic because, at first glance, people kind of might laugh at it because it's like timed intercourse. Well, that really sounds very sexy, but I think it's an important topic to address, especially for anyone on here listening that might be at the very early stages of their journey, and they're kind of more on the proactive side. You might pick up new information because I think that a lot of us lack the basic knowledge of what it takes to get pregnant because so much of health class and our exposure to reproductive medicine as a whole has been focused on how to avoid pregnancy. I think very little attention was paid, at least for me, before getting into this field on what it takes to get pregnant in a really realistic view of sometimes how inefficient it can be. So I think this is a great starting point when we talk about the overview of all the different interventions and ways to get pregnant.

Kristyn Hodgdon:
Absolutely. So when a patient, when you have a patient, they've gone through their sort of diagnostic workup and testing on both sides, both male and female, and you say you think timed intercourse is the best first step for them. How do you sort of decide who goes the timed intercourse route versus the IUI route?

Lucky Sekhon:
Well, I think, you know, everything we do should be based on evidence. And if you're talking to a couple with unexplained infertility, really the recommended approach is to pair medication to give your body the opportunity to release more than one egg with an insemination because you don't know what you're treating. And you could be focusing on ovulating more than one egg when really this is more about the interaction between the sperm and the egg or the ability of the sperm to get to where it needs to go. So off the bat, I would recommend Medicated IUI. Obviously, patients might not want to do that right away, and I'm always an advocate for speaking up if you're not comfortable, if you're paying out of pocket, maybe you want to try just the medication with timed intercourse. So there's obviously no rule book, but in general, based on the evidence, I would say the most effective and efficient thing to start with would be the combination of medication with IUI. I will say it makes sense for patients who might have sexual dysfunction. Maybe that's why they're coming to me, and perhaps they ovulate regularly on their own, if they don't, we could also use medication for them. But for patients who have difficulty because of sexual dysfunction on the male side or even on the female side, some women have such severe problems like vaginismus that they can't really have sex with their partner. And so, in that case, timed intercourse is not going to be the best approach, and you should be going straight to IUI. But for patients who have irregular ovulation and that's the real, the main thing that you're focusing on and the semen analysis is completely normal, in those situations I think that it makes sense to just help them timed intercourse and help them figure out when they're ovulating. If they're not ovulating regularly to help them get on track with that with medications and then to tell them, okay, this is your window of opportunity of when you should be having sex. And all of this is predicated on the fact that sperm can survive in the reproductive tract for 3 to 5 days, whereas an egg, when it's released in the fallopian tube is only able to maintain its viability for about 12 to 24 hours. So the ideal time frame is to have sex or be exposed to sperm in your reproductive tract in that 2 to 3-day window before ovulation takes place. So that's what timed intercourse is all about.

Kristyn Hodgdon:
And then, the IUI is done on the day of ovulation?

Lucky Sekhon:
No, it's actually usually done around a day before.

Kristyn Hodgdon:
Okay.

Lucky Sekhon:
So if you're taking medications to make yourself ovulate or if you're just tracking your natural ovulation, usually in the setting of a fertility clinic, we would like to bring you in for an ultrasound. And the way we can tell that you're ready to ovulate usually is based on the size of the follicle. A follicle is a fluid-filled bubble that contains an egg inside and the size or the diameter of the follicle usually gives us a clue of how mature the egg inside of it is and how ready it might be to ovulate. Now, you could release that egg on your own because your brain will normally send signals to your ovary to tell it to do that, or we could try to be even more precise with the timing and add in another step called a trigger shot, which is an injection that usually a nurse or your doctor will administer once they do that ultrasound and determine that you have a mature follicle. So that medication will usually take about two days to work. So if we're giving you the trigger shot to make you ovulate in a timed fashion, usually we'll schedule the insemination to happen anywhere from 24 to 36 hours after that.

Kristyn Hodgdon:
Okay.

Lucky Sekhon:
So that's the general recommended timeline for IUI.

Kristyn Hodgdon:
Okay! And can you, just going back to what the different ovulation induction medications are and why you choose sort of one over the other? I did Clomid, but I know a lot of people do Femara or Letrozole. How does that work?

Lucky Sekhon:
So, both of them work in similar ways. Basically, it's hijacking your biology, right? Which consists of your pituitary gland that sends hormonal signals to your ovary to select an egg that eventually matures and then ovulates. And so it's all about signaling. And both Clomid and Femara and Letrozole, which are the same thing, are working by fooling your brain into thinking there isn't enough estrogen. And so your pituitary gland in your brain ends up churning out a stronger hormonal signal to either overcome blockages in communication that can be there in patients with PCOS and to just get through to the ovary to tell it to ovulate, or to make that signal stronger and select more than one egg. Because normally, in a natural cycle where patients ovulate on their own, they're already ovulating one egg. So we're trying to up the ante and make it a little bit more aggressive by selecting two or three eggs to ovulate, that's usually the goal when you're treating unexplained infertility. So these medications are trying to make that signal stronger, they just work in slightly different ways. Clomid is basically binding a receptor for estrogen on the brain, and that's how it blocks the brain's ability to detect estrogen. Letrozole works more peripherally at lowering estrogen levels because it blocks the conversion of testosterone to estrogen. So they're doing essentially the same thing, they're fooling your brain and your brain is cranking out a stronger signal. They're both pills, they're both taken during the same window of your cycle. Usually, we start them anywhere from day 3 to day 5, day 1 being the first day of a full flow bleed, and they're taken for 5 days. And then we usually bring patients in. If we're doing ultrasound monitoring to see how they're responding, we'll bring them in maybe 4 to 5 days after they finish their last pill. So there are differences. Usually, Clomid tends to be first-line for patients with unexplained infertility, and that's based on a really large clinical trial that was done that showed slightly higher live birth rates, Clomid was used versus Letrozole in patients with unexplained infertility, whereas Letrozole tends to be the first-line approach for women with PCOS. Similarly, based on another clinical trial which showed that it had a slight advantage when it came to overall clinical pregnancy rates, I think you can use either/or. I think it also could be trial and error. Some patients that start with Clomid because they have unexplained infertility, sometimes Clomid can lead to a thinner lining, not in all patients. But if I notice that side effect, then I'm going to recommend if this cycle isn't successful, next cycle let's switch to Letrozole. Letrozole also tends to lead to less follicles overall. So if you feel like someone had an overresponse, you're always worried about releasing too many eggs, like this.

Kristyn Hodgdon:
Oh, I was going to ask about that.

Lucky Sekhon:
Yeah. So you might say, okay, let's switch to Letrozole because you're young, you have presumed good egg quality and you know, you're a patient with PCOS. We're not trying to make you release tons of eggs, we're just trying to get you to release one, maybe two eggs in a regular fashion. So I think it just depends on so many different factors. And looking at whether someone has side effects, which tend to be worse with Clomid versus Letrozole is definitely a huge factor as well.

Kristyn Hodgdon:
Got it. And do you see a lot of multiple pregnancies through IUI?

Lucky Sekhon:
No. I mean, if you're doing Natural Cycle IUI, meaning just tracking someone's single ovulated egg, then it's not going to make a difference. IUI doesn't increase the, the twin rate. If you're using medications like Clomid or Letrozole, overall, the rates of multiple pregnancy, which in most cases are twins, not things like triplets, is about 3 to 8%. So not the most likely thing to happen, and I think that's important context to have. I always tell my patients, yes, this is something that is on the table as a potential outcome if you're taking medications that result in ovulation of more than one egg. But the reality is, most of my patients that have a live birth from these types of treatments are getting pregnant with one baby, one at a time.

Kristyn Hodgdon:
Okay, that's really good to know. So how much more effective is IUI then than just having intercourse when you ovulate?

Lucky Sekhon:
I think it depends on the situation, right? I think if someone is coming to me for treatment because their main issue is they never ovulate or their ovulation is super irregular, and their partner has a completely normal semen analysis, doing IUI is probably not that much more effective than timed intercourse, as long as they're timing it appropriately. If someone has a partner that has a slightly lower concentration, maybe slightly lower motility, I think doing IUI can make a huge difference because it's going to concentrate the sperm, it's going to help the sperm get closer to where it needs to go, and that might be rectifying the underlying issue. I think in terms of unexplained infertility, we don't know what we're treating or what the barriers are, though doing medications with IUI is definitely going to be more successful than just doing medication with timed intercourse. It's hard to quantify because every case of unexplained infertility is different because we don't know what the underlying explanation truly is. But, you know, I usually tell patients it might be an improvement of 5 to 10%, but it really just depends on the exact situation.

Kristyn Hodgdon:
Gotcha. And this is the question that we received the most of, which is how many IUIs should I do if we're moving on to IVF?

Lucky Sekhon:
Again, you know, it depends on the situation. So I'll use specific examples. If someone is doing, so first, it depends on the diagnosis, right? And I already mentioned earlier that if you have a diagnosis of unexplained infertility and we're just trying to do this as a combined approach, along with inducing the ovulation of hopefully multiple follicles, we're also going to do inseminations, I would recommend moving on to a different strategy if you're not pregnant after six rounds. Now, that's just like the standard blanket approach. Obviously, for a patient who's 35 and older, particularly someone who wants to have multiple children, I'm not going to just blindly say, yeah, keep going until around six and then we'll move on because it might be prudent to move on after three rounds, right? Maybe even sooner, because there may be a benefit to just going straight to IVF, because you have the ability to genetically test embryos, and we know that the rate of genetic errors in embryos is certainly higher over age 35. So that will help you get pregnant fast or potentially it might reduce your risk of a miscarriage. And the biggest thing, though, is family planning, right? Being able to have extra embryos that are created in the process that after you get pregnant from hopefully that first transfer or the first few transfers that you do, if you have extra embryos frozen for future use, that's going to streamline future family building. We know that at baseline IVF with an embryo transfer is a higher success approach than medicated IUI because whether you're using medication or not, IUI is really not doing anything that much different than when you're trying on your own. All of the things that happened downstream of that IUI that you would normally have to get past all those different hurdles like fertilization or that single or a couple of eggs turning into an embryo. And that embryo hopefully being genetically normal and finding the right spot to implant, all of that are still challenges that you have to face, whereas with IVF, you're controlling a lot of those things. And if you are using genetic testing, you can select the healthiest embryo for transfer, so I think it depends on your goals and your age and your underlying diagnosis.

Kristyn Hodgdon:
Yeah. And if you have insurance coverage and there's so many...

Lucky Sekhon:
Yeah! That's like a whole different topic.

Kristyn Hodgdon:
Exactly.

Lucky Sekhon:
I mean, sometimes your insurance will say and that's, you know, I hate when this happens, but some patients will be ready to move on. And it's more ideal for their strategy to achieve their specific goals to move on to IVF sooner but their insurance might dictate that they have to do a minimum of six rounds of medicated IUI before their insurance will consider coverage. And IVF is expensive, so that's a huge consideration.

Kristyn Hodgdon:
Absolutely. So the actual procedure day. Is it painful? I mean, I've been there, but I want to hear it from you. And if you can just sort of walk us through what the actual IUI looks like.

Lucky Sekhon:
Yes. So I think the best way to think about it is it's very similar to having a pap smear, right. This is not a major surgery or procedure that's going to require sedation or pain medications. You're coming in at a specific time, usually we'll tell you to drop off the sample. Your clinic may want your partner to produce the sample on-site, if you're using donor sperm, that means thawing it out. So everything is done in a timed fashion because there's coordination of care that is required and you'll be told to come in at a certain time. We'll be doing a speculum exams, you're lying on the examination table in the stirrups and we're using the speculum to visualize the cervix clearly. And the cervix looks like a little doughnut with a hole in the center, and that's the entry way into the reproductive tract. And so we're taking a very soft, flexible, long catheter, it's very thin, it's almost like the caliber of the inner sheath of a pen that holds the ink, but it's not rigid, it's flexible. And we're using our kind of tactile feel and feedback to snake that thin, flexible catheter through the narrow cervical opening and to the top of the uterus. A lot of people assume that when we're doing insemination, that we're going all the way into the fallopian tube and dropping the sperm off right next to the egg. but we're not. We're not aiming for a specific side, we're just injecting it at the top of the uterus. And then we take the catheter out and usually we'll take the speculum out and have you lie there for like 5 to 10 minutes to rest and just find your Zen moment. We always tell patients it's normal to have a bit of discharge, it's even normal to have spotting. A lot of times that's not coming from the uterus, it's just coming from maybe the speculum exam rubbing up against the cervix or maybe the, the catheter as it made its way into the outer part of the cervix, so don't be alarmed if you have a bit of spotting, even cramping for the first couple of hours. But it could last even a few days and some of that cramping might be coming from the actual ovulation itself, too. It's sometimes hard to figure that out, but it's really not a big production. But it's just something to be mentally prepared for, especially if you find it hard to be relaxed during a speculum exam, patients who have issues with their pelvic floor or vaginismus sometimes not all the time, but sometimes I'll recommend taking something to relax like valium about an hour before the IUI.

Kristyn Hodgdon:
Ok, yeah. I don't, I didn't think they were painful and, you know, I watched them ...

Lucky Sekhon:
They're fast.

Kristyn Hodgdon:
Yeah.

Lucky Sekhon:
They're fast, right?

Kristyn Hodgdon:
Yeah. And I always watch SNL videos while I'm waiting for those like 10 minutes after, after their procedure to just put myself in a good mood.

Lucky Sekhon:
I thought you were going to say you saw, like, a skit about IUIs on SNL.

Kristyn Hodgdon:
No, but that would be amazing. But I just kind of wanted to end this episode with like hearing from you that IUIs are, do provide live births. Because I think so often in this community, especially on Instagram, IVF is like what is talked about most often because chances are when you when you're going through IVF, you've been at this a long time, you might be more willing to open up and share, and, and so but there is hope with IUI or else you wouldn't do them, right?

Lucky Sekhon:
Yes. Oh, my gosh. And I'm guilty of this, too, on social media, I feel like so many of us focus more energy talking about and preparing people for the IVF process, whether it be the stimulation, egg retrieval or transfer, but I think because it just feels like a higher stakes game, you know, like I think it's expensive, it's more labor intensive, but that's really an important point that you're bringing up because yes, in and of itself, the IUI is not a major procedure. And doing one round of medicated IUI, you know, taking the meds, coming in for the ultrasound, doing the trigger shot, doing the IUI, yeah, it's not as much work as IVF, but something to consider is because it's more of the long game, because it's not likely to get you pregnant after the first try. But it takes persistence to pay off, it can be very fatiguing and it can be very emotionally trying and I think that's not talked about enough, so I'm glad.

Kristyn Hodgdon:
Obviously, it's something I'm passionate about because after three failed IUIs, I was at my breaking point. I went to my doctor and said, you know, I know I'm young, but I'm ready, I'm ready to do IVF. I know I want a bigger family if I can. Like, you know, you, I wish I had known all that went into it, but I also felt a lot of hope when I was, when I was doing them, it just didn't work out that way for me but.

Lucky Sekhon:
Yeah.

Kristyn Hodgdon:
I do know a lot of, a lot of people that it did work out for so.

Lucky Sekhon:
I think it's, I mean, I've seen hundreds of women go through this process now at this stage, and I think it's one thing to be told these are the success rates, don't expect the first one to work, it's going to take time. It's one thing to intellectualize that and it's another thing to actually take the medication, go through the process, wait for two weeks, pee on a sticl, be let down, like all of that's hard whether or not someone tries to mentally prepare you for it or not. And I think doing the same thing over and over and hoping for a different result is not how humans are wired to think. And I think it can be very soul crushing and difficult. So I'm glad that we have a whole episode devoted to this because it is a really important treatment approach for a variety of indications. And if you can get away with getting pregnant with IUI or timed intercourse with the help of medications or without, then that's wonderful. You know, and I think if that fits your family building goals and your strategy, then that's great. And you should know that they do work, we just want to always mentally prepare people to not be let down if the first one doesn't work. But that doesn't mean that there's no point doing them. And there's very specific cases where I can say like, it's the right thing to start with. You know, I've had lots of success with same sex couples who their only issue is they need to be exposed to sperm at the right part of their cycle. We have so many successful IUI stories in that setting and it makes a lot of sense. Patients with sexual dysfunction where we're giving them the opportunity to be exposed to sperm at the right part of their cycle. And I've had amazing and I, and I talked about this a lot on social media recently because one of my pet peeves is when people have low AMH automatically thinking that makes them infertile. And I've had amazing success with patients with astonishingly low AMH levels, like I'm talking 0.1 or 0.3 where they've maybe been told or they Googled and they felt like something was wrong with their bodies and they're not going to get pregnant no matter what. And some of them went straight to IUI as the first approach and got pregnant. Because your AMH level doesn't define you, your egg count doesn't tell me anything about your egg quality and your ability to get pregnant. And I've had patients who have tried IVF because they were worried about having a low egg count and they wanted to try to freeze embryos for future use. But IVF wasn't a great approach for them because their bodies just weren't able to respond to the drugs, because your egg count can sometimes dictate your ability to respond to the injections for IVF. And we pivoted and said, okay, let's do IUIs instead, and I've had so many patients get pregnant successfully that way, and maybe it's not the initial way that they set out to do things, but we pivoted our approach and they were successful. So I think that that should leave everyone listening to this episode with a lot of hope that IUI is a very valid treatment option and it can work well in a lot of different patients.

Kristyn Hodgdon:
I love that. Well, thank you. Dr. Sekhon, this was wonderful, and we'll be back next time.

Lucky Sekhon:
Awesome. Thank you for having me!

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear Infertility. We hope it helps you feel more empowered to be your own advocate on your fertility journey. Whatever you're currently struggling with, Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe. To find this episode, show notes, resources, and more, head to Rescripted.com and be sure to join our free fertility support community while you're there.

Sonix is the world’s most advanced automated transcription, translation, and subtitling platform. Fast, accurate, and affordable.

Automatically convert your mp3 files to text (txt file), Microsoft Word (docx file), and SubRip Subtitle (srt file) in minutes.

Sonix has many features that you'd love including powerful integrations and APIs, automated subtitles, advanced search, upload many different filetypes, and easily transcribe your Zoom meetings. Try Sonix for free today.