Fertility and Sterility On Air - Roundtable: Should you do ultrasound monitoring for IUI cycles?

Welcome to Fertility and Sterility Roundtable, hosted by Dr. Emily Barnard and Dr. Ben Peipert! Each week, we will host a discussion with the authors of "Views and Reviews" and "Fertile Battle" articles published in a recent issue of Fertility and Sterility. 

Today, we will be discussing the Fertile Battle from the February issue of Fertility and Sterility which is entitled “Should you do ultrasound monitoring and trigger for intrauterine insemination cycles? We are joined by two of the authors, Dr. Cassie Hobbs who will be taking the “pro” side in favor of ultrasound monitoring, and Dr. Lindsay Hartup, who will be arguing to do away with ultrasound monitoring. 

Dr. Cassie Hobbs is a second-year Reproductive Endocrinology and Infertility fellow at the University of Pennsylvania. She completed her OB/GYN residency training at Brown University and received her medical degree from Duke University School of Medicine. She is passionate about examining disparities that exist in reproductive medicine and taking steps to make family building a more equitable process for all. 

Dr. Lindsay Hartup is a Reproductive Endocrinology and Infertility fellow at Brigham and Women's Hospital. She completed medical school and Obstetrics and Gynecology residency at the University of Texas Health San Antonio. Her research interests are fertility preservation/oncofertility, assisted reproductive technology, and chronic endometritis.

Read the Fertile Battle from Volume 125, Issue 2 p228-233 in the February 2026 issue

View Fertility and Sterility at https://www.fertstert.org/

Welcome to Fertility and Sterility Roundtable. This podcast will delve into sections of the journal previously unexplored in the Fertility and Sterility podcast family. Articles that we would consider some of the most timely, cutting edge, thought provoking, and dare I say controversial.

We will be joined by a couple of the authors each month to explore the themes, debate the pros and cons, and generally expand our knowledge in a conversational format. I'm your host and FNS interactive associate, Dr. Emily Barnard. And I'm your co-host and producer, Dr. Ben Peipert.

We will be covering articles in the fertile battle and views and reviews portions of Fertility and Sterility. This podcast is brought to you by the Fertility and Sterility family of journals in conjunction with the American Society for Reproductive Medicine. Welcome everyone to Fertility and Sterility Roundtable.

I'm your host, Dr. Emily Barnard, and I'm joined by my producer and co-host, Dr. Ben Peipert. Today, we will be discussing the fertile battle article from the February issue of Fertility and Sterility. This article is entitled, should you do ultrasound monitoring and trigger for intrauterine insemination cycles? We are joined by two of the authors, Dr. Cassie Hobbs, who will be taking the pro side in favor of ultrasound monitoring, and Dr. Lindsay Hartup, who will be arguing to do away with ultrasound monitoring for IUI.

To give a little background on our guests today, Dr. Cassie Hobbs is a second year reproductive endocrinology and infertility fellow at the University of Pennsylvania. She completed her OBGYN residency training at Brown University and received her medical degree from Duke University School of Medicine. She is passionate about examining disparities that exist in reproductive medicine and taking steps to make family building a more equitable process for all.

Welcome Cassie. Thank you so much for having me today. I'm excited to have this discussion.

We're also joined today by Dr. Lindsay Hartup. She is a reproductive endocrinology and infertility fellow at Brigham and Women's Hospital. She completed medical school and obstetrics and gynecology residency at the University of Texas Health San Antonio.

Her research interests are fertility preservation and oncofertility, assisted reproductive technology, and chronic endometritis. Welcome Lindsay. Thank you so much for having me.

I'm so excited to be here. Now I will give a disclaimer before we get into our discussion today. The authors for these fertile battles are chosen to represent the full breadth of opinion.

And even though they may be sort of arguing or pushing for one side of the debate, that does not necessarily mean they fully agree with all the viewpoints that we'll be discussing today. So just to start us off, I would love for each of you to summarize your position on this issue. And I think to put some parameters on what we're discussing today, this is about the use of ultrasound monitoring for intrauterine insemination cycles.

So that's specifically the context that we're looking at today. And we'll just have each of you share just a brief summary. So our position is that people who are undergoing intrauterine insemination should be monitored.

And so whether that looks like, you know, doing both an ultrasound or a blood work, some type of monitoring. And that's so that we can monitor follicle development and counsel patients appropriately. So our stance is that monitoring should not be universally performed for IUI cycles.

And the reason for that is because IUI is often the first fertility treatment that's pursued before a patient moves on to IVF. And the reason that it's pursued first is because it is less expensive, less invasive, and more convenient to the patient. And so doing ultrasound monitoring and triggering for IUI cycles really kind of opposes these goals without a demonstrated improvement in pregnancy rates or decreasing rates of complications.

So when we think about monitoring, I think it's really interesting because I bet almost every fertility practice in the country does intrauterine insemination. But even when we talk about monitoring versus not monitoring, I think there's probably a lot of variability. When you've kind of looked at the research on this and even just in your own practices, when we say monitoring, kind of what does that typically tend to mean? Monitoring specifically at our practice, generally what that looks like is we'll bring in patients around cycle day two or three of their cycle.

We'll do a baseline ultrasound. We'll get baseline labs with their estrogen, LHP4, HCG, just to make sure that they're earlier in their cycle and suppressed. And then we generally instruct them to start taking their medications generally on day four of their cycle, take their medications for five days.

And then we have them return between cycle day 10 and 12. And we generally do an ultrasound at that time to monitor follicle development and then counsel the patient about whether it's time to trigger at that time or whether we don't want them to return at a later date. And Lindsay, is there anything about that practice that is different that you've seen where you're training? I would say it's pretty similar.

Oftentimes when we are doing monitoring, it's going to involve both blood work and ultrasound, which will be done, of course, involving a patient presenting both to a laboratory to get their blood drawn and then to our radiology department to get an ultrasound. And frequently, you know, if a patient's not ready to be triggered or to time their IUI, it's going to involve them probably coming back in a couple of days. And so oftentimes when you are monitoring, you know, it could be, you know, two to three to four visits within just a given IUI cycle to come in to check on follicular development and where a patient's at.

Is there some consensus that we have kind of between the pro and the con side on some instances where monitoring should probably universally be done, certain patient populations or treatment cycles? I think that if someone is using injectable gonadotropins, oftentimes that leads to, you know, several follicles being developed. And so I think that in those situations, we should definitely monitor to prevent over-response and risk of multiples. I would say additionally from our side, the alternative to doing this kind of monitoring is using ovulation predictor kits at home, which just is a basic like urine test at home to see if you're developing your LH surge.

And so for some patients, these work very well and reliably, but for others, they do not. There can be false positives, which could be seen, you know, in patients that maybe have PCOS, that have tonically elevated LH levels. And so the tests are always reading positive and not truly picking up a surge.

And so I would say in patients where we know that that has been the case, you shouldn't be using an ovulation predictor kit to time an IUI. And then conversely for other patients, they may always be negative. And if you're not ever picking up a positive, you won't be able to do an IUI based on that either.

I think another population in which, you know, we should monitor someone who, you know, has potentially a severe contraindication to having multiples. So someone who has a severe heart disease, pulmonary disease, someone where truly having a multiple gestation would put them at risk. I think this is going to be a fascinating discussion just because there's so many different pros and cons between these two approaches to dive into.

I want to start with LH monitoring because I love covering these articles because I always learn something. And I knew that urinary LH detection kits were imperfect, but I did not realize how low the sensitivity actually is across several different brands. In this fertile battle, a 2025 article was cited indicating that the sensitivity for these urinary LH detection kits is only 62 to 77%.

That means that there are patients who are having a surge and it's not being picked up. How do we incorporate that into our counseling when we're talking to patients about monitoring or not monitoring for your more routine IUI cycles? I think oftentimes when a patient is presenting to an REI for potential fertility treatment, many patients have already tried ovulation predictor kits. And so I think for some patients will probably know already that they either have had success with them in that these kits turn from negative to positive consistently at a given point in their cycle.

So I think we can be more reassured that they could work for these patients. But for others, if they're telling us, you know, they're always positive, we know that that's not the case. I do think in the sense of negative, like they're always negative, that's a little bit more of a challenging situation.

You know, is that just because they're not ovulating? Or is that because the test isn't picking it up? And so for them, I think the approach is a little bit more nuanced. And that can be a discussion with the patient as to whether or not they want to go straight to doing monitoring, or maybe they want to try ovulation induction unmonitored. And then that cycle, you know, if they don't have a surge, you know, do a serum progesterone draw seven days before they're expected to start their cycle and see if they did ovulate and the test just didn't pick it up, in which case then we would counsel towards monitoring in the future.

Yeah. And I wonder how much some of that sensitivity data will change as we look at some of the newer urinary testing kits that have come out, which are measuring estrogen metabolites and other hormones to try to improve the detection of the fertile window. So it's possible that we'll see some improvements with those technologies, but it has yet to be proven.

So the other point that you brought up, Cassie, is this risk of multiples, even with the oral ovulation induction agents. You talked about the medical risks that are heightened in patients with certain comorbidities, but do you think that the decision to monitor should change based on if you're in a state with more or less restrictive abortion laws or if a patient is more or less willing to consider selective reduction? No, I think that's a great question and a very complex one. I think that if you are at an institution or at a state that, you know, completely doesn't do monitoring, I think that it's reasonable to have an option for monitoring, particularly if you're in a state where selective reduction and abortion are limited so that you can have that information.

And so when the patient is going through their cycle, they have information about how many, you know, follicles they have and have the option to cancel. I don't think it needs to be mandatory, but I think that patient, again, should have all the information about their cycle. So, you know, whether that's monitoring and, you know, counseling about follicle number and potential cancellation.

And if they decide, you know, maybe I don't want to monitor, be sure to reiterate that, hey, we're in a state where selective reduction is not legal. If you have multiple follicles, you do potentially increase your risk of having multiples and just having a conversation and being able to allow the patient to make an informed decision. All right.

Any of you familiar with kind of some of those studies? I know there were some different ones that you quoted on what the risks of multiples are with using Clomid and Letrozole and how does that kind of factor in with whether you'd recommend monitoring or not? Do we think it's pretty risky? So the rate of multiples with Clomid and Letrozole are really on the order of 8 to 10%, but that's more so looking at twins. The rate of higher order multiples is under 1%. And I think just to bring up kind of the counterpoint to this, even though, you know, multiple gestation is a known risk of ovulation infection, the risk hasn't been shown in the studies to be different whether monitoring is done or not done, that monitoring hasn't been shown to decrease the risk of multiple gestation, nor has follicular development just with regards to Clomid and Letrozole been shown to be predictive of multiple gestation.

I agree that the absolute risk is relatively low. I know that in the MIGOS trial, one of the things I noticed in a supplementary table is that when they discuss people who were excluded from the study, there were several people excluded from the Clomid arm because they had over four follicles developed. And so we were able to exclude them and potentially avoid that kind of higher level or higher order multiples because we monitored and saw their follicle development.

And so, you know, whether they would have gone on to get pregnant and have triplets, that's not known. But again, they were excluded because of excessive follicular growth. And so I think that's just something to be noted.

But I agree that overall, the absolute risk of higher order multiples is low. But I do think that though it's low, it's not zero. So perhaps the most compelling data I've seen in support of monitoring, because this is an area where we're very good randomized controlled trials that are doing head to head comparisons between monitoring.

And what we have so far really doesn't look like there's much of a difference. The one area where I think there is potentially some impact is, and it does appear that in some studies, you see higher rates of cancellation in the group without monitoring. And so, Lindsay, how do you think about that in the context of your position for this? Yeah.

So I think if you're canceling a patient who was doing home LH monitoring with urine tests, they will have paid most likely for the oral ovulation induction medication and those test strips. But you won't actually proceed with the IUI if you had a negative result. So I think that your reason for cancellation would be failure to pick up an LH search, which overall is, you know, it's not nothing, but it's relatively low stakes that that was what was missed in the cycle to be able to prevent, you know, potentially excessive monitoring and cost if it weren't necessary and to have never tried an unmonitored cycle.

But that is a risk, you know, that for some patients, if you don't pick up a surge or you miss the surge, that would be a wasted cycle. It's, you know, though the financial risk, there is kind of like emotional risk of, you know, having taken this medication and expecting a procedure and not being able to. And so I think that that's something that also needs to be factored in.

Time is a precious resource. We're, you know, not seeing these or we're missing surges or we're not picking up surges, you know, month after month. That's hard on the patients and particularly our fertility patients where time is critical.

One aspect that both sides brought up is the patient experience with monitoring or without monitoring for IUI cycles. And I think that you can look at either approach as being better for the patient's experience going through treatment. And so I was wondering, could each of you touch on your perspective on how the choice to do monitoring impacts the patient experience? Simply put, you know, it's invasive to have to go in and get your blood drawn.

It's also invasive to have to go in and get repeated transvaginal ultrasounds. You know, I mean, we're both coming from big cities, we're going into the hospital or to the clinic, finding parking, doing this when you're trying to work, you know, it's a lot of work for something that overall has a success rate of 10%. And so to put in kind of all of this effort to go in for monitoring when you could just do urine LH monitoring at home and these test strips are less than $1 to $3 per strip.

I think it's no question that it's more convenient to do this at home. You'll save a ton of money. I actually asked our financial people over at the Brigham, what are the costs of doing monitored IUI versus unmonitored? And the monitoring costs like globally for us, if you're a self-pay patient, it's $2,000 as opposed to if you're doing an unmonitored cycle at home, you're paying for those test strips, the medications and the IUI itself, which is like more like 700.

And so I think, I mean, there's no question that it's cost time and inconvenience to be monitoring. From my experience, I feel that, you know, though the ultrasound and the blood work is invasive, I think that patients actually appreciate having the extra information. Oftentimes these are patients who have experienced infertility for years and years without answers as to, you know, why they can't conceive.

And so being able to talk through, especially if it's a physician doing the ultrasound and their physician talk through, you know, what we're seeing on ultrasound, you know, what our follicular development looks like, how this cycle looks different from last time. I think that patients actually really appreciate having that extra information. And then, I mean, even for providers themselves, being able to just kind of like eyeball the ultrasound, see what worked from one cycle to the next, trying to replicate that, just combining all of that information, I think it helps to develop a clear plan for both the provider and the patient.

Maybe there's some opportunity, like you're saying, to sort of tailor it to different patient desires. Because I know personally in my own practice, taking care of patients, some people really are like, oh gosh, I have to come in again tomorrow. And other people are like, why aren't you bringing me back tomorrow? Why are you my visits out? So it was actually when Ben and I were kind of talking and thinking about this, I was thinking it'd be an interesting study for a fellow to do, you know, because I think we are sort of supposing what the patients are wanting and there's different reasons for that.

But I don't actually know if it's been studied. And I would be really curious, again, knowing all people are coming with different perspectives to things and living different, you know, amounts of time away from the clinic and that sort of thing. But yeah, this is a really important consideration with all this, I think.

How about using donor sperm? How do we feel about monitoring with that? Do we feel the same as using sperm from a partner? Does it change how we think about this just with the cost of donor sperm? Again, I'm on Camp Monitor and having done a lot of research on the cost of donor sperm, just to put it out there, it's $2,500 to $3,000 a vial. And so timing that LH surge correctly and, you know, having sperm there to meet the egg, I think that that's essential, particularly because, you know, it often takes a couple IUIs to, you know, achieve a pregnancy. So we want to minimize that if possible.

And I think that having more data will help us achieve that. So I mean, I agree, it's another higher stakes situation, like financially as well. But you know, that study that was done in 2025, looking at ovulation predictor kits did say overall, they were more than 90% accurate.

And so I still think for the vast majority of patients, they would be accurate. And so I don't think that it's a setting where a patient should ever be forced to say I have to have monitoring if they know that the kits work for them, that I think they could use them. But I think, you know, in all of these cases, really, like it should be at the discretion of the patient and the physician, like shared decision making, and whatever the patient feels most comfortable with doing, I think should be done.

Okay, my next scenario that I've been kind of thinking about with this is unexplained infertility. And I think we've sort of been talking about this along the way anyway. But you know, with ovulation predictor kits, we're kind of saying, can we pick up the surge? Can we appropriately time? And it sounds like in many circumstances, we can, I am sold on this from Lindsay.

But with unexplained infertility, you know, we're kind of trying to do ovulation induction, we're not necessarily just trying to get ovulation to happen, which is probably already happening. We're trying to, you know, probably get two eggs to grow or maybe three eggs to grow. But if we're not monitoring, we don't really know if we're achieving that goal.

And so I'd be curious your thoughts on that from both well, I mean, we know Cassie's perspective, she would say, yes, now we can monitor and we can tell. But I guess I'm curious from Lindsay's perspective, are we, I don't know, not able to detect or missing out on that benefit that we're trying to get by using these medicines? Yeah, I mean, you're definitely wouldn't know if you're super ovulating them, like you don't know if you're developing the two or three follicles, which would be our goal in these patients. So I mean, yeah, I agree with that point.

I think just though, on the opposite end, it's in the end, your alternative treatment for unexplained infertility will be IVF. And I think just like thinking that through as far as like the costs and the time that how many visits go into monitoring these patients, by the time you add up how much that would be over three or four consecutive cycles, you're ultimately doing more monitoring there than you would have done in one IVF cycle, which I think is just an interesting thing to think about for something that's ultimately less efficacious than, you know, going to IVF. Again, I just think that it gives us good data.

So in these people who have unexplained, if we do a letrozole cycle, and we see that, you know, twice, we're just getting one follicle, then maybe we can move to IVF sooner. And again, just having that information, I think it's helpful. We all know that the reality here is that the truth is somewhere between your two positions.

In our practice at Penn, we see a lot of patients who end up doing a monitored cycle first to help with their dosage and their timing. And assuming they have urinary ovulation predictor kits that are working for them, thereafter, they may do unmonitored cycles. And so I'm wondering how that compromise sits with each of you, or if there's other compromises you've thought of that could be a nice middle ground to settle on.

I think truly bringing the risks and benefits to the patient of both sides. I think, honestly, this can be different depending on the state that you live in, too, as far as, you know, we talked about with abortion laws, but also, you know, are you self-pay or do you have insurance coverage? Because if you have insurance coverage, there's definitely no harm to monitoring. So if a patient wants to monitor and they have coverage for it, it's kind of like, why would you not? And so I think the middle ground is like, not necessarily mandating one over the other, and just kind of discussing with the patient, these are the risks and benefits.

And in your case, based on your history, I would recommend this, or I think that this would give us more information for you, or maybe this would be more convenient for you. This might be an unnecessary intervention for you, and then just letting the patient make the decision. I agree.

I think there certainly is a role for a middle ground and certainly all the things that Lindsay said about insurance coverage versus self-pay and where you live. I think it really just comes down to like having a conversation, looking at the patient's individual history, and then just make a decision from there. I love to hear the emphasis on patient-centered medicine and thinking about autonomy and the other factors that may matter to patients besides outcomes, because there are many aspects of the treatment that we provide our patients that impact them beyond if they come home with a baby or not.

I think it is nice how thoughtful we're all being about this though, because we know this is a lower tech, less invasive treatment. We know it does have lower success rates, but I think for some people, I mean, I see this all the time with my patients, it is such a huge step for them to do an IUI. So I'm glad that we aren't minimizing this.

This is a big treatment for a lot of people. So I really like that we're thinking about this and how can we make this better for them? Because it does work for a percentage of people. And for a lot of people, it's their foot in the door to other things.

So I appreciate both of your insight into this. Thank you. Thank you.

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