Intrauterine insemination (IUI) is the process of preparing a sperm specimen to concentrate it for the most active motile sperm and placing the washed sperm into the uterus as close as possible to the tubal opening.

Intrauterine insemination is often recommended because studies have shown that pregnancy is more likely to occur if timing of exposure to sperm is controlled, and if sperm is placed in higher numbers closer to the egg or eggs.

IUI is often recommended for women or couples who:

• have ovulation problems and are undergoing ovulation induction;
• are unable to have normal intercourse with ejaculation into the vagina at appropriate times;
• have mild male factor infertility;
• have unexplained infertility;
• are single women who are using donor sperm;
• have failed other treatments, such as Clomiphene alone.

In many cases, IUI is performed in natural cycles without the use of any fertility medications. However, studies in the fertility literature have demonstrated that, especially in combination with clomiphene citrate (Clomid or Serophene) or gonadotropins (Gonal-f, Repronex or Follistim) administration, performing an IUI significantly increases chances of conception.

The Intrauterine Insemination Process

There are many techniques available for preparing the sperm, most of which are derived from in-vitro fertilization laboratory techniques, or from study of sperm behavior in the laboratory. The goal in sperm processing is to separate the sperm cells from the seminal fluid, fluid that can be irritating to the uterine lining. In the process, the most active, motile sperm are concentrated and separated from dead sperm, cellular debris and bacteria.

The sperm can be collected at home and brought within one hour to the office or can be produced in a clinic's sperm collection room. The laboratory will then perform a sperm count and motility evaluation and prepare the sperm. The usual preparation procedure takes about two hours. After preparation, the sperm concentrate is placed into the uterus, through the cervix, using a small catheter. The actual insemination process takes approximately 2 to 5 minutes.

In the vast majority of cases, IUI is a completely painless process. Some inseminations are accompanied by cramping, but this is usually very mild and transient. It is not necessary to remain lying down after the procedure and you may immediately resume your usual activities. Sometimes couples are encouraged to have intercourse on the day or evening of insemination to further increase chances for conception.

Studies have been done demonstrating that one well-timed insemination per cycle is as effective as two inseminations per cycle so most clinics, including Pacific Fertility Center, perform a single insemination per cycle.

Preparing for an IUI Cycle

After consultation with your fertility physician, a treatment plan is usually made between you and your physician. Some couples will need some testing to be performed in order to determine the best treatment option. These tests vary, depending on the evaluation already completed and the reason for considering IUI. In most cases the status of the fallopian tubes needs to be determined, ovulation needs to be verified and the quality of the sperm assessed. All women who have regular menstrual cycles should have an early cycle FSH and estradiol blood level tested. For each test we will consider with you: Will it help to diagnose your infertility? Will it change your individual treatment plan? Is the information worth the expense of the test?

It is optimal for men to abstain from ejaculation for 1 to 3 days prior to the anticipated IUI. Abstaining for more than 7 days can result in decreased motility.

Fertility Medications and IUI

Whether or not to use fertility medications along with the IUI treatment depends on your diagnosis and your age. For unexplained infertility, including age-related infertility, it is the combination of more eggs from fertility drugs, better timing of ovulation and exposure to sperm with improved sperm numbers around the egg, which are the goals. Therefore, these couples or women will usually be offered combination of fertility drugs and IUI. Even in cases of endometriosis or male factor infertility, "super-ovulation" with fertility medications improves chances of conception significantly over IUI alone.

The type of fertility medications recommended will also depend on age and diagnosis. Younger women with no known ovulation problems might be offered progressively more aggressive treatment, such as:

• three to six cycles of clomiphene citrate with IUI timed by ultrasound monitoring and injection of hCG to ensure ovulation; and
• three to four cycles of gonadotropins with IUI, timed by ultrasounds and an injection of hCG.

Women over 35 years of age with no known ovulation problems are more likely to be encouraged to skip the clomiphene citrate and proceed more aggressively to gonadotropin treatment, or to consider only two or three cycles at each step.

Even with natural conception the probabilities of getting pregnant in any one month, even under ideal circumstances, are low (around 25% of young couples with no known fertility problems will get pregnant in any one cycle). This means that if a treatment is going to be successful, whether it is clomiphene with IUI or in-vitro fertilization, it usually requires at least three tries to know if there has been any improvement in the chances. As far as we know, the chances per cycle for a group undergoing IUI alone will never be better than natural fertility, which is approximately 25% per month for patients les than 35 years of age. For women over 40, women with elevated FSH levels, or when sperm are compromised in number or function, chances are much lower.

A well designed study published in the New England Journal of Medicine reported that the cumulative pregnancy rate over four months of treatment in couples with unexplained or mild male factor infertility was 18% with natural cycle (no medications) plus IUI, as compared to 10% with intra-vaginal insemination. The four-month cumulative pregnancy rate was reported at 33% with gonadotropins (injectable fertility medications) plus IUI. Keep in mind that the average age of the women in this study was 32 years of age.

How long to stay with any treatment is an important decision for you to make. Your decision may be based on any number of factors, including your age, reason for infertility, cost of treatment, your patience, or your willingness to be more aggressive. All of these factors need to be considered. If your strongest wish is to have the least intervention possible, then a less aggressive approach can be offered for longer intervals. If your desire is for the most aggressive approach with the highest likelihood of success, then your treatment plan may be different.

IUI Treatment Costs

Costs will depend on whether or not the female partner is taking fertility enhancing medications, the type of medications, necessary monitoring and the insemination itself.

For example, here are some estimates of costs (not actual costs):

Clomiphene citrate...........................$55 to $165 (depending on dose)

Gonadotropins.................................$40-75 per ampule (approximately 10-40 ampules/cycle)

hCG................................................$60

Ultrasound monitoring.......................$300 per test

Estradiol blood test...........................$85-100 per test

Insemination with sperm preparation...$350

The cost per cycle can vary greatly depending on the center where treatment is undertaken and whether the medication is clomiphene or gonadotropins. For example, a woman taking clomiphene and timing her IUI with an ovulation kit could spend about $750 in one cycle. A woman using gonadotropins with IUI could spend up to $5,000, depending on the amount of medication needed and the number of monitoring ultrasounds needed. Some programs monitor blood levels for estrogen along with ultrasounds, particularly for gonadotropin and IUI cycles.

Risks of Intrauterine Insemination

There is a <1% chance of pelvic infection with intrauterine insemination. If using fertility medications, there are possible medication side effects to consider such as ovarian hyperstimulation syndrome.

What to Consider if IUI is Not Successful

Options for treatment in the cases where IUI is not resulting in successful conception vary from individual to individual. For some, in-vitro fertilization is the ultimate test of the ability of the sperm to fertilize, and provides for the most controlled environment for maximizing chances for pregnancy. For others, egg donation or adoption will offer the highest likelihood for parenting. A consideration of resources, including time, effort, and expense, as well as probabilities, will help to determine choices.

If you are not pregnant within an appropriate number of tries, it is important to schedule a consult visit or a phone consultation with your reproductive endocrinology physician, to review the progress and discuss alternatives.