Intrauterine insemination (IUI) is the process of placing a catheter into the cervix to inject washed, motile and concentrated sperm directly into the uterus. This procedure increases a woman’s chances of becoming pregnant because sperm are in their best possible form, and are injected at a time when she is most fertile.

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 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 using other treatments alone, such as infertility medication.

In many cases, IUI is performed during natural cycles without the use of any fertility medications. However, studies demonstrated that an IUI in combination with clomiphene citrate (Clomid or Serophene) or gonadotropins (Gonal-f, Repronex or Follistim) significantly increases a woman’s 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 demonstrate 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 your consultation, you and your physician will devise a treatment plan. Some couples will need to schedule testing, in order to determine the best treatment option available to them. These tests vary, depending on which tests you have already completed, the fertility evaluation 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 test. For each test, we will consider: how it will help us to diagnose your infertility, how it will change your individual treatment plan, and whether or not the information obtained by the test will be worth its expense.

In addition to the testing, it is optimal for men to abstain from ejaculation for 1 to 3 days prior to the anticipated IUI. However, abstaining for more than 7 days can result in decreased motility.

Fertility Medications and IUI

Whether or not to use fertility medications along with IUI depends on your diagnosis and your age. The short-term goals for treatment of unexplained infertility (including age-related infertility) are the production of more eggs from fertility drugs, as well as better timing of ovulation and exposure to sperm with improved sperm numbers around the egg. Therefore, our female patients will usually be offered a combination of fertility drugs and IUI. Even in cases of endometriosis or male factor infertility, "super-ovulation" with fertility medications in combination with IUI improves chances of conception significantly over IUI alone.

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

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

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 improve your 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 less 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.

How long to stay with any one treatment is an important decision for you to make. Your decision may be based on any number of factors, including your age, the reason(s) behind your infertility, cost of treatment, your patience, and/or your willingness to be more aggressive. All of these factors need to be considered. If your strongest wish is to move forward with the least invasive procedures available, then a less aggressive approach can be offered for longer intervals. If your desire is to begin treatment aggressively with the highest likelihood of success, then your plan may look different.

IUI Treatment Costs

Costs will depend on whether or not the female partner is taking fertility enhancing medications, as well as the type of medications she is taking. For all women who will receive IUI, there will be costs for the monitoring that occurs during the cycle and the insemination itself.

Below you will find estimates of costs you may incur from IUI:

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 you are using fertility medications, there may be possible 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 endocrinologist, to review your progress and discuss alternatives.