For couples experiencing infertility, there are several, proven assisted reproductive technologies that differ in their invasiveness, success rate, and cost. IUI, which stands for Intrauterine Insemination, is typically the first of the assisted techniques suggested by a doctor since it is the lease invasive, has high sucess rates for certain causes of infertility, and is by far cheaper than IVF (In Vitro Fertilization) and ICSI (Intracytoplasmic Sperm Injection). Basically, IUI uses a medical device to deposit the sperm very close to the egg, much closer than during intercourse, so that they don't have far to swim to fertilize the egg. Think of it as a head start for the sperm. The fertilization process still occurs naturally within the woman's body, not like IVF where fertilization occurs outside the body in the laboratory. In this article we will discuss more details about IUI, which causes of infertility it may be successful in overcoming, and its relation to other, more invasive assisted reproductive technologies like IVF and ICSI.
IUI is a technique that basically gives a man's sperm a bit of a head start by bypassing much of the path to the woman's egg. By injecting “washed” sperm directly into the woman’s uterus (this is what the "IntraUterine" part of IUI means) using a catheter, much closer to the eggs, the chances of fertilization are much improved. The sperm used can be from a partner or donor, but in all cases the sperm is "washed". What this means is that a semen sample is taken from the man and much of the non-sperm material that makes up the semen is removed. Sperm only makes up about 1% of the composition of semen, the rest is mostly fructose (sugar), water, protein and enzymes. All that is needed for ferilization is the sperm, so the rest is removed for the IUI procedure.
The steps in the sperm washing procedure. The semen sample is placed
in a centrifuge to separate out the spem from the surrounding fluid.
The injection procedure itself is quite simple. A tube, or catheter, is inserted vaginally into the woman's uterus as shown in the figure below. The inserted end of the tube is quite close to where the eggs are produced. Once inserted, a syringe containing the washed sperm is attached to the external end of the catheter and the sperm injected.
IUI procedure showing how a catheter is used to inject washed
sperm directly into the uterus. The inset shows the sperm must still swim a short distance
and fertilize the egg in the natural way.
IUI Procedure Preparation
The first thing to know about preparing for an IUI cycle is that timing is everything. If you've been trying to concieve for some time prior to your first IUI, you are probably already used to calculating the optimal time to try and conceive. The right time is immeadiately after, or with, ovulation (i.e., when an egg is released by the ovaries down the fallopian tube). In general, the egg(s) can only be fertilized with one day (12 to 24 hours) following ovulation. As such, ensuring that the sperm reach the egg at the correct time requires some preparation.
A preliminary step to IUI is determining if there are any infections, hormonal issues, or obstruction problems. Such issues may reduce the chances of IUI succeeding, or prevent IUI all together. More on this in the next section.
So back to the timing. The first step is to determine exactly when a woman is ovulating. To do this doctors use an ultrasound (transvaginal) to monitor the ovaries and signs of egg growth. The technical name for this is ultrasound follicular monitoring and can be one of the largest costs associated with IUI, especially if 3 or 4 of these are required per cycle. The doctor can determine when mature follicles have been produced. These follicles turn into eggs. Another method for determining the precise timing of ovulation is to monitor the levels of luteinizing hormone (LH). This hormone is produced by the pituitary gland at the mid-point of the menstrual cycle and triggers ovulation to begin. The typical over-the-counter ovulation tests simply measure the LH level to let you know you're about to ovulate. You may also be placed on oral contraceptives for a couple of cycles. This may seem counterproductive to the process, but this allows the doctor to control the timing of the egg realease. Once the doctor has detected an increase in the LH levels and determined that you are ready to ovulate , you can expect an IUI to be scheduled for the following morning. As you can see, there will be lots of doctor's appointments, testing and scheduling when attempting IUI.
So what about the men? Well up until ovulation, the man has to do only one thing. That is to NOT ejaculate for 3 to 5 days before ovulation is scheduled to occur. He will be required to produce a semen sample, either at home or in the doctor's office on the day of the IUI procedure. If you are using donor sperm, you will want to coordinate with either your donor, or donor bank such that the sperm is provided to your doctor by the scheduled day.
An actual IUI catheter used in the IUI procedure.
To increse the chances of a successful fertilization, IUI (and other techniques like IVF and ICSI) is typically done in conjunction with ovulation stimulation. This is the process of using medication to stimulate the woman's body into producing more than one egg per menstrual cycle. If there are more eggs, the sperm have more targets and the chances of pregnancy go up accordingly. The medications used to stimulate multiple egg production are usually Clomid (Clomiphene Citrateor) or a class of drugs called gonadotropins (e.g., hMG). These drugs prevent the natural increase in LH from the pituitary gland to give the body time to continue producing eggs, so an injection of another medication called hCG is used to "trigger" ovulation within 36 hours. If a hCG "trigger" shot is used, the IUI is typically scheduled for 36 hours after the shot, mark your calender accordingly.
When is IUI Appropriate?
Doctors will not recommend IUI for everyone experiencing infertility. This is for two basic reasons. The first is that some causes of infertility cannot be overcome by the IUI assisted technology, and the second is if the probabiity of success is so low that it would make more financial succes to go straight to IVF or ICSI. For example, women who are older than 43 are typically recommended to go straight to IVF as the success rates of IUI drop with age. Other causes on infertility in which IUI will not be helpful are blocked fallopian tubes, severe fallopian tube damage, very low egg quality, menopause, or motile sperm count less than 5 million. For cases where IUI is appropriate (the majority of cases), read on.
Treating Male Infertility
This fertility enhancement technique can be used to overcome both male and female based fertility problems. For example, in male infertility the problems are typically a low sperm count and / or decrease sperm motility, i.e., not many sperm, or not many strong and fast sperm. In such a case, the IUI procedure makes the distance the sperm must travel to find an egg much smaller, essentially placing the sperm very close to the finish line. Once inside the uterus, the sperm still must compete to be fertilize any available eggs.
Treating Female Infertility
In female based fertility difficulties, for example cervical scar tissue or above average cervical mucus viscosity, the IUI procedure uses the catheter to allow sperm to bypass these difficult regions, once again increasing the chances of successful fertilization.
Types of IUI
There are a couple of medication regimens that can accompany an IUI cycle. These are usually referred to as "Clomid" and "inject" type IUI cycles. The Clomid type is just what we have described above. Below we descrive how the "inject" type cycle differs, and also a somewhat newer approach known as "twice a cycle" IUI.
As we discussed above, there are two types of medication used to stimulate ovarian production giving multiple eggs. These are the gonadotropins and Clomid. The gonadotropins (e.g., hMG) are typically self-injections that you or your partner do at home throughout the menstrual cycle. Your doctor will help you decide whether oral Clomid, or "inject" type IUI is right for you. Some deciding factors are age and if there is a history of ovulation problems. The "inject" type IUI is considered to be more a aggressive treatment and as such is usually recommended only to younger women. However, it is also true that the "inject" type IUI may be recommended for women over the age of 35, also because it is more aggressive and may allow fertilization sooner rather than later. An example of an "inject" type IUI is using Follistim instead of Clomid. Follistim consists of highly purified rFSH Rec, which is a recombinant follicle stimulating hormone and may have higher success rates than the normal Clomid IUI.
In recent years "twice a cycle" IUI has become popular. As we discovered above, timing is everything in IUI. The twice a cycle method basically tries to improve the chances of getting the timing right, by trying the IUI procedure one day following the trigger shot, and again at two days following the trigger. There have been several studies that suggest this approach increases the chances of fertilization. However, it does cost more, but usually only double the IUI procedure cost itself, i.e., an extra $350 or so.
The cost of IUI can be a little confusing. Mostly because people mistakenly think the cost of the "IUI procedure" is the "total IUI cost". It is not. The total IUI cost covers the entire IUI cycle, not just the IUI procedure (the actual injection of the sperm using the catheter). This includes doctor's appointment costs, blood work, ultrasounds, medications, sperm washing, and other costs. You can expect the total IUI cost to be between $1200 and $2000 per cycle. It will depend on your particular circumstances, for example, the number of ultrasounds needed, or whether you use a sperm donor or not. For more information please read our article on the cost of IUI.
IUI Sucess Rates
The success rates vary, especially with age, but in general the odds of a successful IUI procedure is about 1 to 2 in 10 (10 to 20 %). While this is much less than IVF and ICSI, the cost of IUI and the overall difficulty of the procedure is less. It is often recommended that IUI be tried before IVF. Also, it is common that the doctor prescribes some type of additional hormone treatments for the female to increase egg production, hopefully giving multiple eggs for the inserted sperm to target and increasing the success rate.
A Note on Post IUI Pain
While the IUI is a relatively non-invasive technique, it does still involve inserting a catheter quite a long way into the uterus, near to the fallopian tubes themselves. As such, the day of, and perhaps several days after you can expect some discomfort. The level of discomfort can range quite a lot, with those having a sensitive uterus possibly experiencing pain that will require medication and confining you to bed. Others will barely notice they had the procedure. A special note for those who do not ovulate regularly, or whom have never ovulated, the trigger shot that induces the ovulation may further induce ovulation pain that your body is not accustomed to.