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IUI – Artificial Intrauterine Insemination

Artificial Intrauterine Insemination (IUI) is one of effective infertility treatment methods. This infertility treatment method should be used in very specific group of couples and should not be used in several cases. If Artificial Intrauterine Insemination (IUI) is used in correct cases and in proper manner, it could be very effective. Millions of healthy children were born after Artificial Intrauterine Insemination (IUI).

Since the early 1900’s this method was used in animals with great success. Human artificial insemination with the male partner’s sperm for infertility began being used in the 1940’s.

When IUI is recommended and effective

IUI is most commonly used in following infertility cases:

  • Unexplained infertility,
  • Infertility with cervical factor,
  • Female infertility affected by mild endometriosis,
  • Mild male factor infertility,
  • Female infertility with ovulation problems.

When IUI is not recommended and not effective

In general the IUI procedure can be effective in women before 40. At the same time the IUI would not be recommended for infertile couples in following cases:

  • Tubal blockage or severe tubal damage,
  • Ovarian failure (premature ovarian failure or early menopause),
  • Severe male factor infertility,
  • Advanced stages of endometriosis.

It is well known that artificial intrauterine insemination (IUI) should not be used in women with blocked fallopian tubes. Best method for blocked fallopian tubes is In Vitro Fertilization (IVF).
Female age is a significant factor with IUI. Intrauterine insemination has very little chance of working in women over 40 years old. IUI has also been shown to have a reduced success rate in younger women with a significantly elevated day 3 FSH level, or other indications of significantly reduced ovarian reserve.
Male partner’s health and the quality of sperm is crucial for IUI. If the sperm count, motility and morphology scores are low, intrauterine insemination is unlikely to work. With significant male factor issues, IVF with ICSI is recommended.

In general IUI pregnancy rates are lower when insemination is used:

  • in women over 38 years old;
  • in women with low ovarian reserve;
  • with poor quality sperm;
  • in women with moderate (or severe) endometriosis;
  • in women with any degree of tubal damage or pelvic scarring;
  • in couples with a long duration of infertility (over 3 years).

How artificial intrauterine insemination (IUI) is performed

There are several important steps which are usually implemented during artificial intrauterine insemination.
Step 1
Women cycle charting is crucial for IUI. The IUI procedure could be done in women with normal ovulation and in women with ovulation problems. Some clinics prefer ovulation stimulation with multiple eggs for increasing the success rate. Woman usually is given medications to stimulate development of multiple eggs and the insemination is timed to coincide with ovulation – release of the eggs.
This combined therapy is used frequently in the treatment of couples with unexplained infertility, male factor infertility, or failed treatment with more conservative therapies. Sonograms are performed every 1-4 days in order to monitor the effects of the medications and properly schedule the IUI, intercourse, or other procedures.
Step 2
Good quality sperm should be prepared. A semen specimen is either produced at home or in the office by masturbation after 2-5 days of abstinence from ejaculation.
Step 3
The semen is “washed” in the laboratory (called sperm processing or sperm washing). The processing of the semen sample include separation of the sperm from proteins within the semen. The sperm is separated from the other components of the semen and concentrated in a small volume. Various media and techniques can be used for the washing and separation. Sperm processing takes about 30-60 minutes.

Artificial Intrauterine Insemination

Step 4
Preparation of vagina and cervix. A speculum is placed in the vagina and the cervical area is gently cleaned.
Step 5
A sterile catheter is used to inject the sperm through the cervix into the uterine cavity. The washed specimen of highly motile sperm is placed either in the cervix (called “intracervical insemination” – ICI) or higher in the uterine cavity (called “intrauterine insemination”- IUI) using a sterile, flexible catheter.
The intrauterine insemination procedure, if done properly, is easy for woman and it should seem similar to a pap smear. The IUI procedure is generally painless although some women experience mild cramping. But IUI could be pretty emotional and stressful for woman and she should be properly prepared. There should be little or no discomfort.
Some clinics offer for the woman to remain lying down for minutes or hours after the procedure, although it has not been shown to improve success rates. The sperm has been put above the vagina and cervix and it should not leak out when you stand up.

Artificial intrauterine insemination (IUI) success rates

IUI success rates can be different in different cases and could vary considerably. IUI success rate depends on several important factors:

  • Age factor – age of the woman;
  • Ovulation status and/or type of ovarian stimulation for induced ovulation (if needed);
  • Duration of infertility;
  • Cause or causes of infertility;
  • Sperm quality – number and quality of motile sperm.

Age Factor
Female age and reduced ovarian reserve are a significant factor for IUI. Success rates for IUI in women over 35 is dramatically reduced. It is very low after 40.
Artificial intrauterine insemination (IUI) has less success chances in Women over 40 years old; Younger women with a significantly elevated day 3 FSH level; Significantly reduced ovarian reserve.

Ovulation Status
The rates are slightly higher for women that do not ovulate on their own (anovulation) that are stimulated to ovulate with medication and then inseminated. The sole cause of their infertility is likely to be the ovulation problem – which is hopefully overcome with the drugs.
According to many published studies, intrauterine insemination with partner’s sperm in conjunction with ovarian stimulation yields a higher pregnancy success rate than insemination in natural menstrual cycles (no ovarian stimulation).

Sperm quality
If the sperm count, motility and morphology scores are low, intrauterine insemination is unlikely to work. With significant male factor issues, IVF with ICSI is recommended and has a higher success rates for women under age 40.

IUI treatment cycles

Insemination is a reasonable initial treatment that should be utilized for a maximum of about 3-4 months in women who are naturally ovulating. It is reasonable to try IUI for longer than this in women with polycystic ovaries (PCOS) and lack of ovulation that have been given drugs to ovulate.
Most pregnancies resulting from insemination with the male partner’s sperm occur in the first 3 attempts (first 3 months of IUI). The chances for success rate per month drop off after 3 months (3 menstrual cycles) and it is drop considerably more after about 4-5 unsuccessful attempts. Therefore, IUI treatment is usually recommended for a maximum of about 3 or 4 tries.
If the reason for infertility is lack of ovulation, it may be reasonable to try more IUI cycles. However, many couples with fertility problems are ready to move on to IVF treatment after 3 IUI’s have failed.
In vitro fertilization is the next step in treatment after inseminations – with a much higher success rate per cycle.

Cervical or intrauterine IUI

The intrauterine insemination procedure is more effective than intracervical insemination. By placing the sperm higher in the female reproductive tract, more sperm will get to the area in the fallopian tube where they could have more chances to meet the ovulated egg.

IUI procedures during one menstrual cycle

There are many published studies that address this. Some studies show no improvement in pregnancy success rates with two inseminations done on sequential days as compared to one well-timed insemination. Other studies show higher pregnancy rates when two inseminations are done on back to back days.
A possible explanation for the different findings is that if single inseminations are not properly timed for ovulation, success rates would improve with a double insemination protocol. At least one of the 2 insems might be timed correctly.
Most fertility experts believe that one well-timed IUI is sufficient.

IUI timing

Any insemination should be carefully timed to occur at or a little before the time of ovulation. We know that in some couples, sperm can remain viable in the female reproductive tract and result in fertilization of an egg for five days (after having sex).
Eggs are fertilizable for only about 12-24 hours (maximum) after ovulation. Therefore, IUIs must be properly timed so that sperm show up for the date while the eggs are still viable.

IUI for male factor infertility

Studies have shown that intrauterine insemination can be effective for some cases associated with poor sperm quality. However, if the total motile sperm count at the time of insemination (after the processing) is less than 5 million, the chances for pregnancy are substantially lower.
If the total motile sperm count is below 1 to 5 million, success rates are very low. Therefore, in vitro fertilization with ICSI (injecting sperm into the eggs) is usually done for these cases.

IUI Risk factors

The risk for complications with intrauterine insemination is very low. The woman could develop an infection in the uterus and tubes from bacterial contamination that originated either in the semen sample, or through a contamination of the sterile catheter in the vagina or cervical area during the procedure. Careful cleaning of the cervix and cautious technique make this a rarity.

IUI with Donor Semen

In many cases, donated semen is required to achieve conception. These cases include:

  • couples in which the male partner has no sperm;
  • single women desiring conception;
  • same sex couples.

There are several donor semen banks in most infertility clinics. These banks provide written or online information regarding the age, race, ethnicity, health, education level and other characteristics of anonymous donors. All prospective semen donors are required to undergo testing for infectious diseases and if appropriate, certain genetic diseases, in order to have their semen used by a donor semen bank. The donors are re-tested six months after their first tests and must test negative for infectious diseases prior to release of the semen samples. This process of testing and repeat testing of donors prior to release of semen to prospective recipients is known as a quarantine process.

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