Intrauterine Insemination (IUI)

IUI is a procedure in which sperm is directly introduced into the uterus by passing a small fine catheter through the cervix. The procedure may also be referred to as artificial insemination (AIH).

The sperm may be either fresh or frozen, but usually a fresh sample is used. The sample is “prepped” before treatment to obtain a high concentration of motile (active) sperm in a small volume of fluid.

Artificial insemination of your partner’s sperm (AIH) is an established method of treatment for some types of infertility. The use of donor sperm (AID, or DI) is also a widely used treatment when the partner has no sperm in his semen at all.

You may wonder why simply inseminating your partner’s sperm into the uterine cavity might increase your chance of success.

There are a number of reasons why IUI may improve your chances:

• This technique enables us to put much larger numbers of sperm inside the uterine cavity, close to the opening of the tubes, than would ever occur naturally.  A large proportion of the sperm in a man’s ejaculate never passes from the vagina, through the cervix, and into the uterine cavity.  Obviously, the larger the number of sperm that reach the uterine cavity, the greater the chance for fertilization.
• The IUI procedure is most often carried out in association with specific medications (gonadotrophins) designed to stimulate the ovaries to work more efficiently and produce two or three follicles in a cycle.
• With IUI treatment, the treatment is carefully timed so that the procedure is carried out precisely at the time of ovulation. You will have a “trigger” injection to initiate ovulation. By doing this, I am able to pinpoint the time of ovulation very precisely. By co-ordinating the time of your IUI at the moment of ovulation we are further able to improve the chances of a successful conception occurring.

IUI, Step by Step

Having completed the necessary preliminary tests and investigations, you will begin the IUI treatment at the start of your cycle. You will generally begin your injections on Day 3. You will need to have had a brief nurse interview on your first injection day to teach you how to give these injections.

Your progress is determined by studying the growth of the ovulation follicles in your ovary using ultrasound (a “scan”). You may require 2, or occasionally even 3 scans during this time. On the basis of the size of the follicles seen in your ovary on these “scans”, I am able to predict accurately when ovulation is going to occur. When ovulation is almost ready to happen (when the follicle(s) have grown to 18-20 mm), I will ask you to have an injection of a special hormone designed to “trigger” the ovulation process.  The IUI procedure will then be scheduled ~36 hours after the time of the “trigger” injection.  To be sure that you do not have a natural ”surge” of the ovulation hormone before you reach the time of your injection, I may ask you to test your urine each day, using special urine testing strips.

As previously discussed, the IUI procedure itself is relatively simple one, performed as an “outpatient”. The procedure will usually be carried out at Melbourne IVF in East Melbourne. You will not require any anaesthesia, or admission to hospital.  Because the “sperm prep” takes a considerable time to complete in the laboratory it will be necessary for your partner to provide his semen sample at least one hour before the scheduled time of the IUI. Your partner is welcome to remain after the semen sample is provided and be with you during the procedure. It is not essential, however.

First, a speculum is inserted into the vagina, as we would for a Pap smear. A very fine soft plastic tube (about 2-3 mm) is then gently passed through the opening of the cervix. The volume of the “prepped” sperm introduced into the uterus is approximately ½ ml (less than ¼ of a teaspoon). The procedure takes only a few minutes and is usually painless. Occasionally, spasms of the uterus may occur, but it is uncommon for these to be painful or to require treatment. No special precautions need to be taken after an IUI procedure. You should be able to return to your normal duties immediately following the procedure.

What are there risks of IUI treatment?

AIH is a relatively simple method of treatment with minimal risk. There are two potential areas of risk and complication.

1.  Risk of the insemination procedure itself

The technique of uterine insemination involves passing a tiny, fine catheter through the cervix and into the uterus. This does not require admission to hospital, or anaesthesia. For the majority of women it is a procedure that should be no more uncomfortable than a smear test. In a very small group of women, however, the procedure does cause more severe period pain. Occasionally, the woman may even experience a vasovagal (fainting) reaction.

IUI does have the potential to cause a small amount of bleeding from the uterus, but this is also very rare. It is also possible to introduce infection into the uterus when performing IUI.

If either the woman or the man happened to be a carrier of AIDS or hepatitis (or indeed any other as yet unrecognised viral disease) the IUI procedure might have the potential to transmit that infection to the developing embryo. It is for this reason that I will ask both partners to be screened for these conditions before commencing treatment.

2.  Risks associated with the use of the ovarian stimulating hormones (gonadotrophins)

There are two potential ways that these hormones might cause complications:

a) Risk of multiple pregnancy

The purpose of these hormones is to stimulate the ovaries to work strongly and efficiently. This may cause the formation of two or possibly even three ovulation follicles. Clearly, if two follicles were formed and the egg from each of these follicles was fertilised, then twins would be created. I will cancel a cycle if the ovaries respond in an excessive fashion and would certainly do so if more than three follicles formed.

b) Side-effects of the hormone therapies

Gonadotrophins have relatively few side-effects and are generally well tolerated. They must be given by injection, and may very occasionally cause mild allergic reactions at the injection site. They may also cause mild headaches.

Most of the “side-effects” associated with these hormone therapies are not so much side-effects from the medication itself, but rather the effect that they have on the ovaries causing enlargement of the ovary and increased production of oestrogen and progesterone hormone. You may, for example, experience some breast soreness and mild nausea. You may very possible experience some ovary (ovulation type) pain during the brief time you are on therapy. The effects are completely reversible.

In very rare cases the ovaries may unexpectedly respond excessively. Multiple follicles may then develop in the ovary causing Ovarian Hyperstimulation Syndrome (OHSS). This is a serious complication, which although completely reversible, might necessitate admission to hospital. OHSS is very unlikely to occur with the small doses used in IUI.

Success rates

Various studies have quoted very different success rates for IUI treatment and this is one of the reasons why there is some controversy about the place of IUI in infertility treatment. Results are rarely ever as good as with IVF. Clinical studies of IUI report success rates (the chance of pregnancy per cycle of treatment) of between 6% and 25%. In our unit success rates of between 10-12% per cycle are more common.  While this figure may possibly seem small to you, it is important to remember several key facts:

• These success rates quoted to you are success rates per cycle. Your chances of achieving a pregnancy over time, and a number of cycles of treatment, are cumulative and much greater than 10-12%.
• The best chance that any couple, without fertility problems, has of achieving a pregnancy in any one cycle is only about 20-25%. A couple who has been trying to achieve a pregnancy for two years without success have a natural chance of conception of ~5% per cycle.  After three years their natural chance of conception is ~3%.

IUI techniques do, therefore, provide a relatively simple method of infertility treatment which may increase your chances of pregnancy by as much as a factor of 4 or 5, depending on how long you have been trying to become pregnant. IUI treatment does have the advantage, when compared to IVF, of being somewhat simpler to perform, and is certainly cheaper.  Conception still occurs in a perfectly normal and natural fashion and IUI treatment might, therefore, be acceptable to some couples who would not be able to consider IVF treatment for religious or ethical reasons.

The controversies

1. The place of controlled hyperstimulation. (using injections to stimulate the ovaries)

There is some debate around the world about the place of controlled ovarian hyperstimulation in association with IUI treatment.  There are certainly some situations where we do not believe that it should be automatically used.  When IUI is being performed because of sexual dysfunction we think it is not always necessary.  The same applies when AID (donor sperm) is being performed.  For most other causes of infertility, however, controlled ovarian hyperstimulation is normally used.  It is almost universally used in the Melbourne IVF programme except for the clinical situations mentioned previously.

It is important for you to understand that most of the studies that have been performed around the world have used COH and the success rates quoted to you here are where controlled ovarian hyperstimulation has been used.  It is much more difficult to know what the success rates are without COH, but they are certainly likely to be considerably lower.

2. The place of the sperm “prep”

It is possible to perform an IUI treatment using sperm freshly produced by your partner without having any special laboratory sperm treatment. However, there are several reasons why the sperm “prep” is highly preferable:

• A man’s normal ejaculate volume may be as much as 4 or 5mls. It is certainly not possible to put 5mls of fluid into the uterus. When fresh sperm is used, therefore, only a portion of the ejaculate (and therefore only a portion of the total number of sperm) can be inseminated into the uterine cavity.
• The sperm “prep” washes away many of the powerful hormones found naturally in semen. The presence of these hormones may cause very strong uterine contractions when an IUI procedure is performed with fresh “non-prepped” sperm. Sometimes the response is so strong that the woman experiences a vaso-vagal response (collapse).

Despite these apparent advantages, it is true that there has been very little scientific study to prove the value of the sperm “prep”.  The use of a sperm “prep” does complicate the scheduling of your IUI procedure.  Because the sperm “prep” has to be performed at our IVF laboratory this means that you must attend the hospital for your IUI procedure. There are also some scheduling restrictions. At the present time, we are unable to perform IUI procedures before 10.00am. Your partner is welcome to produce his sample before this time, however. At the present time, no IUI procedures are performed on the weekend.  If it works out that your cycle is such that you will be likely to ovulate during the weekend, it will be necessary for you to use a special antagonist injection that will defer ovulation for twenty-four or a maximum of forty-eight hours.  You will be required to pay for this antagonist injection as a further out-of-pocket expense.  Please refer to the Melbourne IVF IUI costs for more detail.

3. The place of IUI. (IUI versus IVF?)

There are certainly several clear attractions to the AIH procedure.  It is certainly somewhat simpler to perform than an IVF cycle although, as you can see, it is still quite a detailed treatment cycle involving daily injections, regular scans, and a visit to the hospital for the AIH procedure itself.  There are two clear differences between IUI and IVF.

• No egg collection procedure is required, such as is necessary with an IVF cycle.
• Fertilization still occurs naturally in the fallopian tube, just as would occur with normal conception.

There is much discussion and debate around the world about the place of IUI treatment in comparison to IVF. Opinions range from doctors who believe that it should be virtually compulsory that IUI treatment be carried out before proceeding to IVF, to others would argue that the success rates with IVF are so much higher that it is unreasonable not to expect and allow patients to proceed directly with this treatment.

Human embryo development (day 2)