IntraUterine Insemination (IUI)
by Richard Sherbahn, M.D.

Indications for insemination

Insemination with partner’s sperm can be used as a potentially effective treatment for infertility of all causes in women under age 43 except in cases of tubal blockage, severe tubal damage, very poor egg quality, ovarian failure (menopause), and severe male factor infertility.
Insemination is most commonly used for infertility associated with endometriosis, unexplained infertility, anovulatory infertility, mild degrees of male factor infertility, cervical infertility and for some couples with immunologic abnormalities. It is a reasonable initial treatment that should be utilized for a maximum of about six months in women who are ovulating (releasing eggs) on their own. It is reasonable to use insemination for somewhat longer than this in women with anovulation that have been stimulated to ovulate.
Insemination should not be used in women with blocked fallopian tubes. Tubal patency should be demonstrated prior to performing insemination. This is usually done with an x-ray study called a hysterosalpingogram. Insemination has very little chance of working in women that are over 42 years old or with very poor sperm or egg quality.

How is insemination performed?

The woman usually is stimulated with medication to stimulate multiple egg development and the insemination is timed to coincide with ovulation.
A semen specimen is either produced at home or in the office by masturbation after 2-5 days of abstinence from ejaculation.
The semen is washed, and the sperm is separated from the other components and concentrated in a small volume. Various media and techniques can be used to performs the washing and separation, depending on the specifics of the individual case.
The separated and washed specimen consisting of a purified fraction of highly motile sperm is placed either in the cervix or high in the uterine cavity using a very thin, soft catheter. Most programs have the woman remain lying down for 15-30 minutes following the procedure, although this has not been reported to improve pregnancy rates. This procedure, if done properly, usually seems similar to a pap smear for the woman. There should be little or no discomfort.

Pregnancy Rates

Success rates for intrauterine insemination vary considerably and depend on the age of the woman, type of ovarian stimulation (if any) used, duration of infertility, cause of infertility, number and quality of motile sperm in the washed specimen, and other factors.
Ovarian stimulation with clomiphene citrate versus stimulation with injectable gonadotropins
Although there is not universal agreement in published studies or among infertility experts, intrauterine insemination with partner’s sperm in conjunction with ovarian stimulation seems to provide higher pregnancy rates than insemination in natural menstrual cycles (without ovarian stimulation). Insemination with injectable gonadotropins provides better pregnancy rates (and higher multiple pregnancy rates) as compared to insemination combined with clomiphene. Injectable gonadotropins usually stimulate more mature eggs to develop than does clomiphene. More mature follicles and eggs leads to a better chance for a pregnancy.
In general, published reports show monthly pregnancy rates for unexplained infertility of about 5-10% per cycle for clomiphene stimulation with insemination and about 15% per month for injectable gonadotropins with insemination. The rates are higher for women that do not ovulate on their own (anovulation) that are stimulated to ovulate with medication and then inseminated. Pregnancy rates are lower when insemination is used:

• In women over 40
• In women with poor egg quality
• With poor quality sperm
• In women with moderate or severe endometriosis (
• In women with tubal damage

How many insemination cycles should be done?

Most pregnancies with insemination using partner’s sperm occur in the first three to four attempts. The chances for success drop off considerably after about four to six unsuccessful attempts. Therefore, this therapy is not usually recommended for more than a maximum of 6 cycles. If the reason for infertility is lack of ovulation (anovulation) then it is more reasonable to try several more cycles.

Cervical vs. intrauterine insemination

Intrauterine insemination has been shown to be more effective than intracervical insemination.

Stimulation with injectable gonadotropins plus insemination vs. in vitro fertilization

Studies have compared the effectiveness of these two therapies for unexplained infertility. Pregnancy rates are improved substantially with either method of therapy as compared to no treatment. Chances for pregnancy are better with in vitro fertilization as compared to gonadotropins plus insemination.
However, IVF involves a minor surgical procedure to obtain the eggs and is much more expensive than insemination. Therefore, unless the couple has severe tubal damage or very poor sperm quality, three to six insemination cycles are usually attempted before moving on to in vitro fertilization.

Should one or two inseminations be done per cycle?

There are several published studies that address this issue. Some studies show no improvement in pregnancy rates with two inseminations done on sequential days as compared to one well-timed insemination. Other studies show significantly higher pregnancy rates when two inseminations are done. A possible explanation for this discrepancy could be that if the single inseminations are not properly timed with respect to ovulation, pregnancy rates should improve if the two insemination protocol provides at least one insemination with appropriate timing.

Any insemination should be carefully timed to occur at or a little before the expected time of ovulation. We know that, at least in some couples, sperm can remain viable in the female reproductive tract and result in fertilization of an egg for five or more days. However, we know from in vitro fertilization that eggs are fertilizable for only about 12-24 hours post-ovulation. Insemination done 24 hours after ovulation is, therefore, very unlikely to result in fertilization and pregnancy (although they might conceive if intercourse occurred earlier that cycle). Even if two inseminations per cycle would result in a small improvement in pregnancy rates, the additional cost and inconvenience for the woman is probably not warranted. If the couple is not very concerned about cost or the number of office visits, two inseminations might increase their monthly chances for pregnancy.

Insemination for male factor infertility

Studies have shown that intrauterine insemination can be effective for some cases associated with poor sperm quality. If the total motile sperm count at the time of insemination is less than five million, the chances for pregnancy are significantly lower than with higher counts. If the total motile sperm count is below one million, success rates are extremely low. Therefore, in vitro fertilization or donor sperm insemination is usually performed for these cases. However, sperm counts are not perfect predictors of fertilizing potential. Rare pregnancies can occur even with total motile counts of less than one million.

Cost

Charges for insemination with partner’s sperm, including the semen processing vary considerably between infertility programs. The general range is from about $150 to $600. Ultrasound and blood tests, if needed, are additional.