Intrauterine Insemination (IUI)

In general, IUI is a reasonable initial treatment that can be attempted for a maximum of about 3-4 months in women who are ovulating (releasing eggs) on their own.

For women with polycystic ovaries (PCOS) or those that are not ovulating and have been given drugs to ovulate, it may be reasonable to try IUI longer (up to 6 months). 85-90% of patients who will successfully conceive using ovulation induction with IUI will do so within 4-6 cycles (months of treatment).

If superovulation (i.e. Clomid) with IUI is unsuccessful, options for more aggressive treatment include ovulation induction (with injectable gonadotropins) with IUI versus proceeding directly to IVF. In many cases, given that the success rates with ovulation induction and IUI are not that much better when compared to clomid and IUI, the most effective path towards success may be to pursue IVF directly.

Any insemination should be carefully timed to occur at or a little before the time of ovulation. Sperm can remain viable in the female reproductive tract and result in the fertilization of an egg for up to five days (after having sex). However, eggs are fertilizable for only about 12-24 hours (maximum) after ovulation during the time they are moving through the fallopian tubes. Therefore, IUIs must be properly timed so that sperm are present in the fallopian tubes at the same time as the egg.

There are many published studies that address whether one or two inseminations should be performed in order to facilitate the egg and sperm meeting in the fallopian tube. 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 consecutive days. One 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 inseminations might be timed correctly. However, most fertility experts believe that one well-timed IUI is sufficient.

At Advanced Fertility Care we perform both single and double inseminations based mostly on the development of the follicle and endometrial lining as well as logistical considerations. For patients using donor sperm purchased through a sperm cryobank, the doctor will recommend a single well-timed IUI in order to minimize the cost to the patient for multiple vials of sperm which can run between $300 to $500 per vial. The cost of the actual cycle varies depending on the medication used and the amount of ultrasound and blood monitoring being done. Click here to see pricing.

The amount of monitoring with IUI or artificial insemination varies based on the type of cycle:

Natural Cycles with IUI

Natural cycles with IUI have the least amount of monitoring, In these cases, either over-the-counter LH predictor kits are used to determine when ovulation occurs and the IUI is timed accordingly. Alternatively, an ultrasound can be performed between cycle days 11-14 to determine if a mature follicle has developed, and subsequently, HCG is administered which will cause ovulation to occur within 36-44 hours. Then the insemination(s) are scheduled. Progesterone vaginal supplementation is then started one day after the IUI and continued for 12-14 days until the pregnancy test. If the pregnancy test is negative, the progesterone must be stopped in order to allow for the period to occur.

Clomid Cycles

Clomiphene citrate (Clomid) cycles have slightly more monitoring. An ultrasound is performed on cycle days 2, 3, or 4 in order to confirm that no ovarian cysts are present prior to starting the Clomid. Taking Clomid in the presence of cysts can lead to an abnormal response and the enlargement of already present cysts. The woman then takes Clomid either 50 to 150 mg daily for five days. A mid-cycle (days 11-14) ultrasound is performed to determine if and how many mature follicles (measuring 20-24mm) are present and also evaluate the endometrial lining. In 10% of women, the anti-estrogen effect of Clomid can cause unexpected thinning of the endometrial lining which is detrimental to the implantation of an embryo. If this persists over two or more attempts, Clomid may not be an appropriate treatment option. Once mature follicles are present, HCG is administered and the IUI(s) will follow within 24-48 hours, once again followed by the use of vaginal progesterone. The risk of a multiples pregnancies with Clomid is approximately 8% with the majority being twins.

Gonadotropin Cycles (Fertility Shots)

Gonadotropin cycles (fertility shots) increase both medication costs and the necessity of ultrasounds and bloodwork. In these cycles, a baseline is once again performed between cycle days 2 through 4 to confirm no cysts being present. At this point, the injectable medication is started. Multiple days of ultrasounds and blood hormone levels will follow in order to closely follow the growth of the follicles and assure that the ovaries do not over-stimulate (ovarian hyperstimulation syndrome) and that too many follicles are not present. One of the risks for this type of stimulation is that of higher-order multiples. If multiple follicles are developing, the risk of higher-order multiples (triplets and above) increases. The overall risk of multiples with gonadotropins is approximately 20% and the presence of too many follicles (greater than 4-5) may prompt the cancellation of the cycle. Many people are unaware that the majority of higher-order births (triplets and above) are a result of gonadotropin/IUI treatments that are not managed and canceled appropriately. It is a misconception that these higher-order births are a result of IVF; IVF provides a much more controlled treatment limited to the number of embryos being transferred. Once a reasonable number of mature follicles are noted (between 1 to 4), the HCG trigger shot is given followed by the insemination(s). Once again this is followed by progesterone vaginal support.

IUI (artificial insemination) is not recommended as an effective treatment for couples with:

• Tubal blockage or severe tubal damage
• Diminished ovarian reserve (high FSH) or ovarian failure (menopause)
• Severe male factor infertility – If the sperm count, motility and morphology scores are significantly abnormal, intrauterine insemination is unlikely to work. For example: if the total motile sperm count at the time of insemination (after the processing) is less than 10 million, the chances for pregnancy are substantially lower. In these cases, IVF in vitro fertilization with ICSI (injecting sperm into the eggs) is the best treatment option.Advanced stages of endometriosis
• Advanced female age (>40 years old) – More aggressive treatment with IVF or donor egg IVF is recommended for these patients.

IUI or artificial insemination treatments are used together with ovulation induction medications for the treatment of many diagnoses. IUI can be an effective treatment for patients with:

• Patent (open) fallopian tubes
• Cervical factor – abnormalities of cervical mucus or cervical canal
• Some ovulatory abnormalities – irregular menstrual cycles, PCOS
• Absence of or minimal endometriosis (Mild or Stage I-II Endometriosis)
• Mostly normal sperm evaluation
• Complete absence of sperm in the male (azoospermia) requiring donor sperm IUI. Advanced Fertility Care Physicians will outline the necessary female testing and provide a list of FDA-approved sperm banks throughout the country from where donor sperm can be purchased and sent directly to our Center.
• LGBTQ couples with no sperm providers or single women– IUI with donor sperm is the optimal means to achieve pregnancy.

The intrauterine insemination procedure does not hurt. It will feel a lot like a pap smear and there should be little or no discomfort. At Advanced Fertility Care, patients should plan to remain lying down with elevated hips for ten minutes after the insemination at our office. After ten minutes, you are free to go and resume normal daily activities.