Intrauterine Insemination (IUI) & Artificial Insemination
What is IUI?
IUI stands for intrauterine insemination. It is sometimes called artificial insemination as well. Essentially, IUI is a technique to directly place sperm into the uterus.
Who needs IUI?
IUI is a technique to overcome a variety of mild fertility problems, many of them on the male side. IUI is also often performed in cases of so-called "unexplained" infertility by many fertility specialists. Since CHR does not believe that "unexplained infertility" really exists (we believe that in "unexplained infertility" cases, something important has been overlooked during diagnosis), we don't routinely use IUIs for this purpose at CHR. Male infertility indications for IUI are:
- Low sperm count (there are not enough sperm for a decent chance of natural fertilization)
- Low sperm motility (sperm doesn't have normal ability to swim up to the egg)
- Cervical factor infertility (cervical mucus inactivates sperm motility)
- Sexual dysfunction
When the male partner's sperm count is low, his sperm have a lower chance of fertilizing the egg, simply because there aren't as many sperm. Similarly, when the male has sperm that has too little "motility" to swim on its own up the vagina, uterus and fallopian tube to the egg, sperm is unlikely to reach and fertilize the egg. By placing sperm directly into the uterus by an IUI, the greatest barrier--the mucus in the cervix--is bypassed, and sperm does not have as far to travel to meet the egg in the fallopian tube. Therefore, more sperm reaches the egg, creating a better chance of fertilization for the egg.
IUI is also used when patients use donor sperm. CHR works with reputable sperm banks where patients can select and procure semen samples for this purpose. IUI with donor sperm is called donor insemination. Donor inseminations become necessary when the male does not produce even minimal amounts of sperm, and semen extraction procedures (TESE, for example) fail. Donor inseminations are also routinely used when single women wish to conceive on their own.
How does IUI work?
IUI is usually combined with ovulation induction, a process in which a woman's ovaries are mildly stimulated. Mild ovarian stimulation is a good idea in an IUI cycle, because ovarian stimulation encourages the ovaries to produce more than one mature egg. (In a natural menstrual cycle, only one egg matures and gets released from the ovary.) Having more than one mature egg means that the sperm used in IUI have a better chance of "meeting" an egg and fertilizing it. Ovulation induction with IUI, however, also creates a risk for multiple births.
Ovulation induction means that in the weeks leading up to IUI, the female patient takes medications to make her ovulate. This can be clomiphene citrate (Clomid) in oral tablet form, or a group of medications called gonadotropins, which are injected. Clomid represents the mildest form of ovarian stimulant, though Clomid can have some unpleasant side effects. At CHR all patients undergoing ovulation induction are monitored: the growth of ovarian follicles (fluid-filled sacs that contain eggs) is monitored by vaginal ultrasound, and hormone levels are checked by blood tests.
When the ovaries have a good number of mature eggs, a hormonal injection (hCG) is used to trigger ovulation (release of the eggs from the ovaries). This injection determines when the patient ovulates. Inseminations are timed accordingly. At CHR, we inseminate twice every month in most cases, once just before, and a second time just after ovulation on consecutive days.
What are the risks of IUI?
The main risk for IUI is the risk of multiple gestations, especially of high-order multiples (triplets or more). This is an inherent risk that is extremely difficult to avoid. The difficulty lies in the fact that the physician does not have good control over how many eggs are released at the time of ovulation, and how many of those eggs are fertilized by the semen from the IUI. Physicians try to strike the right balance between good pregnancy chance and a low risk for multiple gestations, but even in best of hands, high-order multiples will happen.
Indeed, some years ago physicians from CHR published a classic paper on the subject in the prestigious New England Journal of Medicine (Gleicher N et al., Reducing the risk of high-order multiple pregnancy after ovarian stimulation with gonadotropins. N Engl J Med 2000;343:2-7). This study demonstrated well that, even with best precautions, with IUI, there is simply no way to control the number of eggs that are available for sperm to fertilize, and the number of eggs that actually do get fertilized. CHR researchers concluded in the paper that a high level of control over the multiple birth risk is only possible through in vitro fertilization (IVF). As a consequence of this paper, the practice of infertility has changed significantly, with the number of IUI cycles declining and number of IVF cycles increasing worldwide.
Fertility practice has come to try to avoid multiple births, especially high-order multiples, because they carry elevated risks, especially of premature delivery. The goal of good infertility treatment is, of course, not only to achieve pregnancy but to achieve pregnancy responsibly, and with as low a risk as possible to mother and newborn children.
Should I choose IUI or IVF?
For many fertility patients, IUI is the gateway to infertility treatment. IUI can be a good starting point if:
- The female partner is young—under age 35
- Ovarian reserve is normal for your age
- Cause of infertility is a mild male cause
- You don't mind having twins
This treatment decision, however, does not always make clinical sense, especially if:
- The female partner is over age 35
- Ovarian reserve is low (indicated by high FSH and/or low AMH)
- Cause of your infertility is a severe male factor
- You want to avoid multiple gestations
IUI is not recommended for women who are over 35, or women with low ovarian reserve. Older women and women whose ovarian function has already started declining should go straight to IVF, because their remaining time of reproduction with use of their own eggs is likely to be short. IUI's lower pregnancy rates, compared to IVF, means that more cycles of IUI will be necessary for conception. If you don't have the luxury to "wait and see," your best option is probably IVF.
Similarly, if the male partner has severe male-factor infertility, IUI is not the best option. In severe male infertility, sperm may need to be microsurgically injected into the eggs, in a procedure called intracytoplasmic sperm injection (ICSI). Even when there is no sperm in the ejaculate, in about 80-85% of cases, our urology colleagues can extract sperm from the testicles, which can then be used in ICSI (but not in IUI). For couples with severe male-factor infertility, IVF combined with ICSI is often a better (and sometimes the only) option.
Is IUI less costly than IVF?
Many patients choose IUI over IVF, thinking that IUI is more cost-effective than IVF. Insurance policies tend to offer more generous coverage for IUI than IVF, for the same (somewhat wrongheaded) reason. Although IUI cycles, indeed, are less costly on a per-cycle basis, IUI cycles aren't any more cost-effective, because of IUI's much lower pregnancy rates. Indeed, a number of recent studies concluded that, at least in many patients, going straight to IVF, skipping the interim step of up to four IUI cycles as previously suggested, represents a more cost-effective approach. It certainly represents a more time-efficient approach!
The right question, therefore, is not "is IUI less expensive than IVF?" but "is IUI more cost-effective than IVF?" And the answer, sometimes, is a definite "no".
Is IUI less invasive than IVF?
There are a lot of fears circulating when it comes to IVF. Many of these fears, if not most, are completely unwarranted. Because of these misconceptions, some patients are hesitant to proceed to IVF for all the wrong reasons, and feel more comfortable with IUI. One important aspect that these patients overlook is that at least once they reach ovarian stimulation with gonadotropins (after the Clomid phase), IUI and IVF cycles are very similar: Both require daily self-injections; both require monitoring with ultrasound and blood testing; both take between 2-4 weeks. The only difference is that the IVF cycle requires egg retrieval under intravenous sedation.
Contrary to widely distributed misinformation, egg retrieval is not a surgical procedure. While performed while the patient is asleep (not with a general anesthetic; just an I.V. sedation, administered by an anesthesiologist), egg retrieval involves no incisions whatsoever! Egg retrieval involves only the aspiration of follicles through the vagina with a long needle. It is not that different from a blood draw.
So, yes, because of egg retrieval, IVF has to be considered a little bit more "invasive," but as most patients who have gone through both kinds of experiences will tell you, the difference is minimal. When deciding on your fertility treatment, we, therefore, recommend that you thoroughly review your options with your fertility doctor, including IUI and IVF, and ask the right questions!
Donor Insemination is akin to artificial insemination and involves many of the same processes as in Intrauterine Insemination (IUI). The difference is that in donor insemination, the semen sample comes from a donor. CHR works with reputable sperm banks from which such donor semen samples are procured by the patient for artificial insemination.
Procedures like donor insemination and IUI are generally recommended to accompany ovulation induction cycles to increase pregnancy chances.
Last Updated: November 15, 2014