Intrauterine insemination (IUI) is sometimes recommended for the treatment of infertility unrelated to obstructed or damaged tubes, mild to moderately severe male factor infertility, “unexplained” infertility, and infertility due to immunologic causes or cervical mucus abnormalities.
To prepare for IUI, the woman is given fertility agents to promote the development of multiple follicles (fluid-filled spaces within the ovary that contain eggs). A masturbation specimen of semen is repeatedly washed and centrifuged to separate the milky-seminal fluid (which compromises 98% of the semen sample) from the sperm. The sperm is subjected to laboratory procedures which “enhance” fertilizing potential and reconstituted in a uterine friendly media. The “enhanced” sperm sample is drawn into a thin catheter and the sperm is injected past the cervix into the uterus a few hours prior to anticipated ovulation (IUI). If you choose, on the following day, a few hours after ovulation has occurred, a second specimen of “enhanced” sperm can be injected.
IUI is unlikely to result in an acceptable pregnancy rate when used for the treatment of severe male factor infertility when the male has less than two million living sperm. In vitro fertilization and embryo transfer (IVF/ET) combined with intracytoplasmic sperm injection will achieve much better pregnancy rates.
Preparation for Cycle of Treatment
Prior to the performance of IUI, both partners should be investigated to exclude infection, hormonal imbalance, sperm abnormalities, and anatomical abnormalities of the reproductive tract. The latter can best be assessed through the performance of a hysterosalpingogram-HSG (a dye x-ray test of tubal patency) and/or laparoscopy (the introduction of a telescope-like instrument into the pelvic cavity of the anesthetized woman, that allows direct visualization of pelvic anatomy).
IUI requires prior administration of fertility agents, which may be either oral drugs or the more potent injectable agents (gonadotropins). With oral drugs (clomiphene and femera), the pregnancy rate per cycle will be about 5-10 %, whereas with gonadotropins, the rate is 15-20 % per cycle. The results of either are highly dependent on the patient’s age, and may be as low as 5% in women over 40 years of age.
Because of the expense of IVF, some couples choose to have one or more cycles of IUI before embarking on IVF, a much more effective procedure. Most clinics do not do more than 3 or 4 cycles of IUI before moving on to IVF.
Controlled Ovarian Hyperstimulation, superovulation – administration of fertility agents to promote the development of multiple mature follicles and eggs
During each natural cycle, a number of eggs start the maturation process. About five or six days after the menses start most of the eggs undergo atresia (death) and are resorbed back into the woman’s body. The use of fertility drugs is to induce multiple ovulations and enhance the probability of pregnancy. Placing the sperm in the uterus allows the sperm to get as close to the eggs as possible.
Sperm Enhancement and Preparation
About 30 to 36 hours after hCG has been given a fresh specimen of semen is prepared for insemination. To acquire optimum fertilizing ability, sperm must first be separated from the seminal fluid through repeated washing and centrifugation, and be subjected to laboratory “enhancement”procedures,which initiates a process called “capacitation.” “Capacitation,” which normally begins in the cervical mucus and continues as sperm pass through the uterine and tubal environment, involves intracellular changes as well as alterations on the surface of the sperm head. In the laboratory, sperm capacitation is accomplished by incubating the separated sperm in a specially prepared culture media.
Intrauterine Insemination – prior to ovulation
At a specified time of the cycle, about 30 to 36 hours after the hCG injection, a masturbation specimen of semen is subjected to some or all of the “enhancement” procedures described above. An “enhanced” sperm specimen is drawn into a catheter, which is passed through the cervix into the uterine cavity where it is deposited. This procedure is referred to as intrauterine insemination (IUI) and usually is painless.
- The pregnancy tests:
About 14 days after the final insemination, a blood or urine test is performed to measure the amount of human Chorionic Gonadotropin (hCG) in the woman’s blood. The presence of significant amounts of this hormone indicates that implantation has been initiated. These tests are referred to as a quantitative beta-hCG assay or a urine pregnancy test. In some cases, the pregnancy test will have to be repeated a few days later in order to confirm that hCG levels are rising, and that the pregnancy is implanting properly
- Hormonal support:
Some patients it may be advised to add vaginal or injectable progesterone to supplement the luteal phase of the cycle.
- Ultrasound diagnosis of a clinical pregnancy:
A vaginal ultrasound examination is performed about three weeks after the positive pregnancy test to ascertain the normalcy, number, and the location of any existing conception.
Anticipated Success Rates with IUI:
We currently have a 15- 20 % pregnancy rate with gonadotropins followed by IUI and 7 % when clomiphene is used. The best success rates are achieved in young couples (less than 35) with “unexplained infertility” and in cases of cervical mucus insufficiency. Poorer success rates are obtained in cases of male infertility when there are less than a total of 2 million motile sperm. Couples who fail to conceive within 3-4 attempts at IUI should seriously consider IVF/ET.
Intrauterine Insemination with Donor Sperm (Therapeutic Donor Insemination)
Donor insemination using sperm derived from a donor unrelated to the husband has been used for many years, and is an accepted practice throughout the world. This practice has made childbearing possible for many women who would otherwise not be able to achieve motherhood. The most common indication for use of donor semen is the absence of sperm in the husband’s semen or severe oligospermia, although a rare male may have a severe genetic disorder that he does not want to transmit to his progeny.
The increased prevalence of HIV (Aids) and various other sexually transmitted diseases, including hepatitis, chlamydia, syphilis and gonorrhea have greatly complicated the practice of donor insemination throughout the world. It is well documented that a male may become infected with HIV and transmit it to sexual partners for up to four months before the standard antibody tests become positive. Sadly, the infectious agents for all these diseases survive freezing in liquid nitrogen for many years, further complicating the problem. Because of this, all modern sperm banks test the potential donor extensively, and if tests are negative, several semen samples are collected and frozen in liquid nitrogen. After six months quarantine, the donor is tested again and if all tests are again negative, the samples are released for use. While these procedures make the process somewhat cumbersome, it at least assures almost complete safety for the recipient woman.
In addition to infectious disease testing, the donor provides a three-generation genetic history, and some genetic testing is done, although it is impossible to test for every potential problem. Donors are rejected for any abnormal genetic condition in the close family, including psychiatric illnesses, alcoholism, etc.
The next hurdle is a semen analysis on the donor. The male must have, at least, a normal semen analysis, and the sperm must survive freezing.
Most sperm banks supply a donor list that includes the physical characteristics, education, occupation, etc. of the donor, and the couple decides which donor is suitable for them. All donors sign a release which disavows any interest or ownership of the sperm. Some states, including North Carolina, make the husband the legal father of any resulting child or children.
The process of insemination is simple and painless. In natural cycles, the woman monitors her cycle with one of the ovulation detection kits, and the insemination is done within twelve hours from the detected surge.
The expected pregnancy rate for each cycle depends on age and other complicating factors, but the rate declines with advancing age. For a young, healthy woman (less than 35 years) the rate should be about 20% per cycle.
Some clinics accept only married women, but it has been the practice of NCCRM for many years not to discriminate against single women.
If some abnormality is suspected in the woman, more testing is done before embarking on treatment, and it is common to have the woman’s tubes proven to be normal before starting therapy.
For those women who do not become pregnant after six or more cycles, further testing is done, and it may be necessary to use fertility drugs in order to achieve pregnancy.
The physicians at NCCRM have been involved with donor insemination for many years and have never seen a couple or single mother who were unhappy with their choice. Indeed, it is a way to achieve parenthood in an otherwise hopeless situation.