Intrauterine
Insemination (IUI)
In an IUI procedure,
the practitioner inserts specially treated sperm
through the cervix into the woman?s uterus. IUI
increases the likelihood of fertilization. This
procedure is performed around the time of ovulation.
In some cases, particularly if low sperm count
is a concern, two IUI procedures can be performed
several hours apart. IUI may use the partner's
sperm, or if indicated, sperm from a donor.
Intrauterine insemination
with partner's sperm can be used as a potentially
effective treatment for infertility of all causes
in women under about age 45 except for cases with
tubal blockage, severe tubal damage, very poor
egg quantity and quality, ovarian failure (menopause),
and severe male factor infertility. In vitro fertilization
with the woman's eggs or IVF with donor eggs are
alternatives for couples that are not candidates
for artificial insemination.
It is most commonly
used for infertility associated with endometriosis,
unexplained infertility, anovulatory infertility,
very mild degrees of male factor infertility,
cervical infertility and for some couples with
immunological abnormalities.
It is a reasonable
initial treatment that should be utilized for
a maximum of about 3-6 months in women who are
ovulating (releasing eggs) on their own. It can
be reasonable to use it for somewhat longer than
this in women with anovulation that have been
stimulated to ovulate.
It 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.
It has very little
chance of working in women that are over 40 years
old, or in younger women with a significantly
elevated day 3 FSH level, or other indications
of significantly reduced ovarian reserve.
If the sperm count,
motility or morphology is more than slightly low,
insemination is quite unlikely to be successful.
In that situation, IVF with ICSI is indicated
and has high success rates.
How
is insemination performed?
1. The woman usually
is stimulated with medication to stimulate multiple
egg development and the insemination is timed
to coincide with ovulation.
2. A semen specimen
is either produced at home or in the office by
masturbation after 2-5 days of abstinence from
ejaculation.
3. The semen is
"washed" in the laboratory (called sperm
processing or sperm washing). By this process,
the sperm is separated from the other components
of the semen and concentrated in a small volume.
Various media and techniques can be used to perform
the washing and separation, depending on the specifics
of the individual case and preferences of the
laboratory. The sperm processing takes about 20-60
minutes, depending on the technique utilized.
4. 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 5 minutes following
the procedure, although this has not been shown
to improve pregnancy rates. Since the sperm is
above the level of the vagina, it will not leak
out when she stands up.
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.
Rates for women over 35 drop off, and for women
over 40 are much lower. For this reason, we are
more aggressive in "older" women.
Pregnancy rates
are lower when insemination is used:
- in women over 40
- in women with poor with poor
quality sperm in women with moderate or severe
endometriosis
- in women with any degree
of tubal damage or pelvic scar tissue
- in couples with a long
duration of infertility (over 3 years)
The rates are slightly
higher for women that do not ovulate on their
own (anovulation) that are stimulated to ovulate
with medication and then inseminated. This is
because it is likely that the sole cause of their
infertility is their ovulation disorder - which
is overcome with the use of the ovulation stimulating
medicine.
For a couple with
unexplained infertility, the female age 35, trying
for 2 years, and normal sperm - we would generally
expect about:
5% chance per month of conceiving and delivering
with clomiphene and intrauterine insemination
for up to about 3 cycles (lower after 3 attempts)
8% chance per month of conceiving and delivering
with injectable FSH (e.g. Follistim, or Pergonal)
and insemination for up to about 3 cycles (lower
after 3 attempts)
50% chance of conceiving and delivering with one
cycle (month) of IVF treatment (at our center
- pregnancy rates vary greatly between IVF clinics)
Our IVF
pregnancy and delivery rates
Ovarian stimulation
with clomiphene citrate versus stimulation with
injectable gonadotropins (Pergonal or Follistim)
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 combined
with ovarian stimulation 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 more chance for a pregnancy. However, more
follicles and eggs also entails more risk for
multiple pregnancy. It is a double-edged sword...
How many
insemination cycles should be done?
Most pregnancies
with insemination using partner's sperm occur
in the first 3-4 attempts. The chances for success
per month drop off after about 3 attempts and
considerably more after about 4-6 unsuccessful
attempts. Therefore, this therapy is not usually
recommended for more than a maximum of 4-6 cycles.
If the reason for infertility is lack of ovulation
(anovulation) then it may be more reasonable to
try several more cycles (6-12 cycles total).
In vitro fertilization
is the next step in treatment after inseminations
- and has a much higher success rate per cycle.
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