Indication of IUI

The IUI procedure can be an effective treatment for some causes of infertility in women under about age 41. However, it is not effective for couples with:

• Tubal blockage or severe tubal damage
• Ovarian failure (menopause)
• Severe male factor infertility
• Advanced stages of endometriosis

Artificial insemination should not be used in women with blocked fallopian tubes. The tubes are often checked out with an x-ray test called a hysterosalpingogram.

Female age is a significant factor with IUI. Intrauterine insemination has very little chance of working in women over 40 years old. IUI has also been shown to have a reduced success rate in younger women with a significantly elevated day 3 FSH level, or other indications of significantly reduced ovarian reserve.

If the sperm count, motility and morphology scores are low, intrauterine insemination is unlikely to work With significant male factor issues, IVF with ICSI is indicated and has high success rates for women under age 40.

Insemination for male factor infertility

Studies have shown that intrauterine insemination can be effective for some cases associated with poor sperm quality. However, if the total motile sperm count at the time of insemination (after the processing) is less than 5 million, the chances for pregnancy are substantially lower.

If the total motile sperm count is below 1 to 5 million, success rates are very low. Therefore, in vitro fertilization with ICSI (injecting sperm into the eggs) is usually done for these cases.

IUI is most commonly used for unexplained infertility. It is also used for couples affected by mild endometriosis, problems with ovulation, mild male factor infertility and cervical factor infertility.

Insemination is a reasonable initial treatment that should be utilized for a maximum of about 3-4 months in women who are ovulating (releasing eggs) on their own. It is reasonable to try IUI for longer than this in women with polycystic ovaries (PCOS) and lack of ovulation that have been given drugs to ovulate.

How is insemination performed? What is the process for artificial insemination in humans?

• The woman usually is given medications to stimulate development of multiple eggs and the insemination is timed to coincide with ovulation - release of the eggs.
• 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" in the laboratory (called sperm processing or sperm washing). The sperm is separated from the other components of the semen and concentrated in a small volume. Various media and techniques can be used for the washing and separation. Sperm processing takes about 30-60 minutes.
• A speculum is placed in the vagina and the cervical area is gently cleaned.
• The washed specimen of highly motile sperm is placed either in the cervix (intracervical insemination, ICI) or higher in the uterine cavity (intrauterine insemination, IUI) using a sterile, flexible catheter.

Most clinics offer for the woman to remain lying down for a few minutes after the procedure, although it has not been shown to improve success rates. The sperm has been put above the vagina and cervix - it will not leak out when you stand up.

Intrauterine insemination success rates vary considerably and depend on

• age of the woman
• type of ovarian stimulation used (if any)
• duration of infertility
• cause of infertility
• number and quality of motile sperm
• other factors

Success rates for IUI in women over 35 drop off, and for women over 40 they are much lower. For this reason, we are more aggressive in "older" women.

Pregnancy rates are lower when insemination is used

• in women over 38 years old
• in women with low ovarian reserve
• with poor quality sperm
• in women with moderate (or severe) endometriosis
• in women with any degree of tubal damage or pelvic scarring
• 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. The sole cause of their infertility is likely to be the ovulation problem - which is hopefully overcome with the drugs.

For a couple with unexplained infertility, female age under 35, trying for 2 years, and normal sperm - we would generally expect about

• 8% chance per month of conceiving and delivering with artificial insemination and Clomid for up to about 3 cycles (lower percentages with Clomid and insemination after 3 attempts)
• 12% chance per month of conceiving and delivering with injectable FSH medication (e.g. Follistim, Gonal-F, or Menopur) and insemination for up to about 3 cycles (lower after 3 attempts)
• 55% chance of conceiving and delivering with one cycle (month) of IVF treatment (at our center - success rates vary greatly between clinics)

Insemination combined with ovarian stimulation with injectable gonadotropins provides higher pregnancy rates (and higher multiple pregnancy rates) as compared to insemination combined with Clomid.

• Injectable gonadotropin meds will stimulate more mature eggs to develop than Clomid
• More mature follicles and eggs leads to more chance for a pregnancy
• However, more follicles also gives you more risk for multiple pregnancy. It is a double- edged sword...

How many infertility treatment cycles should be done with insemination?

Most pregnancies resulting from insemination with the male partner's sperm occur in the first 3 attempts. The chances for success per month drop off after about 3 attempts and drop considerably more after about 4-5 unsuccessful attempts. Therefore, IUI treatment is usually recommended for a maximum of about 3 or 4 tries.

If the reason for infertility is lack of ovulation, it may be reasonable to try more IUI cycles. However, many couples with fertility problems are ready to move on to IVF treatment after 3 IUI's have failed.

Risks of artificial insemination in women

The risk for complications with intrauterine insemination is very low. The woman could develop an infection in the uterus and tubes from bacterial contamination that originated either in the semen sample, or through a contamination of the sterile catheter in the vagina or cervical area during the procedure. Careful cleaning of the cervix and cautious technique make this a rarity.