What is IUI?

When  you are recommended for the first time any fertility treatment, it  sounds confusing and not conclusive. Or JUST weird. And you are mentally  entrapped into all those medical abbreviations without any thought what  you should start with…Embarrassed, frustrated, and lost, you cannot  choose what treatment option you should start with because you JUST  don’t know what you are involving yourself in… You feel yourself like a  bundle of nerves but you shouldn’t! We are here to navigate you in this  complex Ecosystem! 

If  you are not sure should you CHOOSE IVF treatment, or ICSI treatment, or  IUI treatment, or something else, IT IS ESSENTIAL to ‘GLIMPSE’ through  the basic information about all these treatments, to analyze their  BENEFITS, COMPLICATIONS, and RISKS. And only after that to CONSULT with  the doctor and to choose the one. If your doctor has already recommended  you to start with Intrauterine Insemination, then this article is designed for you!

Envisioned  or not but the first document entitled “Intrauterine insemination” was  published in 1962! So long time ago! Since that timeline, Intrauterine  Insemination’s technique became more advanced and more sophisticated.  The innovations that were designed for this technique and are used today  include sperm preparation, monitoring for preovulatory timing, and  ovulation induction.

(1) What is Intrauterine Insemination?

Intrauterine  insemination is the non–invasive procedure where sperm are washed  (to remove dead sperm and proteins), concentrated (to increase the  volume of the viable sperm), and placed in a woman’s uterus via catheter  (a very small tube that is passed up the cervix and into the uterus)  around the most optimal time of ovulation. This procedure is done as  close to the time of ovulation as possible. The Reproductive Specialist  may recommend you Intrauterine insemination with ovarian  stimulation or without ovarian. The mode of IUI insemination also varies  as the sperm suspension can be deposited in the cervix, the uterus, the  peritoneum or the Fallopian tube.

(2) What is generally accepted about Intrauterine insemination?

It  is generally accepted that intrauterine insemination should be  preferred to more invasive and expensive techniques of assisted  reproduction. That is why IUI is one of the first assisted reproductive  technologies typically recommended by the doctors (reproductive  endocrinologists). IUI is proven easier to perform, less invasive and  less expensive than other methods of assisted reproduction.

(3) When should the Intrauterine insemination treatment be recommended as the fertility treatment? 

It  is proposed as a first–choice treatment in cases of unexplained and  moderate male factor subfertility (when the male partner is experiencing  low sperm count, decreased sperm motility, or decreased sperm  viability), Endometriosis, Polycystic Ovarian Syndrome, cervical mucus  issues, for most cases of non–tubal infertility, unexplained infertility  (with potential male factor), combined male subfertility and ovulatory  dysfunction, and immunologic causes.

(4) In which cases Intrauterine insemination is not only recommended but effective treatment? 

Cervical factor subfertility

Bypassing the hostile cervix, it increases the probability of conception because the sperm is INJECTED directly into the uterus.

Unexplained infertility/subfertility

IUI is effective only when controlled ovarian hyperstimulation (COH) is used.

Male factor infertility

IUI  in natural cycles should be the treatment of choice in case of male  subfertility, providing an inseminating motile count (IMC) of more than 1  million can be obtained after sperm preparation and in the absence of a  triple sperm defect.

(5) In which cases IUI is forbidden to be used? 

Surely,  there are several contraindications for this treatment option. IUI is  contraindicated in women with a blocked or damaged Fallopian tube,  cervical atresia, cervicitis, endometritis or bilateral tubal  obstruction and in most cases of amenorrhea or severe oligospermia.

(6) What Benefits Does IUI Have? 

(I) Washing procedures enhance sperm quality

The  washing procedures clinicians perform to remove prostaglandins,  infectious agents, antigenic proteins, non–motile spermatozoa,  leucocytes, and immature germ cells. As a result, sperm quality  increases. This may also enhance sperm quality by decreasing the  formation of free oxygen radicals after sperm preparation.

(II) Natural (unmedicated) cycle IUI is possible to perform

With  IUI you have options with medications. You can do a natural cycle (no  medications), with Clomid (a pill to stimulate follicles) or with low  stimulation medications. Natural cycle IUI and minimal dose regimen with  gonadotrophins are valuable options to prevent the unacceptable high  multiple gestation rates described after ovarian hyperstimulation.

(III) Less invasive method: more physiological

Intrauterine  insemination is the procedure where sperm are washed (to remove dead  sperm and proteins), concentrated (to increase the volume of the viable  sperm), and placed in a woman’s uterus via a catheter (a very small tube  that is passed up the cervix and into the uterus). You don’t have the  oocyte retrieval [surgical procedure which is performed under the  anesthesiology on the operating table] as you do with IVF.

(IV) Reduced psychological burden 

After  the oocyte retrieval [the whole procedure only takes about 15 minutes,  so you wake up about 20–30 minutes later in recovery], at first you  don’t feel any pain because they give you some good pain medications  through the IV, but once those wear off the pain is terrible.  Apparently, the amount of pain a woman feels after oocyte retrieval  depends entirely on pain tolerance and the number of oocytes retrieved.

(V) The procedure is performed under the transvaginal ultrasound guidance

The  IUI is performed under an internal ultrasound [a transvaginal  ultrasound] and as soon as the technician performed an external  ultrasound, a tiny catheter is inserted into cervix. Using the  ultrasound screen as the guide, the doctor pushes the catheter through  the cervical canal and points it toward the top of the uterus and right  or left Fallopian tube (the side with the mature follicle). Ultimately,  the doctor injects the sperm through the catheter and into the uterus.  The IUI may be performed also without ultrasound visualizing. The  technique is the same: a tiny catheter is placed inside and the sperm is  transferred via that tiny catheter inside uterus. IUI procedure usually  is usually completed within a few minutes!

(VI) The timing of the procedure performance is surprisingly short

The process lasts only about 60 to 90 seconds. After that, you will be advised to stay seated for a few minutes.

(VII) Less expensive treatment option

In  comparison with IVF and ICSI, Intrauterine Insemination is less expensive fertility treatment  option. The whole IUI treatment cycle cost around $2,000–$4,000  including medications where the average IVF treatment cycle costs around  $10,000–$36,000. So, you can get a few IUI treatment cycles in for the  rate of 1 IVF treatment cycle.

(VIII) Low risk for ovarian hyperstimulation syndrome (OHSS)

Ovarian  hyperstimulation syndrome (OHSS) occurs in 1%–10% of women undergoing  ovarian hyperstimulation with exogenous gonadotrophin administration and  is a recognized and potentially life–threatening complication. Ovarian  hyperstimulation syndrome (OHSS) may complicate all methods of treatment  in which gonadotrophins are used; however, OHSS seems to be rare after  controlled ovarian hyperstimulation–IUI (COH–IUI) compared with IVF due  to the fact that lower dose stimulation protocols are more often used.

(IX) Low risk of thromboembolism

Deep  venous thrombosis (blood clots) has been reported extensively following  ovarian hyperstimulation syndrome during in–vitro fertilization (IVF)  treatment cycles. The thromboembolic event is dangerous because it is a  prominent cause of maternal deaths. It is also unpredictable because  there is no clinical marker to reveal it early. The site of the  thromboses, the timing of thromboses relative to oocyte retrieval, and  possible predisposing factors are hard to diagnose.

(X) More effective than Intracervical Insemination (ICI)

If  you are proposed ICI, you should know that IUI is more effective.  Wondering why? ICI involves placing the sperm into the cervix. Once  placed in the cervix, the sperm then make their way to the uterus where  they can fertilize the oocyte, mimicking the action of natural  fertilization. IUI involves placing the sperm directly inside the  uterus. Because this technique bypasses the cervix and does not rely on  the sperm traveling to the uterus themselves, the chances of  fertilization are increased.

(7) What side effects does IUI have? 

(I) Most women experience little to no pain during the IUI procedure.

(II) Some women may experience mild cramping with IUI procedure.

(III) Severe side effects, like infections, can occur following IUI, but these are very rare.

(IV)  Most Intrauterine Insemination side effects are caused by the fertility drugs taken during  the IUI cycle, not the IUI procedure itself. When you begin an Intrauterine Insemination cycle, your doctor may prescribe you fertility medications to increase  your chances of IUI success. These drugs will stimulate your ovaries to  produce multiple oocytes for the insemination. These medications have  the side effects: Mood swings, Depression, Hot flashes, Breast  tenderness, Nausea, Bloating, Headaches or visual disturbances, Swelling  or a rash around the injection site (if you are given the injections),  Swollen and painful ovaries, signaling ovarian hyperstimulation syndrome  (OHSS), Pelvic discomfort, Ovarian cysts. IUI side effects caused by  fertility drugs should disappear once the medication is stopped. Always  call your doctor if any uncomfortable symptoms develop during an IUI  cycle.

(8) Is there the risk of conceiving multiples?

Dreaming  about having twins or triplet? The risk of conceiving multiples (becoming pregnant with twins, triplets, or even more) with IUI without  ovarian stimulation is very small but sometimes it happens. IUI without  ovarian stimulation can be assumed as a natural conception, and as you  know sometimes it is possible to get pregnant with more than one tiny  one! But if you start IUI treatment with ovarian stimulation, you may  conceive the multiples because of taking fertility drugs.

(9) What are IUI medical procedures and insemination methods? 

The  first appointments with the Reproductive Endocrinologist will be  unbelievably overwhelming. They will be inspiring, ‘glowing’ and even  thrilling. So many wonderful options and you have the choice. Surely,  there are so many various treatment options and treatment protocols.  Some of them are even FLEXIBLE! You will DISCUSS everything with your doctor, including medications you need and listed further testing to undergo.

BUT  there is still ONE BUT. Any infertility treatment option starts with  Testing and Screening. After fertility testing and screening your doctor  will suggest you the treatment options. If your doctor has already  discussed with you all the options, and you chose IUI, then you should  expect the following things.

Semen preparation

Prior  to IUI procedure, they will remove seminal plasma to avoid  prostaglandin–induced uterine contractions. If seminal plasma is not  removed, then uterine contractions can make the procedure not only  painful but complicated and ineffective. Moreover, insemination with  unprocessed semen can cause a pelvic infection. Removal of the seminal  plasma can be achieved by relatively simple procedures. The most  frequently used methods involve centrifuging spermatozoa through culture  medium or density gradients followed by resuspension in suitable  culture media.

Quality of the specimen

There  is no consensus on a lower limit of semen quality. The experts define  lower limits differently, as sperm concentration per milliliter, or as  the total number of motile spermatozoa in the semen sample, or as a  total number of motile spermatozoa in the sample for insemination. But  here it should be noted that if the semen sample contains <10 million  sperm in total the chances to conceive the tiny one is lower.

Mode of insemination procedure

During IUI procedure the sperm suspension can be deposited in the cervix, the  uterus, the peritoneum or the Fallopian tube. IUI is by far the most  common method. It is performed by introducing a 0.2–0.5 ml sperm  suspension into the uterus with a tiny catheter, usually without  ultrasound–imaging guidance.

With  Fallopian tube sperm perfusion (FSP), the sperm volume usually taken for  insemination is 4 ml, so that with this large volume of fluid the  inseminate may fill not only the uterine cavity and Fallopian tubes.  With Fallopian tube sperm perfusion some of the sperm volume may even  end up inside the peritoneal cavity.

Sometimes IUI procedure is done using the frozen semen samples. Here it is vital  to underline that for frozen semen samples, IUI is better than  intracervical insemination (ICI).

The timing of the insemination procedure

Correct  time–scheduling of IUI is essential, because of the limited time  interval in which spermatozoa can retain their capability to fertilize  the oocyte and survive in the female reproductive tract for  approximately 3 days after ejaculation, while oocytes remain  fertilizable only for 12–16 hours after ovulation.

In  the case of IUI, spermatozoa are processed, devoid of seminal plasma  and only the fraction of selected. After that, motile spermatozoa is  transferred via a tiny catheter directly into the uterine cavity.  Considering these facts, the time frame within which a successful  conception after IUI procedure is possible is shorter than in the  setting of natural conception cycle. Therefore, the procedure should  ideally be scheduled as closely to the time of ovulation as possible to  increase the possibilities of successful oocyte’s fertilization.

IUI  can be done one time or several times. Insemination can be done at  various time points around ovulation. If it is done without ovarian  stimulation with fertility drugs, then the ovulation timing is closely  monitored by the internal ultrasound. If ovarian stimulation is  necessary for IUI procedure, then the most optimal time for the  insemination is 32–36 hours following hCG administration.

(10) Sometimes they recommend the insemination using the donor sperm

Artificial  insemination with donor sperm (AID) may be performed for medical  reasons. The medical reasons include: (1) obstructive and  non–obstructive azoospermia, (2) severely impaired semen quality in  couples who do not want to undergo or were not successful with ICSI, (3)  severe rhesus isoimmunization, (4) prevention of vertical transmission  of a genetic defect. Insemination with donor sperm is also the great  treatment option that allows to build LGBT families (to assist lesbian  couples) or to make the dreams of single women to achieve pregnancy come  true.

Something to say in conclusion?

As  the conclusion note, it should be underlined that Intrauterine  insemination without controlled ovarian stimulation or  Intrauterine insemination with controlled ovarian stimulation is  frequently used in couples with unexplained infertility. If there is an  increased risk of conceiving multiples, your doctor may recommend you to  start Intrauterine insemination cycle without controlled ovarian  stimulation (COS) as COS is closely associated with an increased risk of  multiple pregnancies and ovarian hyperstimulation syndrome (OHSS). IUI cycle without controlled ovarian  stimulation should be assumed as the most natural designed treatment  option.

The most essential thing your  doctor should closely monitor is the time frame for scheduling the IUI.  Time framing is of vital importance for eventual oocyte’s fertilization  and thus pregnancy.

This technique  is a wonderful treatment option for the couples diagnosed with  unexplained subfertility, mild endometriosis or mild male factor  infertility. It can be also the most sophisticated solution for those  couples who have social, cultural or religious objections to In Vitro  Fertilization (IVF).

Surely you have  already envisioned in your mind the first ‘DATE’ with your small bundle  of joy as the moment of cordial connection. But have you ever envisioned  how your future baby may look like? Have you ever mentally ‘glanced’ at  your future baby’s gorgeous eyes? Have you ever thought that those  intriguing gorgeously–shaped dark–golden curls fall around your future  baby–girl’s back and shoulders? The gorgeous baby–girl with the cascade  of dark–golden curls down to her waist, so intriguingly curled, so  glittering, so gorgeous, so tempting… And you are captured by the divine  beauty of her curls… Your girl is basically so attractive, that even  you wonder if she is for real. She is impeccably charming. Or if you  have a tiny dude, have you ever envisioned him with so impeccably  charming? With so sparkling dark eyes? With so cute tiny curls? Dreaming?Wondering if that possible? Be sure, everything is possible! The Advanced and Sophisticated OptionsWill TurnYour Dream into Reality!

Wondering  what every option noted in this list means? Worrying about the  advantages and disadvantages it has? Not sure that this option is  designed for you? Feeling like a bundle of nerves because you have no  idea what option should be chosen because there are several ones that  may be proposed for you? No worries here! We will navigate you in this  Complex Ecosystem and will show you what is “inside” every treatment  option! Why Waiting? All the Options are at your Fingertips! Just Bundle  Up and Glance Through!

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