Intra Uterine Insemination – IUI
Patient information
The treatment of infertility by intrauterine insemination is one of several methods of assisted
conception. It is frequently used by doctors in cases where there is no obvious cause for a
couple's infertility - and in certain cases of male infertility. This booklet has been produced by
the health-care company Organon as a patient guide to the treatment - to explain how it works
and how successful it has been so far.
Acknowledgement
Organon is grateful for the help of Mr Anthony Rutherford, MRCOG, consultant gynaecologist at Leeds General Infirmary,
in preparing the text for this booklet.
INFERTILITY
Many couples are unable to have children, and their number may even be increasing. The
suffering and despair which childlessness may bring to an otherwise fulfilling relationship is
substantial. Couples who are unable to conceive turn to their family doctor for advice and
guidance - and sometimes to the specialist for dedicated treatment.
The specialist's choice of one particular procedure will depend on the type (or cause) of
infertility which investigations reveal. This booklet tells you more about intrauterine
insemination, just one of several treatment techniques which are collectively known as
'assisted conception'.
The scale of the problem
A normal fertile couple in their mid-20s having regular sex have a one in four chance of
conceiving each month. This means that around nine out of ten couples trying for a baby will
conceive within a year. However, one in ten will not - and within this 10 per cent of the
'fertile' population are those couples who will be diagnosed as infertile. Around two-thirds of
them are actually subfertile, and they can be helped by assisted conception treatments. Doctors
usually define infertility as the inability to conceive after at least one year of trying.
IUI is one of the simpler methods of assisted conception which might be considered in
couples thought suitable. Usually, IUI will only be performed in couples whose first
investigations have failed to detect a specific cause of infertility and who have been trying for
a baby for at least two years. By then, most will have received advice about temperature charts
and timed intercourse; in some cases, ovulation induction may have been tried using fertility
drugs.
Assessing the causes
Investigations carried out by a family doctor or specialist clinic
can provide the likely cause of infertility in most cases. Only around 20 per cent remain
unexplained
and studies have shown that intrauterine insemination can be a useful treatment for these
unexplained cases.
The tests required to determine a specific cause of infertility will assess ovulation, the quality
of the fallopian tubes (by laparoscope), and hormone levels in women, and sperm production
(numbers, movement and shape) in men. A postcoital test will tell if sperm is actually passing
into the cervix after intercourse.
INTRA UTERINE INSEMINATION
The objective of IUI is to introduce a quantity or semen into the female partner's uterus ind
thereby encourage fertilisation.
Which couples benefit?
Because the semen is transferred to the uterus it is important I hat, the female partner has no
obvious reproductive abnormalities. Investigations should ideally show that the female is
ovulating normally and has open fallopian tubes. Indeed, infertility tests are often normal in
both partners since IUI has been found useful in couples with no obvious cause of infertility.
However; IUI can still be effective in women with ovulatory disorders provided they respond
adequately to fertility drugs. In such cases, ovulation is stimulated by a course of hormone
treatment such that insemination is timed to take. place shortly after the of ovulation. Indeed
this technique of stimulating ovulation with hormones and introducing the semen just after –
has proved very effective ill a variety of cases, and is now the preferred method in couples
with or without ovulatory disorder.
Because IUI relies on the ability of sperm to fertilize an egg within the reproductive tract it is
important that tests for male infertility indicate reasonable sperm function (numhers,
movement and shape). However, IUI is also a useful treatment in those cases where the male
partner produces an immune reaction to his own sperms. This defect known as “anti sperm
antibodies” usually means that sperms will not penetrate the cervical mucus of the female
partner, and will thus not reach the egg. The technique of IUI allows prepared sperms to pass
beyond the cervix into the uterus and thus may overcome some of the problems of anti sperm
antibody defects. There have been some success with IUI in cases where the female partner is
experiencing mild suymptoms of a condition known as endometriosis. This is a very common
disorder, particularly in women in their thirties who have had no children, and may account
for as many as one in fifteen cases of infertility. The condition occurs when tissue from the
womb lining (endometrium) is found elsewhere in the reproductive tract. Women with mild
endometriosis are usually treated similarly to women with unexplained infertility.
Studies show that IUI will not be effective where the male has low sperm counts, or poor
shape. Similarly, women with damaged tubes, will not be helped by IUI.
How the technique works
The most recent studies of intrauterine insemination suggest that the best results are achieved
when insemination coincides with ovulation induced by fertility hormones. Therefore,
following investigations, the first steps in IUI treatment are similar to those used in other
assisted conception methods in that ovulation is controled and stimulated by fertility
hormones. For this reason, doctors refer to “Superovulation and IUI” to describe the
technique.
Because fertility hormones can produce several eggs, monitoring is important during this drug
treatment phase. To ensure that any sideeffects of the treatment and/or the risk of multiple
pregnancy are avoided. Monitoring of treatment is carried out by meassuring hormone
concentration in blood samples, and by tracking the development of follicles by ultrasound. A
lot of follicles will produce too many eggs and increase the risk of multiple pregnancy – so
usual aim in IUI is to generate around three eggs. (Superovulation in IUI differs from that in
IVF the former aims to stimulate just one dominant follicle, while the latter aims to produce as
many eggs as possible for laboratory fertilisation.)
When two or three follicles have reached their target size, ovulation is induced with a further
hormone injection (HcG). Then, shortly after the time of ovulation a sample of fresh semen
(produced that same day) is prepared and placed high in the uterus of the female partner
through a fine catheter. This is a quite painless procedure.
Whose semen?
Under normal circumstances, IUI uses sperm from the male partner. However, another
insemination technique, IUI D (Donor) uses screened sperm samples from anonymous donors.
This treatment is reserved for cases of male infertility where the male partner’s own sperm is
severely abnormal perhaps very low (or zero) sperm counts or poor shape and swim-ability.
Around one in eight infertile couples are treated in this way. IUID is an emotionally difficult
procedure and usually requires much counselling. New “micromanipulation” techniques of
treating these difficult cases of male infertility are considered very exciting. The success of
these techniques seems likely to make IUID less frequently used. IUI as a treatment differs
from IUI D in that the male partner has better quality sperm and usually prvides his own
sample. The treatment, therefore, poses none of the emotional difficulties of IUI D, because
no third party is involved.
STEP BY STEP IN IUI
1 . Drug treatment, to encourage two or three eggs to mature
- Usually a mixture of clomiphene citrate and gonadotrophins to stimulate the growth of
follicles and cause ovulation
2. Monitoring of treatment, to measure the growth of follicles, individualize drug doses,
and prevent serious side effects
By transvaginal ultrasound scanning (two or three times during a treatment cycle). Sometimes
by measuring hormones in a blood sample
3. Sperm sample, provided on morning of ovulation, is prepared and inserted later that
day
4. Pregnancy testing, monitoring
The risks of treatment?
The risks involved in IUI are few. In cases where more than three follicles develop to a size
greater than 14 milimeters, there is a risk of multiple pregnancy which could mean
abandoning treatment. Multiple pregnancies are associated with higher rates of pregnancy loss
and lower birth weight babies as well as greater social difficulties. Cycles would also be
cancelled if there was any hint of rare condition known as hyperstimulation syndrome, which
is why drug is always monitored. Too high a dose of drug can cause excessive stimulation of
the ovaries, which may be noticed as pain in the abdomen.
The chance of success?
The success rates of superovulation and IUI are between 10 and 15% after each cycle, but can
reach per cent after several attempts in one yaer provided that the male partner’s sperm count
is within the normallimits, and the female’s tubes are healthy. This means that for every 100
couples embarking on repeated cycles of IUI, about 50 of them will become pregnant and
have healthy babies after a year’s treatment.
Doctors might try four cycles of IUI and, if these are nor successful, then recommend other
methods like IVF.
Unlike IVF, IUI involves no difficult egg collection and is currently a popular and quite
successful treatment method for infertility.