Intrauterine Insemination (IUI)

It is not necessary to abstain from intercourse before an IUI. Sperm counts always vary, and the frequency of ejaculation does not have a consistent effect on sperm count. There may be more sperm on a second or third ejaculate at one time and at other times there may be less sperm.

Our recommendation is to have intercourse on the day that an ovulation kit turns positive or on the day that an hCG trigger injection is given. The IUI is then timed as indicated above.

The semen sample is collected through ejaculation into a sterile collection cup that we provide in the office. The specimen is usually collected in the office in a specially designated private room. A partner may be in the room to help with the collection. On occasion, an individual may be unable to collect a sperm specimen in the office. In those situations, we allow collection at home, but it is important to get the specimen to the office within a half hour and that it be kept warm. It is also possible to use a specialized nontoxic collection condom. However, ordinary condoms cannot be used for IUI.

We will schedule the semen collection approximately one hour before we schedule the IUI. This allows time for the sperm to liquefy in our incubator and to prepare for the IUI.

Before sperm can be placed into the uterus, it must be prepared. The fluid that is emitted upon ejaculation is composed of two main components: seminal fluid and sperm. Seminal fluid contains many types of hormones and chemicals. One group of chemicals in particular can cause problems and are known as prostaglandins.

Prostaglandins are responsible for many bodily functions. If high levels of certain types of prostaglandins are placed directly into the uterus, they can cause the individual to become very sick. The symptoms of prostaglandin absorption during intrauterine insemination – IUI, are nausea and vomiting, fever, diarrhea and cramping. The symptoms usually begin within a few minutes of performing the IUI.

Preparation for an IUI involves separation of the sperm from the seminal fluid and is known as a sperm wash. Sperm “wash” for IUI is actually a bad term because the sperm are not actually being washed or cleaned.

There are several methods for performing a sperm wash for an intrauterine insemination. The medical literature does not clearly indicate that any method is any better than any other. It is therefore up to the personal preference of the physician performing the IUI.

Once the semen is collected it must sit for a while to allow it to liquefy. The consistency of the semen will still be thick at this point. Next the semen is mixed with a chemical solution called sperm wash media. This solution is specially designed to not harm sperm. The semen and the media are thoroughly mixed.

Next, the semen and media mixture is placed into an instrument called a centrifuge. The centrifuge will rapidly spin the test tube containing the mixture. This causes the sperm to settle at the bottom in a small pellet. The fluid above the pellet contains the seminal fluid and can be poured out.

Finally, the sperm pellet is dissolved by adding some fresh sperm wash media and mixing thoroughly. The specimen is now ready for insemination.

During the IUI procedure at our clinic, the patient will experience a process similar to a routine pap smear. Once in the treatment room, the patient will be asked to undress from the waist down and use a drape sheet for privacy. Positioned on the examination table with feet in stirrups, a speculum is inserted into the vagina to facilitate the introduction of a washed sperm sample via a catheter and syringe directly into the uterus.

After the procedure, there is no specific requirement for rest, and the patient may resume normal activities immediately, including returning to work or engaging in exercise. Couples are also advised that it is safe to have intercourse following the procedure, which can be particularly beneficial for those with very low sperm counts, as it can increase the total sperm count in the uterus and potentially enhance the chances of pregnancy.

It is not uncommon for the patient to notice some fluid leakage after the insemination, which can be due to the semen refluxing through the cervix or minor uterine contractions expelling some of the fluid. This should not cause concern, as sufficient sperm typically remains within the uterus to enable pregnancy. Resting afterward to prevent reflux is not necessary, as it does not impact the success of the procedure.

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Sometimes, it will be difficult to pass the IUI catheter all the way into the uterus. There are several ways around this problem.

First, there are IUI catheters that contain a flexible wire inside. This wire allows the physician to bend the catheter into a shape that will follow the path of the cervix more easily. It also gives more rigidity to the catheter, which is normally very soft and floppy. Often, this is all that is needed for the IUI catheter to reach the uterus.

In other cases, an instrument called a tenaculum can be used to manipulate the cervix. The physician performing the insemination can tug on the cervix to straighten the angle between the cervix and uterus, thus making it easier to pass the IUI catheter through to the uterus. Having the patient fill her bladder before the procedure can also help straighten the angle.

Finally, ultrasound can be used to help the physician guide the catheter into the uterine cavity.

An IUI generally does not cause much discomfort. Most patients say that they experienced the same level of discomfort as a pap smear. There can be some cramping afterward, but most of what is felt is likely due to ovulation.

The use of IUI appears to improve chances of pregnancy when combined with either clomiphene citrate (CC) or gonadotropins such as Gonal F or Follistim. But does IUI increase the chance for pregnancy if used without fertility drugs? Unfortunately, there isn’t much research that has looked into this.

The best type of study is called a randomized controlled trial. In couples with unexplained infertility, IUI alone has been evaluated against intercourse in just one randomized trial. In this study, couples with unexplained infertility were split into one of two groups. One group was treated with IUI at the time of ovulation. The second group used intercourse alone at the time of ovulation. Conceptions occurred in 6 of 145 (4.1%) IUI cycles and 3 of 123 (2.4%) intercourse cycles. This is not a statistically significant finding, meaning that the variation in conception rates could have been a matter of chance.

Another trial compared IUI with intracervical insemination (ICI). The study was not ideal for the evaluation of unexplained infertility, as 25% of male partners had low sperm counts. The majority of patients had unexplained infertility; pregnancies occurred in 35 of 717 (4.9%) IUI cycles and 14 of 706 (2.0%) ICI cycles.

Combining the numbers from the two trials gives a rate of 4.76% with IUI and 2.05% with controls, and the absolute treatment effect was 4.76 minus 2.05 or 2.71. Thus, one would need to provide 100/2.71 or 37 cycles of IUI therapy to obtain a single additional pregnancy compared with control cycles.

In summary, based on these two trials, there is a significant but small effect of IUI therapy: 1 additional pregnancy in 37 IUI cycles compared with control cycles.