Intrauterine Insemination (IUI): What Patients Should Know (Part 1)

13 Dec
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Intrauterine insemination (IUI), the injection of sperm into the uterus by means of a catheter directed through the cervix, has been practiced for many years. The premise of this procedure is that sperm can reach and fertilize the egg more easily if placed directly into the uterine cavity.

In the early ‘60s, physicians were injecting small quantities of raw, untreated semen, (sperm plus the seminal plasma) directly into the uterus at the time of expected ovulation. However, when more than 0.2 ml of semen was injected in to the uterus, serious and sometimes life endangering shock-like reactions often occurred. It was subsequently identified that the reason for such reactions related to the presence of prostaglandins within the seminal plasma. This led to the practice of injecting small amounts (less than 0.2 ml) of raw semen. However, the pregnancy rates were dismal, and side effects such as severe cramping and infection were rampant.

Soon after establishing the Northern Nevada Fertility Center in Reno in 1982 (the Nation’s first private in vitro fertilization (IVF) program), we began to recognize the potential advantage of washing and centrifuging raw semen, so as to separate sperm from the seminal fluid, and thereby remove the prostaglandins that cause most of the problems. We subsequently introduced and, thereupon, became the first to publish on intrauterine insemination (IUI) in the Journal, Fertility and Sterility (April 1984).

Indications for Intrauterine Insemination (IUI)

 

Artificial insemination using frozen (donor) sperm: The recognition of HIV infection as a sexually transmitted disease, coupled with the fact that the virus is present in semen months before it can be detected in the blood, mandates that all donors have their semen cryopreserved (frozen) and stored for at least six months, whereupon, they be re-tested for HIV infection. Only upon confirmation of a negative test should the cryopreserved semen specimen be thawed and used for insemination. Since cryopreservation inevitably reduces sperm motility and function, it is not adequate to simply thaw the frozen specimen and then inseminate the raw semen into the vagina. Rather, the semen specimen should be processed for IUI. Provided that the recipient is ovulating normally, there is no need to administer fertility drugs such as Clomiphene, Pergonal, etc.

  • Artificial insemination with partner’s sperm: In cases of sexual dysfunction (impotence, retrograde ejaculation, etc.) or timing issues, the partner’s sperm may need to be collected and processed in preparation of IUI.
  • Cervical mucus hostility: Sometimes the cervical mucus acts as a barrier to the activation and passage of sperm as it passes through the cervical canal. Such hostility may be due to poor physical qualities of the mucus, cervical infection, or the presence of antisperm antibodies. In all but the latter situations, IUI can readily be performed during natural cycles, unless the woman has ovulation dysfunction. However, when infertility results from the presence of antibodies in the cervical mucus, IUI will likely be ineffectual and should be replaced by in vitro fertilization (IVF).
  • Absent or dysfunctional ovulation: In some cases where the woman requires the use of fertility drugs to induce normal ovulation, the concomitant performance of IUI might improve pregnancy rates.

 

Selecting the Fertility Drugs for Intrauterine Insemination (IUI)

Clomiphene citrate (Serophene, Clomid): Clomiphene citrate is taken orally for 5 days starting on day 2 to 5 of the menstrual cycle. Ovulation will usually occur 10 days later. In some cases, hCG is used to trigger the ovulation but this is often unnecessary. Clomiphene is a relatively inexpensive and safe method for inducing ovulation and this is why it is so commonly prescribed to women undergoing IUI. However, women receiving clomiphene have about a one third lower pregnancy rate per cycle than is the case when using injectible fertility drugs. But there are draw-backs to clomiphene citrate. Here are a few reasons why:

  1. Clomiphene citrate is an anti-estrogen. Ordinarily, women who ovulate normally (without exposure to clomiphene) produce a single dominant follicle which produces enough estrogen to promote optimal cervical mucous production and an adequate endometrial lining (>9mm) However, when clomiphene is used to induce ovulation, its anti-estrogenic effect blunts this response. In fact, women on clomiphene require much more estrogen to override this effect, such that unless at least 3 large follicles develop to allow the blood estradiol levels to rise above 400pg/ml, cervical mucus production and endometrial development will usually be insufficient to allow a healthy pregnancy to occur. Younger women with normal ovarian reserve (Day-3 FSH of less than 9miu/ml)>3 follicles, whereas women over 40 years of age and those with diminished ovarian reserve (regardless of age) will rarely do so, and thus are very unlikely to achieve viable pregnancies on clomiphene.
  2. Clomiphene-induced ovulation is associated with a 15-20% chance of a condition called luteinized unruptured follicle (LUF) syndrome where the hormonal changes that precede, accompany and follow ovulation (including a rise in blood progesterone level) occur, but this happens without ovulation occurring. LUF syndrome thus leads to the erroneous conclusion that an egg has been released when, in fact, it remains “trapped” in the ovarian follicle.
  3. More than 3 consecutive (back to back) cycles of clomiphene will result in a very significant increase in the anti-estrogen effects referred to in 1&2 above, such that unless a break of at least 1 full menstrual cycle is taken, the likelihood of a viable pregnancy declines to less than 10%, regardless of the woman’s age or her ovarian reserve. This explains why >80% of successful clomiphene pregnancies occur within the first 3 months of treatment, and why the vast majority of clomiphene pregnancies that occur after >3 consecutive (back-to-back) cycles of treatment are lost (usually due to early miscarriages).
  4. Clomiphene causes the pituitary gland to produce increased amounts of FSH and LH. FSH promotes follicle growth development while excess LH causes the ovary to produce male hormones such as testosterone. While a little testosterone is indispensable to follicle and egg development, too much testosterone can have the reverse effect and harm egg development. This effect is even more deleterious in women with diminished ovarian reserve (elevated FSH levels) and those over 40 whose ovaries tend to produce more testosterone-like hormones.

The good news is that upon discontinuation of Clomiphene for 4-6 weeks, adverse effects disappear, leaving the slate clean.

The real benefit of clomiphene lies in its oral route of administration, low incidence of side effects, and its low cost. The birth rate per clomiphene IUI is about 7-10% per cycle of treatment (about 1/3 lower than when injectible fertility drugs are used).

Letrozole(Femara): Letrozole, like clomiphene, is an oral agent used to induce ovulation that causes the pituitary gland to release large amounts of FSH as well as LH. The advantage that Letrozole has over clomiphene is that unlike the latter, it is NOT anti-estrogenic, and thus does not compromise development of the uterine lining or adversely affect the production of cervical mucus. However, as is the case with clomiphene, Letrozole causes increased LH release that can lead to overproduction of male hormones (e.g. testosterone) by the ovaries with potentially adverse effect on egg/embryo quality.

Thus, while Letrozole does have potential advantages over clomiphene, the exaggerated LH-induced testosterone effect, especially in women over 40 years of age and/or those with evidence of diminished ovarian reserve, limits its value.

Gonadotropins (Menopur, Gonal-f, Folistim and Puregon): Women with absent or abnormal ovulation who require fertility drugs in preparation for IUI should receive gonadotropins. Granted, these agents are more expensive than clomiphene, but they have no anti-estrogenic properties.

The birth rate with gonadotropin IUI in women under 35 years of age (in the absence of male infertility, where it is much lower) is about 10-15%. However, success is affected by, and contingent upon, the procedure being performed (1) for the correct indications, (2) avoiding the performance of IUI when contraindications exist (see below) and, (3) where the woman is ovulating normally on her own. Success rates decrease as a woman’s age advances. In women 35-40 years of age the birth rate is 5-10% per cycle and for over 40 years, the birth rate per cycle is under 2%, declining to less than 1% after age 43.

In Part 2 of this topic, I’ll discuss contraindications for IUI – when it is NOT recommended, and in what cases it’s unlikely to be successful. I’ll also touch on the risks of multiple gestations associated with the use of IUI.

14 Comments

  • Aniee says:

    Hi, this is Aniee. I have been married for 6 yrs now and trying to conceive since then. Had 4 unsuccessful attempts of IUI and had one natural pregnancy but misscarraged after 14 weeks. My husband’s sperm count is 90 million and sperm concentration is 30 million, post wash progressive 80% . Still I have never concieved, my eggs also mature very well and my tube test is perfectly normal . I have a perfect 30 days of cycle and hormone levels are also fine. My body weight is 60 kg and height is 5.5 ( which is fine I guess)
    Should keep on trying for for more IUI or go for an IVF.

    I am very concerened, kind!y reply me asap
    Love.

    • Aniee says:

      My age is 29, husband is 35 yrs old

      • Geoffrey Sher says:

        My website has changed. The new site is at http://www.sherIVF.com where I host and populate new and updated blog articles . The blog can also be accessed directly by going to http://goo.gl/4hvjoP. I now only respond to posts on this new site.

        To find and follow updated and new blog articles and to post questions or comments, please use this new venue. I promise to respond promptly.

        In the interim, please re-post this question or comment on my new website-blog.

        Geoff Sher

    • Geoffrey Sher says:

      My website has changed. The new site is at http://www.sherIVF.com where I host and populate new and updated blog articles . The blog can also be accessed directly by going to http://goo.gl/4hvjoP. I now only respond to posts on this new site.

      To find and follow updated and new blog articles and to post questions or comments, please use this new venue. I promise to respond promptly.

      In the interim, please re-post this question or comment on my new website-blog.

      Geoff Sher

  • Mimi says:

    Hello,

    I am 39 going to 40 on 11/11/14 and I did twice with IUI and failed . My FSH and AMH was normal range. The doctor told me that I did not have enough eggs .During two time of doing IUI , the first time only my left ovarian produced eggs and the second the right ovarian produced eggs .

    The question I am asking:

    1. Is that good to do IUI again with more fertility medications ?
    2. Should I consider IVF ? and do you think it is a good idea of using my eggs ?

    Thank you

    • Geoffrey Sher says:

      When it comes to IUI, the number of follicles is not really important because most normally ovulating women on fertility drugs (even if they produce numerous follicles) will only ovulate from one or at most tow dominant ones.

      1. Is that good to do IUI again with more fertility medications ?

      A: I would not take this approach. You need IVF and then with a more individualized and robust regime of stimulation (see below).

      2. Should I consider IVF ? and do you think it is a good idea of using my eggs ?

      A: Yes, you should move to IVF …and the decision on whether to use your own eggs depends on your ovarian reserve (Day 2-4, FSH/LH/E2 and AMH). If you have diminishing ovarian reserve, you might also wish to consider “Embryo Banking” with “Staggered IVF” (see below).

      Please go to the home page of this blog, http://www.IVFauthority.com . When you get there look for a “search bar” in the upper right hand column. Then type in the following subjects into the bar, click and this will take you to all the relevant articles I posted there.

      1. “An Individualized Approach to Ovarian stimulation” (posted on November 22nd, 2010)

      2. Ovarian Stimulation for IVF: The most important determinant of IVF Outcome” (Nov. 2103)

      3. “Agonist/Antagonist Conversion Protocol”

      4. “Embryo Implantation………” (Part-1 and Part- 2—-Posted August 2012)

      5. “Traveling for IVF from Out of State/Country– The Process at SIRM-Las Vegas” (posted on March, 21st 2012)

      6.“A personalized, stepwise approach to IVF at SIRM”; Parts 1 & 2 (posted March, 2012)

      7. “IVF success: Factors that influence outcome”

      8 “Use of the Birth Control Pill in IVF”

      9.”Staggered IVF”

      10.“Embryo Banking”

      11.“Array CGH versus metaphase CGH in IVF patients….’

      12.“Egg Donation”

      13. “Intrauterine Insemination (IUI): Setting the Record Straight on when it is to be considered”.

      Consider calling 800-780-7437 or 702-699-7437 to arrange a Skype with me so we can discuss your case in detail.

      Finally, perhaps you would be interested in accessing my new book (recently released). It is the 4th edition (and a re-write) of “In Vitro Fertilization: The ART of Making Babies”. The book is available through “Amazon.com” as a down-load or in book form. It can also be obtained from most bookstores.

      Geoff Sher

      P.S: Please go to http://www.youtube.com/watch?v=Vp3GYuqn2eM&feature=youtu.be
      To view a video-tutorial by Linda Vignapiano RN, Clinical Manager at SIRM-Las Vegas.

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