By Deborah Smith, MD, FACOG
Published in Resolve for the journey and beyond, Summer 2013
Insemination procedures are utilized to help improve fertility. Initially, inseminations were performed by placing the semen sample on the cervix in a procedure called an intracervical insemination (ICI). The cervical insemination used unwashed or unprocessed sperm samples. For an ICI, the unwashed sperm sample was placed in the vagina, near the opening of the cervical canal, using a catheter. Success with ICI was limited. It worked well for patients needing donor sperm insemination or insemination of partner’s sperm due to difficulties having intercourse, but ICI worked less well in patients with other fertility diagnoses.
In the early 1980’s, a research study compared intrauterine inseminations (IUI) to intercourse in women undergoing fertility therapy. This research study showed higher pregnancy rates in the IUI group. Since this time IUI’s have been more popular than ICI for many couples undergoing fertility therapy. Essentially, an IUI involves the 3 steps:
IUIs are an effective first line therapy for the treatment of many causes of infertility. In contrast to In vitro fertilization (IVF), an IUI costs less and is less invasive. It may also be covered by health insurance. However it is also associated with lower pregnancy rates when compared to IVF.
IUI is an excellent first line therapy for women with coital disorders, unexplained infertility, minimal endometriosis, mild male factor infertility, and those requesting donor sperm inseminations. In order to have good success with inseminations, at least one fallopian tube should be open and there should be an adequate semen sample available.
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. This is very rare.
Preparing for an insemination procedure is similar to preparing for a PAP smear. When you arrive at the doctor’s office, you will be asked to empty your bladder. This will make the insertion of the speculum easier. After the speculum is inserted into the vagina, the cervix is visualized. The cervix is wiped with a clean cotton swab. Then a small catheter (there are many different types of catheters, and each infertility doctor has their favorite!) is inserted through the cervical canal. At many offices, the nurse will perform the insemination procedure. In about 10% of inseminations, it is difficult to pass the catheter into the uterus. It is sort of like putting your pierced earring in. You can see the opening but you have to wiggle the earring until it is through the pierced opening. This is the same with the insemination. Sometimes there is wiggling of the catheter to get it thru the opening into the uterus. This wiggling can cause cramps.
The ability to conceive rapidly declines after the age of 40. Despite this knowledge, there are still many women who use ineffective therapies or postpone attempts at pregnancy who are over the age of 40. Fertility declines with advancing age, and when you are over 40 getting to the most effective therapy quickly to prevent a delay in conception is advised. Recent studies have evaluated the efficacy of fertility drugs with IUI in woman over 40. Many studies have shown that the use of Clomiphene in woman over the age of 40 with insemination does not improve pregnancy rates over not doing anything at all. The use of human menopausal gonadotropins and inseminations are effective with a live birth rate of 3-4%. However the highest pregnancy rates are seen in woman over 40 with IVF with success rates of 10-15% (live birth rate per retrieval) in woman aged 41-42 and 5% in woman over 42 years old. About 20% of women over the age of 40 will get their IVF cycle cancelled due to poor response (i.e., patient takes all the fertility medications but not enough eggs develop to go forward with an IVF retrieval procedure).
Numerous studies have evaluated the use of IUI with fertility drugs in patients who do not ovulate (anovulation) as the only cause of infertility. Compared to intercourse, inseminations do not improve the chance of pregnancy in anovulatory women as long as the partner’s semen analysis is completely normal. Anovulatory women who have failed to conceive after three cycles of fertility drugs with intercourse should consider moving on to the use of fertility drug plus inseminations.
The most difficult part of the IUI is getting the timing correct. There are two popular methods for timing inseminations. One is by the use of an injection of HCG (ovidrel, novarel, profasi, pregynl) and the other is by the use of ovulation predictor kits. Studies have shown that the pregnancy rates in IUI timed cycles using an LH kit versus HCG are equal (as long as you are picking up your LH surge correctly). Getting the correct day for an LH surge with an ovulation kit can be stressful. We have found that using the HCG trigger makes it easier for patients for timing, decreases stress that the surge was missed, and makes the time to conception quicker.
Studies have shown that pregnancy rates are only improved in woman undergoing IUI for infertility if the IUI is coupled with fertility drugs. These drugs include Clomiphene, letrozole, or human menopausal gonadotropins. In woman doing IUI who are not infertile (i.e. those needing donor sperm insemination), the fertility drugs may not be necessary for the first few treatments, but may decrease the time to conception (and therefore total cost) of a donor insemination cycles.
The use of intrauterine insemination procedures in women whose partner has only abnormal sperm morphology, but a normal semen count and normal sperm motility has been controversial. Some infertility treatment centers advise that if the partner’s semen analysis demonstrates an abnormal morphology of less than 5% than IVF with ICSI is the only treatment option. However, in a large study by Sun et al published in 2012 there was no significant difference in IUI success if the male partner had a sperm count above 20 million and motility above 50% if the female partner was under the age of 35. However, in this large study no pregnancies occurred in woman over 35 whose partner’s morphology was less than 5%. So if you are under 35 years of age, IUI may be an option for you with pregnancy rates per cycle of approximately 7% if the morphology is less than 5%, compared with 13% if the morphology is greater than 5%. If you are over 35 years of age, IVF may be a better option.
Intrauterine insemination coupled with fertility drugs are a good treatment option for many patients with infertility. Your individual success will depend upon your age, egg quality, patency of your fallopian tubes, and partner’s sperm count. Your individual success is best determined by your physician.
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2. Sun Y, Li B, Fan LQ, Zhu WB, Chen XJ, Feng JH, Yang CL, Zhang YH.; Does sperm morphology affect the outcome of intrauterine insemination in patients with normal sperm concentration and motility? Andrologia. 2012 Oct;44(5):299-304. doi: 10.1111/j.1439-0272.2012.01280.x. Epub 2012 Feb 16
3. Wiser A, Shalom-Paz E, Reinblatt SL, Son WY, Das M, Tulandi T, Holzer H.; Ovarian stimulation and intrauterine insemination in women aged 40 years or more.
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Deborah Smith, MD, FACOG, is a reproductive endocrinology and infertility specialist who is in private practice in Parker, Colorado. She completed her residency at St Francis Hospital in Hartford, Connecticut and her fellowship in reproductive endocrinology at the University of Connecticut. She has been on faculty at Creighton University, University of Nebraska, University of Texas, and the University of Colorado, before going into private practice. Dr. Smith has had a infertility practice for the past 20 years specializing in infertility, Inseminations, in vitro fertilization, and cycles utilizing donor oocytes.