Artificial insemination for infertility
Intrauterine insemination - IUI
Advanced Fertility
Center of Chicago
Infertility and IVF Specialist Clinic
Gurnee & Crystal Lake, Illinois
Our IVF Success Rates
Our IVF with Donor Eggs Success Rates
Intrauterine
insemination is also called artificial insemination, or IUI. Human artificial
insemination with
the male partner's sperm can be used as a potentially effective treatment for infertility
of all causes in women under about age 45 except for cases with tubal blockage, severe
tubal damage, very poor egg quantity and quality, ovarian failure (menopause), and severe male factor
infertility. In vitro fertilization with the woman's eggs
or IVF with donor eggs are alternatives for couples
that are not candidates for artificial insemination.
IUI is most commonly
used for infertility associated with endometriosis, unexplained infertility, anovulatory
infertility, mild degrees of male factor infertility, cervical
infertility and for some couples with immunological abnormalities. The most
common use (by far) is IUI for unexplained infertility.
Insemination is a reasonable
initial treatment that should be utilized for a maximum of about 3-6 months in women who are
ovulating (releasing eggs) on their own. IUI can be reasonable to use it for somewhat longer
than this in women with polycystic ovaries (PCOS) and
lack of ovulation that have been stimulated with drugs to ovulate.
Artificial insemination should not be used
in women with blocked fallopian tubes. Tubal patency should be
demonstrated prior to performing inseminations. This is usually done with an x-ray study
called a hysterosalpingogram.
Intrauterine
insemination has very little
chance of working in women that are over 40 years old. IUI has also been shown
to have a reduced success rate in younger women with
a significantly elevated day 3 FSH level, or other
indications of significantly reduced ovarian reserve.
If the sperm
count, motility and morphology scores are moderately to severely reduced from
normal, intrauterine insemination is quite unlikely to be successful.
In that situation, IVF with ICSI is indicated and has
high success rates for women under 40 years old.
How is insemination performed? What is the
process for artificial insemination in humans?1. The woman usually
is stimulated with medication to stimulate multiple egg development
and the insemination is timed to coincide with ovulation - release of the eggs
from the follicles.
2. A semen specimen is
either produced at home or in the office by masturbation after 2-5 days of abstinence from
ejaculation.
3. The semen is
"washed" in the laboratory (called sperm processing or sperm washing).
By this process, the sperm is separated from the other components
of the semen and concentrated in a much smaller volume. Various media and techniques can be used to perform the washing and separation,
depending on the specifics of the individual case and preferences of the
fertility doctor and laboratory. The sperm processing takes about 20-60 minutes, depending on the
technique utilized.
4. A
speculum is placed in the vagina and the cervical area is gently cleaned.
5.
Then
the separated and
washed specimen consisting of a purified fraction of highly motile sperm is placed either
in the cervix (intracervical insemination, ICI) or higher in to the uterine cavity
(intrauterine insemination, IUI) using a sterile, thin and soft catheter.
Intrauterine insemination has a better success rate than intracervical
insemination. Therefore, it is the preferred method at the large majority of
fertility specialist centers.
Most programs
offer to let the woman remain lying down on the exam table for a few minutes following
the IUI procedure, although this has not
been shown in studies to improve pregnancy rates. Since the sperm is above the level of
the vagina and cervix, it will not leak out when she stands up.
The
intrauterine insemination procedure, if
done properly, should seem similar to a pap smear for the woman. There should be little
or no discomfort.
Picture of artificial insemination procedure
In the real world, sperm are not visible without a microscope
Intrauterine insemination success rate
Success rates for
intrauterine insemination vary considerably and depend on the age of the
woman, type of
ovarian stimulation (if any) used, duration of infertility, cause of
infertility, number
and quality of motile sperm in the washed specimen, and other factors.
Rates for women over
35 drop off, and for women over 40 are much lower. For this reason, we are more
aggressive in "older" women.
Pregnancy rates are lower when insemination is used:
- in women over
38 years old
-
in women with low ovarian reserve
- with poor quality sperm
- in women with moderate
or severe endometriosis
- in women with
any degree of tubal
damage or pelvic scar tissue
- in
couples with a long duration of infertility (over about 3 years)
The rates are
slightly higher
for women that do not ovulate on their own (anovulation) that
are stimulated to ovulate with medication and then inseminated. This is because
it is more likely that the sole cause of their infertility is their ovulation
disorder - which is overcome with the use of the ovulation stimulating
medication.
For a couple
with unexplained infertility, the female age 35, trying for 2 years, and normal
sperm - we would generally expect about:
- 8%
chance per month of conceiving and delivering with artificial
insemination and Clomid for up to about 3 cycles (lower percentages
with Clomid and insemination after 3 attempts)
- 10% chance per month of
conceiving and delivering with injectable FSH medication (e.g. Follistim,
Gonal-F, or Menopur) and insemination for up to about 3 cycles (lower after 3
attempts)
- 50% chance of
conceiving and delivering with one cycle (month) of IVF treatment (at
our center - pregnancy rates vary greatly between IVF clinics)
Our IVF pregnancy and delivery
success rates
Insemination treatment in
conjunction with ovarian stimulation with
Clomid tablets (clomiphene citrate) vs. insemination after stimulation with injectable
gonadotropins (Menopur, Gonal-F or Follistim)
According to
many published studies, intrauterine
insemination with partner's sperm in conjunction with ovarian
stimulation seems to provide higher pregnancy rates than insemination in natural
menstrual cycles (without ovarian stimulation).
Insemination combined
with ovarian stimulation with injectable gonadotropins provides better pregnancy rates
(and higher multiple pregnancy rates) as compared to insemination combined with
Clomid pills. Injectable gonadotropins usually stimulate more mature eggs to develop than
does clomiphene. More mature follicles and eggs leads to more chance for a pregnancy.
However, more follicles and eggs also entails more risk for multiple
pregnancy. It is a double-edged sword...
More
about multiple birth risks with ovarian stimulation drug treatments
How many infertility treatment cycles should be done with insemination?
Most pregnancies
resulting from
insemination using the male partner's sperm occur in the first 3 attempts. The chances for
success per month drop off after about 3 attempts and drop considerably more
after about 4-6 unsuccessful attempts. Therefore, IUI treatment is not usually
recommended for more than a maximum of 4-6 cycles. If the reason for infertility
is lack of ovulation (anovulation), it may be more reasonable to try several
more cycles (6-9 cycles total). In today's world, many couples with fertility
problems move on to IVF treatment after 3 IUI's. Costs of fertility treatments
for women are an important factor in deciding when to move on from inseminations
for many couples. The relative cost-effectiveness of artificial insemination
decreases substantially after 3
failed attempts.
In
vitro fertilization is
the next step in treatment after inseminations - and has a much
higher success rate per cycle.
Cervical vs. intrauterine insemination
Intrauterine
insemination, IUI, has been shown to be more effective than intracervical insemination.
By placing the sperm higher in the female reproductive tract, presumably
more sperm make it to the area in the fallopian tube where they can take a
crack at having a successful date with the egg(s).
Stimulation with injectable gonadotropins plus
artificial insemination vs. in vitro fertilization
Studies have compared
the effectiveness of these two therapies for unexplained infertility. Pregnancy rates are
improved substantially with either method of therapy as compared to no treatment.
Chances for pregnancy
are better with in vitro fertilization as compared to gonadotropins plus insemination.
However, IVF is more invasive and substantially more
expensive than insemination. Therefore, unless the couple has tubal damage or
poor sperm quality, 2-4 insemination cycles are usually attempted before moving on to
IVF.
Learn
more about inseminations versus IVF as a fertility treatment option
Should one or two
inseminations be done per cycle?
There are several
published studies that address this issue. Some studies show no improvement in pregnancy
rates with two inseminations done on sequential days as compared to one well-timed
insemination. Other studies show significantly higher pregnancy rates when two
inseminations are done.
A possible explanation
for this discrepancy could be that if the single inseminations are not properly timed with
respect to ovulation, pregnancy rates should improve if the two insemination protocol
provides at least one insemination with appropriate timing.
Any insemination
should be carefully timed to occur at or a little before the expected time of ovulation.
We know that, at least in some couples, sperm can remain viable in the female reproductive
tract and result in fertilization of an egg for five or more days. However, we know from
in vitro fertilization that eggs are fertilizable for only about 12-24 hours
post-ovulation. Insemination done 24 hours after ovulation is, therefore, very unlikely to
result in fertilization and pregnancy (although they might conceive if intercourse
occurred earlier that cycle).
Since two
inseminations per cycle might result result in some improvement in pregnancy rates, the
additional cost of fertility treatment and inconvenience could be worthwhile. However, it
may not be warranted on a "cost per pregnancy", or
cost-effectiveness basis. Although some
infertility clinics perform 2 inseminations per cycle, we usually do just one.
Insemination
for male factor infertility
Studies have shown
that intrauterine insemination can be effective for some cases associated with poor sperm quality.
However, if the total motile
sperm count at the time of insemination is less than 5 million, the chances for pregnancy
are quite a bit lower than with higher counts.
If the total motile
sperm count is below 1 million, success rates are very low. Therefore, in vitro
fertilization or donor sperm insemination is usually performed for these cases. However,
sperm counts are not perfect predictors of fertilizing potential. Rare pregnancies can
occur even with total motile counts of less than one million. The converse is
also true - some "normal sperm" (by semen analysis) can not
fertilize eggs at all. The biochemical defect at the molecular level is
sometimes not apparent when sperm are looked at microscopically.
In
vitro fertilization with
ICSI is
usually required for severe sperm
defects.
|
Approximate
chance for success getting pregnant with one month of various treatments
Female age
under 35, 2 years of trying to conceive
|
|
Type of Treatment |
Total
Motile Sperm Count (in millions)
|
|
Less
than 1
|
1-5
|
5-10
|
10-20
|
>
20
|
|
Intercourse
- Trying
on your own |
.2%
|
1%
|
2%
|
2.5%
|
3%
|
|
Intrauterine
Insemination -
IUI
|
.4%
|
2%
|
4%
|
5%
|
7%
|
|
Ovarian stimulation with Clomid
plus IUI
|
.5%
|
2.5%
|
5%
|
7%
|
9%
|
|
Ovarian stimulation with injectable
FSH plus
IUI |
.5%
|
2.5%
|
6%
|
9%
|
12%
|
|
In
Vitro Fertilization - IVF
with ICSI
IVF statistics are
dependent on the clinic
|
60%
|
60%
|
60%
|
60%
|
60%
|
Risks of artificial
insemination in women
The risks associated with intrauterine insemination are 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 during
the intrauterine insemination procedure. Careful cleaning of the cervix
during the procedure and cautious technique so as not to contaminate the
insemination catheter makes these infections a rarity.
The uterus could theoretically be perforated with the catheter if
excessive force is used with a stiff insemination catheter. This
complication should be very rare. We have never seen it at our fertility clinic.
Cost of
artificial intrauterine insemination treatment
The cost
of intrauterine
insemination with partner's sperm, including semen processing vary considerably
between infertility programs. It is usually between $300 and
$800. Ultrasound and blood tests, if needed, for monitoring egg development and
ovulation are additional. The
cost of fertility treatment as well as the cost of fertility drugs can sometimes
both be covered by the female partner's insurance plan. However, in many cases
there will be no coverage for
infertility services, or just coverage for "diagnostic testing" and no coverage
for fertility treatment. The fertility specialist clinic will investigate the
couple's insurance coverage situation before treatment begins.
Please call
us for
our current fees for intrauterine insemination - IUI.
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