Intrauterine insemination (IUI), also known as artificial insemination, is a fertility treatment and simple medical procedure in which sperm are collected and specially prepared to be directly injected through the cervix and into the uterus.
After 6 to 12 months of trying to conceive with no success, a couple is advised to seek a consultation with a fertility specialist. After consultation and testing, the physician will know what factors and causes are affecting the fertility or will diagnose the couple with unexplained infertility. When the factors and causes are known, it might be sufficient to
- make some lifestyle changes
- start supplementing some nutrients to correct deficiencies and boost fertility
- take medication for the treatment of underlying conditions affecting fertility
- take fertility drugs to induce ovulation and increase fertility and conception rates
When these basic interventions fail, when the couple suffers from unexplained infertility or when there is no indication for such interventions, the couple may seek assisted reproductive technologies (ART), the most commonly known being intrauterine insemination (IUI) and in-vitro fertilization (IVF).
IUI is cheaper and less invasive than IVF and for this reason it may be suggested as the first-line treatment for infertility. However, intrauterine insemination has a lower success rate when compared to in-vitro fertilization.
IUI may be used in conjunction with fertility drugs or in a natural non-medicated approach depending on the indication for the procedure.
Indications for intrauterine insemination (IUI)
Intrauterine insemination is a fertility treatment to address both male and female causes of infertility. It is indicated for the following conditions:
- Unexplained infertility, usually in conjunction with fertility drugs
- Minimal or mild endometriosis.
- Donor sperm insemination. For single women, lesbian couples or severe male factor infertility.
- Frozen sperm. When the male had his sperm frozen before undergoing surgical or medical therapies, such as cancer treatment, which may cause male-factor infertility.
- Ovulation issues.
- Sperm related issues. Such as low sperm count, sperm motility issues, morphologic abnormalities and low-quality sperm in general.
- Cervical issues. When the mucus produced by the cervix is too thick and doesn’t allow the sperm to travel through it, or when there is a narrowing of the cervix affecting sperm passage.
- Sexual dysfunction. Such as erectile dysfunction, anejaculation and premature ejaculation in the male or vaginismus in the female.
- Semen allergy. In rare cases, women may be allergic to some proteins in their partner’s semen. By undergoing IUI the proteins are washed off during the sperm sample preparation and before the injection into the uterus, so no reaction occurs.
- Sexually Transmitted Diseases (STDs). To avoid transmission of diseases such as HIV or HCV when only one partner has tested positive.
IUI is not indicated in the following cases:
- Advanced maternal age
- Infections, such as cervicitis or endometritis
- Cervical atresia or cervical stenosis.
- Severe male factor infertility
- Severe endometriosis
- Severe fallopian tube disease
- Immunological infertility. When the female partner produces anti-sperm antibodies (ASA).
Intrauterine insemination (IUI) procedure
Intrauterine insemination may be performed during a natural ovulation cycle or in a drug stimulated cycle.
During a natural cycle, IUI will be performed around the time of ovulation when there is a surge in luteinizing hormone (LH) that causes the mature egg to be released. For this reason, the day of ovulation has to be known by using home ovulation kits (urine tests), blood tests or ultrasounds. The male partner will have to abstain from ejaculating for 2-5 days before providing the semen sample.
Semen will be collected at the clinic as it needs to be processed soon after ejaculation. The lab will wash the sample and separate the sperm from the seminal fluid. The best sperm are selected and concentrated and then inserted in a small tube. This process takes about 2 hours.
For the woman, the procedure is quick and painless. After lying down, a speculum will be inserted in the vagina to visualize the cervix. The catheter (small tube) will be inserted into the vagina and through the cervix to deliver the sperm directly into the uterus. This process takes just a few minutes. The patient may have to lie down for 15-45 minutes after the procedure; after that, she will be allowed to go back to work or proceed with her daily activities. After 2 weeks the patient will take a pregnancy test.
During a drug stimulated cycle, the process of IUI is the same. The difference is that drugs will be used to stimulate the ovaries and the follicles to mature the eggs and/or drugs will be used to delay the ovulation or for the ovulation to occur. Usually in this case ultrasound scans are used to monitor egg development.
Other sperm retrieval techniques
There are other techniques that can be employed to retrieve the sperm in case the male partner is not able to produce a sperm sample or when there is no sperm in his ejaculate, as in obstructive azoospermia, vasectomy, congenital anatomical abnormalities, retrograde ejaculation and more. They are usually performed before the egg retrieval process when doing in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI), but they may be performed in the context of IUI too. Sperm are also cryopreserved following these techniques for future use in IVF or ICSI.
Percutaneous Epididymal Sperm Aspiration (PESA)
PESA is a technique where a needle is used to puncture the skin and reach the epididymis and then aspirate with a syringe to extract the sperm. It is performed under local anesthesia.
Testicular sperm aspiration (TESA)
TESA is a technique where a needle is inserted through the scrotum and into the testicle. Testicular tissue and sperm are aspirated and then processed. It is performed under local anesthesia.
Testicular Sperm Extraction (TESE)
TESE is a technique where a small piece of testicular tissue is surgical removed and then processed to extract the sperm. It is performed either under local anesthesia or with sedation.
Microsurgical Epididymal Sperm Aspiration (MESA)
MESA is a technique performed in the operating room with a surgical microscope. It allows for collection of a greater sample of sperm when compared to aspiration techniques. It is performed under general anesthesia.
Microdissection TESE (microTESE)
microTESE is a procedure performed in the operating room with a surgical microscope and under general anesthesia. It allows for better sperm retrieval when compared to TESE and for less tissue damage.
Risks of IUI
Intrauterine insemination (IUI) is a simple medical procedure which is generally safe. With IUI there is a low risk of infection, the possibility of spotting which is usually minimal and harmless for the success of the procedure and the risk of multiple pregnancy when IUI is paired with fertility drugs due to the possible development of multiple follicles which will produce multiple mature eggs. To avoid multiple pregnancies, it is possible to monitor the development of the follicles by performing a transvaginal ultrasound; if the risk of multiple pregnancy is too high, the procedure is postponed.
Chances of success with intrauterine insemination
Chances of success depend on multiple factors such as maternal age, cause of infertility and if fertility drugs are used in combination with the procedure.
On average the success rate of IUI is about 10-20% per cycle. Chances sharply decline after 40 with a success rate around 1-5%.
IUI is generally used for 3-6 month (3-6 cycles) before moving on to other fertility treatments such as IVF.
Costs of intrauterine insemination (IUI)
Treatment prices for intrauterine insemination (IUI) vary greatly based on the clinic, the use of fertility drugs, what tests are included and other variables. On average each IUI cycle costs about:
- 700 to 1,600 GBP (850-1,950 USD) in the UK.
- 800 to 1,400 EUR (870-1,530 USD) in Ireland
- 2,000-3,500 AUD (1,300-2,300 USD) in Australia
- 500-4,000 USD in the USA
- 12,000-22,000 BHT (375-690 USD) in Thailand
Check out our other articles on infertility and fertility treatments:
- Causes of male infertility
- Causes of female infertility
- Supplements for female infertility
- Fertility drugs for women
- The BOSTON IVF Handbook of Infertility – Fourth Edition
SR Bayer, MM Alper, AS Penzias – CRC Press, 2018
- Stimulated intrauterine insemination for unexplained subfertility.
A Nandi, T El-Toukhy – The Lancet, Nov 2017
- Indications of Intrauterine Insemination for Male and Non–Male Factor Infertility.
Y Kim, C Park, SY Ku – Seminars in Reproductive Medicine, Jul 2014
- Predictive factors for pregnancy after intrauterine insemination (IUI): An analysis of 1038 cycles and a review of the literature.
P Merviel, MH Heraud, N Grenier – Fertility and Sterility, Jan 2010
- Human Fertilisation & Embryology Authority – UK
- American Society for Reproductive Medicine (ASRM)
- American College of Obstetricians and Gynecologists (ACOG)
- Society for Assisted Reproductive Technologies (SART)