Intrauterine Insemination (IUI)
Ovulation Induction and Timed intercourse
Ovulation induction is a treatment used to cause multiple eggs to develop in the ovaries. In nature it is normal for one or two follicles to reach maturity. Typically, medication is taken orally for 5 days. Ovulation is then monitored. Using an in-home urine ovulation predictor kit is sometimes used to confirm ovulation. This kit detects the rise in luteinizing hormone (LH) which occurs approximately 36 hours before ovulation. Unprotected intercourse is recommended between days 10 and 16 of the cycle. Studies have shown that the greater the frequency of intercourse the greater is the likelihood of achieving pregnancy.
IUI – Intrauterine Insemination
Intrauterine insemination (IUI) treatment is often the first line of treatment used to assist patients with anovulatory infertility, mild-moderate male factor infertility, and unexplained infertility.
IUI treatment involves stimulating the ovaries to produce multiple eggs (ovulation induction), monitoring the egg development within the ovaries by ultrasound scans, trigerring ovulation at the appropriate time, and injecting the washed partner or donor sperm into the uterus.
For couples who have completed medicated cycles with timed intercourse without success, or have unexplained infertility, IUI is often the next step. Pregnancy success via IUI may range from 10-15% per cycle. An IUI cycle is not considered a suitable treatment for patients with blocked fallopian tubes and may not be an appropriate treatment for women with severe endometriosis or a history of pelvic infections. If a male partner has an extremely low sperm count, the chances of success are diminished, and IVF is often recommended as an initial step
At Oasis, we offer three kinds of Intrauterine insemination treatments. The choice of treatment is personalized, depending on clinical and financial circumstances. These treatments differ in their efficacy and intensity dictated by ovarian reserve and sperm function assessment.
Ovulation Induction and IUI
Ovulation Induction is often one of the first line therapies used to assist women who are having difficulty getting pregnant. Medications such as Femara (Letrozole) or Tamoxifen help women to ovulate more regularly, thereby improving the chance of getting pregnant. OI is a low cost and low-tech option that has minimal side effects.
When is it used?
OI is prescribed for women who do not ovulate or have irregular menstrual periods. It can also be used in women who ovulate regularly as a method of increasing the number of eggs produced. Most women who have regular periods have approximately a 15% to 20% chance of conceiving in any one month. OI does not work for some women, especially if there are other factors contributing to their infertility.
What to Expect:
Typically, medication is taken orally for 5 days. Ovulation is then monitored. Using an in-home urine ovulation predictor kit is sometimes used to confirm ovulation. This kit detects the rise in luteinizing hormone (LH) which occurs approximately 36 hours before ovulation. Unprotected intercourse is recommended between days 10 and 16 of the cycle. Studies have shown that the greater the frequency of intercourse the greater is the likelihood of achieving pregnancy.
Hot flashes and other menopausal symptoms can occur the first few days of taking the medication, as well as mood swings and breast tenderness. Ovarian Hyperstimulation Syndrome (OHSS) is a rare but dangerous complication of treatment. There is also a risk of Multiple Pregnancy when having OI.
80% of women who undergo OI treatment will ovulate, but less that half of these women will conceive. The following study published by Fertility and Sterility in 1998, compared the expected pregnancy rates achieved each month dependent upon the treatment used.
|Type of Treatment
||Approximate Chance for Pregnancy Per Month
|try on own – no treatment
|Insemination, no ovarian stimulation
|Clomid + intercourse
|Clomid + insemination
From: Guzick D, et al: Efficacy of treatment for unexplained infertility. Fertility and Sterility 1998;70:207-213.)
Combined Cycle and IUI
Intrauterine insemination is a fertility treatment where the sperm is placed in the woman’s birth canal, using a narrow catheter. The sperm is washed to separate the sperm from the seminal fluid so that the most vigorous motile sperm are deposited in the birth canal.
IUI can be done in a natural cycle where a woman does not desire or is unable to take fertility medications. This procedure is timed 12 to 48 hours after ovulation, when the ovary releases the egg into the fallopian tube.
IUI is often combined with Ovulation Induction to increase the chances of pregnancy. Follicle development is monitored using ultrasound scans, and a trigger injection is usually given when the follicles (containing eggs) are mature. IUI is timed 24 to 36 hours later.
When is it used?
There are many factors which can affect conception. IUI is often used as a first line treatment in mild or moderate male factor infertility as well as erectile and ejaculatory dysfunction (retrograde ejaculation).
IUI is necessary when using therapeutic donor insemination (TDI) to achieve a pregnancy. TDI is commonly used by single women, same sex female couples, or when the male partner has poor quality sperm. In this instance, sperm is purchased from a certified distributor who meets all of Health Canada Guidelines.
IUI is typically one of the first treatment options used in unexplained infertility. Studies have shown that using IUI in combination with a drug to stimulate ovarian production, increases the chances of a pregnancy occurring.
What to Expect:
1. Monitoring Ovulation:
Intrauterine insemination must be done around the time of ovulation, therefore watching for signs that ovulation is about to occur is critical. At Oasis Fertility Centre we believe that accurate timing of ovulation is important to increase the success rate of IUI treatment. This means your follicle development will be monitored by ultrasound scans, a trigger injection of human chorionic gonadotropin (HCG) will be administered when the egg is ready, and IUI is then timed accordingly.
2. Sperm Preparation:
Your partner will produce a sperm sample (frozen sperm is thawed) and the sample is washed to separate the motile normal sperm from poorer quality sperm. Washing removes chemicals and bacteria that can cause adverse reactions when placed directly into the uterus. Using a small sample of concentrated sperm can increase the chances of achieving a pregnancy.
Intrauterine Insemination is a safe, low risk procedure. But with any medical intervention there is always a risk of complication. These include:
1. Multiple Pregnancy – IUI alone will not increase the chances of multiple pregnancy by itself. However, when it is combined with ovulation induction (where medication is prescribed to stimulate the ovaries to create more eggs) there is a significantly higher chance of having a multiple pregnancy (twins, triplets, etc.)
2. Infection – There is a slight risk of developing an infection as the result of placing the catheter into the uterus.
3. Bleeding – Placing the catheter into the uterus can cause vaginal bleeding. Bleeding should not impact the chance of a pregnancy.
Success rates for IUI vary depending on the woman’s age, and the factors causing the infertility. Success rates can be as low as 5%, or as high as 25% if you are under the age of 35, but it is highly dependent upon the factors causing fertility issues.
Superovulation Induction and IUI
Superovulation (also called controlled ovarian hyperstimulation) can be an effective treatment for many causes of infertility. It is performed when a woman ovulates regularly. Fertility medications are used to recruit the growth and development of multiple ovarian follicles. The probability of achieving a successful pregnancy is therefore enhanced since multiple eggs are available to be fertilized. The washed sperm is deposited directly into the uterus, so its journey to the fallopian tubes is much shorter than during intercourse.
What to Expect:
1. Treatment Schedule:
A typical IUI cycle begins at the start of your period and ends when you take a blood pregnancy test, about two weeks after your IUI.
2. Stimulation of Egg Growth:
You will begin by taking injectable medication to stimulate the growth and maturation of your eggs. The nurses will instruct you on the use of the medication, including the technique. Injection teaching videos can be accessed here. The medication is injected just beneath the skin (subcutaneous) and recommended in an area of the body with fat, such your stomach or the top of the thigh.
During the treatment cycle, ultrasound scans are performed to assess your response to medication, to make sure that the uterine lining is thickening and that the follicles are growing. Follicles are the small, fluid-filled sacs in your ovaries that typically contain one immature, microscopic egg. Careful monitoring minimizes the risks of multiple births (by adjusting the dosage of the medication so the appropriate number of ovarian follicles develop) as well as ovarian overstimulation (ovarian hyperstimulation syndrome).
When at least one mature follicle on the ultrasound measures over 16 millimeters, it is considered mature. An injection of human chorionic gonadotropin (hCG) is then prescribed to predictably induce ovulation so intrauterine insemination can be timed appropriately.
Intrauterine insemination is one of the least invasive fertility procedures. It is usually timed 24-36 hours after hCG administration. If using sperm from a male partner, he will be advised to come to the clinic on the day of your IUI to deposit a sample, and the andrology department will prepare it for insemination. This process involves washing the sperm to remove debris, unwanted substances like non-motile sperm, white blood cells and prostaglandins that can cause painful cramping when deposited into the uterus. Just like a routine pelvic exam, you will be asked to get undressed from the waist down, and a speculum examination will be performed. The sperm sample is injected directly into the uterus through a thin, soft, flexible catheter. The entire process is virtually painless and takes 5 minutes or so to complete. You will be asked to lie down for 10 minutes, after which you may leave. You will be asked to start taking progesterone supplements and will be provided with the requisitions for the blood work which will provide confirmation of a pregnancy.
After the IUI, it is normal to experience mild cramping. You can do everything you used to do with two exceptions. It is best to avoid alcohol, hot tubs, and saunas for the two weeks before your pregnancy test because they can be harmful to a developing embryo. You should also avoid unaccustomed exercises. About two weeks after your IUI, you will take a blood test to see if you are pregnant. For most women, this two-week wait is the hardest part of the IUI cycle, and it can be tempting to read into every symptom you experience. Having sex and drinking one cup of coffee or tea per day is ok.
If the IUI does not work, it is tempting to scrutinize everything you did afterward, wondering if it could have had an effect. This is unhelpful, as there is nothing you can do during the two-week wait to boost your odds.
Immediate complications of the procedure include discomfort with the insertion of the unlubricated speculum. Occasionally, the catheter can create some discomfort as well, especially if the passageway through the cervix is narrow (cervical stenosis) and the, or if the tilt of your uterus makes insertion more challenging.
While there is a risk of infection with any procedure, infections are rare. Women with endometriosis are more prone to pelvic infections following any pelvic surgical procedures.
Multiple pregnancy is an important side effect of treatment. The incidence ranges between 9 percent with clomiphene citrate, 13 percent with letrozole, and may be as high as 32 percent with gonadotrophin (injectable) treatments. In the event of multiple follicles growing, we will counsel you about the risks and discuss cycle cancellation, conversion to IVF or follicle reduction. These are discussed later. Ovarian hyperstimulation can also occur. In most cases, ovarian hyperstimulation is mild, resulting in ovarian enlargement, bloating, and mild pelvic discomfort. In rare cases, symptoms can progress to significant pelvic and abdominal pain, nausea and vomiting with subsequent dehydration, and difficulty breathing. Please alert the clinic immediately if you experience any of these symptoms.”
The chance of success depends on many factors, and chiefly on your age and the cause of the infertility. For example, women with unexplained infertility have about a 20-to-25-percent chance of getting pregnant over a few cycles. Women under 35 who do not ovulate regularly, may have success rates as high as 50 percent across three to six cycles.
On the other hand, if you are older than 40 years, the chances of pregnancy are significantly reduced, partly because of the 30% increased risk of miscarriage at this age. Indeed, it might even behoove women in their 40s to go straight to IVF instead of trying IUI first.
Another disadvantage is the risk of becoming discouraged given the success rates and loosing steam before effective medical treatment for infertility has even begun.
Superovulation and IUI treatment is associated with a higher risk of multiple births than other forms of assisted reproductive treatments, because despite our best efforts, we cannot always predict how many follicles will develop or ovulate. If the number of mature follicles exceeds 4 on the day of the trigger, we advocate cycle cancellation. Other treatment options to rescue the cycle include:
1. Conversion to IVF. If you choose to opt for this treatment, we will convert your cycle to an IVF cycle, and further monitoring will be performed accordingly.
2. Follicle reduction. Occasionally follicle reduction may be advised to rescue the cycle. Although this procedure does not eliminate, it may decrease the multiple pregnancy rate by decreasing the number of mature follicles prior to the hCG injection. A needle is passed into your ovary and all follicles that are over 14 mm are removed, leaving 4 mature follicles in the ovaries. “