Intrauterine Insemination can be an effective fertility treatment achieved by injecting a concentrated amount of sperm directly in to the uterine cavity during ovulation.
Intrauterine insemination or IUI, often known as artificial insemination, is recommended for the treatment of male infertility, cervical factor infertility and unexplained infertility. For cases of severe male factor infertility, In Vitro Fertilization (IVF) with Intracytoplasmic Sperm Injection (ICSI), will achieve far greater success. Furthermore, IUI is usually not the optimal treatment for women over the age of 40, in whom low success rates do little to offset the race against time. IVF is preferable in such cases.
The sperm sample to be used for IUI is collected by masturbation then washed and concentrated to separate the fastest moving sperm from non-moving sperm, seminal fluid and prostate secretions. The sperm is drawn up into a thin catheter. The catheter is passed through the cervix into the uterus of the female partner (the procedure is like a Pap smear) and the sperm are deposited into the uterus as close as possible to the time of ovulation. Sometimes two inseminations are performed one day apart, immediately prior to ovulation and immediately after ovulation.
If the female partner has normal, ovulatory cycles, inseminations may be performed in a natural cycle by timing ovulation with an ovulation predictor kit. However, for unexplained infertility or mild male factor, as well as for women who do not have regular ovulation, pregnancy rates are enhanced by using ovulation induction in conjunction with the intrauterine insemination procedure. Therefore, most women undergoing inseminations with their partner’s sperm are also treated with an ovulation-inducing agent.
Oral medications are taken from the third through the seventh day of the menstrual cycle. The medications increase the output of follicle stimulating hormone (FSH), which you can think of as egg stimulating hormone, from the pituitary gland, and may enhance the quality of egg production. Occasionally, more than one egg will mature and ovulate, thus resulting in a small chance (7%) of producing a twin pregnancy or in extremely rare instances more than twins. Insemination is timed by the detection of the luteinizing hormone (LH) surge in the urine (ovulation predictor kit, OPK) and by ultrasound. The female is instructed to start urine testing, usually on cycle day 11 and to call the office when the color change occurs or by cycle day 14. Call our office at 8:30 am to schedule an ultrasound the same day. You can test the either the first or second urine of the morning.
The ultrasound will confirm the presence of a preovulatory follicle(s) and will evaluate the uterine lining. If a follicle is present, the first insemination will be scheduled for the following day, the most likely time for ovulation to occur. Therefore, we will not need the sperm until the following day. An ultrasound will be repeated with the first insemination, and if follicle rupture is confirmed, only one insemination is necessary. If ovulation has not yet occurred, a second insemination will be recommended for the following day. In this way, we try to ensure that sperm are in the uterus and tubes as close as possible to the time of ovulation. Pregnancy testing will be performed 14 to 15 days later if menses have not ensued. The combination of clomiphene or letrozole and intrauterine insemination has a 15% per cycle pregnancy rate with a cumulative pregnancy rate of approximately 40% in three cycles in women under the age of 40. If conception has not occurred within 3 to 4 cycles (or if the woman is over the age of 40), it is often recommended that the couple consider moving on to more aggressive therapy, such as ovulation induction with gonadotropin therapy in combination with IUI.
More aggressive therapy involves injectable medication with or without clomiphene or letrozole. The injections are FSH and expose the ovaries to more FSH than the brain can release with or without the oral medications (clomiphene and letrozole). In a natural cycle without any medication, usually one egg reaches maturity and is released from the ovary; however, in an injectable FSH stimulated cycle, there is usually maturation and release of several eggs, and egg quality may also be improved. These medications are often prescribed when clomiphene or letrozole have failed to work, or in women of older reproductive age.
When injectable medications is involved the ultrasound monitoring visits are more frequent and combined with estradiol blood draws to optimally time ovulation. The injections are administered daily (or occasionally twice daily) until one or more follicles have reached maturation (approximately 10 days). Monitoring with serial blood estradiol levels and transvaginal ultrasounds begins on the seventh or eighth day of the cycle. Follicles usually grow 2 mm/day and an intramuscular injection of Human Chorionic Gonadotropin (HCG) is given to trigger ovulation when the largest follicle reaches 18 mm in diameter. Since several follicles may reach maturity, and more than one egg may be released at different times, inseminations are performed twice, once on the day after HCG administration and again the following day. This regimen results in a pregnancy rate of approximately 20% per cycle in women under age 40, with a 25% chance of multiple pregnancy. Three attempts of gonadotropin ovulation induction with IUI will result in a cumulative chance of pregnancy of 50%. The luteal phase of the cycle is usually supported with progesterone suppositories placed intravaginally twice daily and pregnancy testing is performed two weeks after the second insemination. If pregnancy is achieved, an ultrasound is performed four weeks after insemination (6 weeks gestation) to document the viability of the pregnancy by detection of a fetal heartbeat.
If a couple with unexplained or male factor infertility has not conceived after three attempts of gonadotropin therapy and artificial insemination IUI, it is our general recommendation that the couple move on to IVF to provide higher success rates.
On the specified day, the male partner will collect a semen specimen by masturbation into a sterile container. The sperm are separated from the seminal fluid by washing and centrifugation in culture medium, which also initiates the process of capacitation. Capacitation is a series of enzymatic changes that occur in the head of the sperm, which give the sperm the capacity to fertilize an egg. The sperm are also centrifuged through a density gradient, which separates dead sperm and debris from the actively motile sperm. The motile sperm are then resuspended into a small volume (0.3 cc) of medium, which concentrates them for the insemination. The preparation procedure takes approximately 2 hours to complete.
The sperm are then loaded into a tiny teflon catheter, which is threaded through the female partner’s cervix to the top of the uterine cavity, where the sperm are deposited. This places the sperm in close proximity to the tubal openings and maximizes the number of motile sperm reaching the egg(s). After the insemination is completed, the female partner reclines on the examining table for 10 minutes and thereafter has no restrictions on physical activity.
Intrauterine insemination is a very safe procedure, although there is a small risk of transmission of infection to the genital tract of the female partner if the male partner has an infection (bacterial, viral, or chlamydial) present in his semen. It is also important to understand that there is a 2% risk of congenital abnormalities in all children born, including those from intrauterine insemination. Ovulation induction, sperm washing and insemination do not change this risk.
Estimated cost for oral medicated IUI cycles are $1300 – $1825, depending if one or two inseminations are recommended in a given treatment cycle (month). The cost provided does not include medications.
Estimated cost for a cycle with oral medications AND injectable medications (a MIX/IUI cycle) is $2200 + medications (estimated $2600).
Estimated cost for IUI cycles with injectable medications, Controlled Ovarian Hyperstimulation (COH IUI), are approximately $3,000 + medications (estimated $2200-4000).
Medication costs vary depending on dosage and pharmacy costs and are subject to change.
*Fees are subject to change without notice. Please be advised fees listed may not reflect current pricing structure. Please contact the NCFMC Financial Department for the most current cost estimates.
Updated January 2021