Frequently Asked Questions about Intrauterine Insemination (IUI)
BY DR. KAVITA MANTRY Infertility Specialist
IUI FREQUENTLY ASKED QUESTIONS
Q: What is an IUI and how is it done?
A: An IUI -- intrauterine insemination -- is performed by threading a very thin flexible catheter through the cervix and injecting washed sperm directly into the uterus. The whole process doesn't take very long — it usually only requires the insertion of a speculum and then the catheter, a process that maybe takes a couple of minutes (60-90 seconds to introduce the catheter, then sperm injection, and another 60 seconds or so to remove the catheter — going slowly helps reduce discomfort). Sometimes when the cervix is hard to reach a tenaculum is used to hold the cervix, which makes the process a bit more uncomfortable. A typical "Tomcat" catheter is shown below.
Q: Where is the sperm collected? How long before the IUI?
A: Usually the sample is collected through ejaculation into a sterile collection cup, but it is also possible to obtain collection condoms for this purpose (through the doctor's office -- Milex is one company that makes them). Most clinics want the semen to be delivered within a half hour of ejaculation, around the time of liquefaction, so if one lives close enough the sample can be collected at home. If not, one has to make do with a room at the clinic, a bathroom, or any private setting.
There is a delay between when the semen sample is dropped off for washing and when it is inseminated. The amount of time depends on the washing technique used, which takes 30 minutes to two hours, as well as on the clinic's scheduling. Most will perform the IUI as soon after washing is completed as possible.
Q: When is the best timing for an IUI?
A: Ideally an IUI should be performed within 6 hours either side of ovulation — for male factor infertility some doctors believe after ovulation is better, otherwise chances of success are higher with insemination before ovulation with the sperm waiting for the egg. When timing is based on an hCG injection, the IUIs are usually done between 24 and 48 hours later. Typical timing would be to have a single IUI at about 36 hours post-hCG, though some do it at 24 hours, and some clinics are reporting better results when doing the IUI at 40-42 hours post-hCG. If two IUIs are scheduled, they are usually spaced at least 12 hours apart between 24 and 48 hours after the hCG. Some reports show no increase in success rates with two IUIs, but others suggest it may increase success as much as 6 percent.
Some doctors will base timing of IUI on a natural LH surge. In that case, a single IUI at 36 hours is the norm, but doing them at 24 hours is also pretty common since ovulation may be a bit earlier. When two inseminations are planned, they are usually timed between 12 and 48 hours after the surge is detected.
The egg is only viable for a maximum of 24 hours after it is released.
Q: What is the success rate for IUI?
A: Searching through about a dozen medical journal articles and a number of web sites resulted in a rather wide range of statistics. Basically the odds of success are reported to be just under 6 percent and as high as 26 percent per cycle. The low statistics are with one follicle, while multiple follicles resulted in as high 26 percent success. Another influencing factor is sperm count. Higher sperm counts increase the odds of success; however, there was little difference between success with good-average counts and those with high counts. The overall success rate seems to be between 15-20 percent per cycle, judging from the articles which will be abstracted below. The rate of multiple gestation pregnancies is 23-30 percent.
Q: What does an IUI feel like?
A: Most women consider IUI to be fairly painless -- along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is ovulation-related rather than from the IUI. The catheter usually doesn't feel like much since the cervix is already slightly open for ovulation -- a poorly timed IUI might cause more discomfort at the cervix. See the personal experiences below for more details.
Q: How long does washed sperm live?
A: Current research indicates that washed sperm can live 24-72 hours; however, it does lose potency after 24 hours. Another issue with IUI is that the sperm can keep on swimming beyond the fallopian tube, so the ideal window is really within 6-12 hours of the egg being released, with a larger margin before ovulation than after since the egg's viability is shorter. Sperm can live up to 5 days in fertile mucus, 2-3 days being pretty common, so combining IUI with intercourse may provide better coverage.
Q: Do I have to lay down after an IUI?
A: You don't have to lay down because the cervix doesn't remain open, but most doctors let patients lay down on the table for 15-30 minutes after the procedure.
Q: Do I need to take it easy after an IUI?
A: Most people don't need to, but if you had cramping or don't feel well afterward it makes sense to take it easy for awhile. Some people reduce their aerobic activity and heavy lifting during the luteal phase in hopes it will increase the chance of implantation. It is more important to take it easy for a bit after IVF, as that is a more invasive process.
Q: How long before an IUI should the male abstain from intercourse/ejaculating and store up sperm?
A: This depends on your individual situation, but it usually should not be more than than 72 hours since his last ejaculation in order to ensure the best motility and morphology. Where low sperm count is the reason for IUI, it is generally best to wait 48 hours between ejaculation and collecting sperm for the IUI. With no sperm count issues, it makes sense to wait at least 24 hours. Some suggest trying for about 36 hours to cover the most territory with the highest counts — a common suggestion is to have intercourse around the time of hCG injection.
Q: How soon after an IUI can I have intercourse?
A: Usually you can have intercourse anytime after an IUI . . . in fact, most doctors suggest having intercourse, when that is an option, soon after the last IUI to help make sure ovulation is covered. Your doctor may suggest waiting 48 hours to resume relations if you had any bleeding during the IUI or if a tenaculum is used.
Q: Can the sperm fall out?
A: Once the sperm is injected into the uterus, it does not fall out. There can, however, be increased wetness after the procedure because of the catheter loosening mucus in the cervix and allowing it to flow out. Some doctors will insert a cup around the cervix to prevent leakage, but most do not.
Q: How come I feel wetter after the IUI — like the sperm is falling out?
A: The catheter loosens cervical mucus and lets it come out more easily. It is common to see more fertile mucus after an IUI for this reason, as well as the fact that well-timed IUI should be close to ovulation.
Q: How many follicles give my best chance of getting pregnant?
A: According to different studies, either 3-4 follicles gives one the best chance of getting pregnant, while more follicles beyond that simply increases the risk of multiples. The U.S. study said 4 follicles, while other countries have data stating 3. The U.S. has a higher rate of multiple births, so 3 may be more likely to be the correct answer.
Q: Does IUI make sense when there isn't a sperm count problem?
A: IUI can help on Clomid cycles where cervical mucus is a problem, and IUI increases the chance of success on injectable cycles no matter what the sperm count. It does make sense to try IUI if you can and haven't had success with intercourse. It is important to note that with intercourse, only the best and strongest sperm make it through the cervical mucus and up into the uterus and fallopian tubes. With IUI, more sperm will be available for fertilization.
Q: How high a sperm count is needed for IUI?
A: A count above one million washed appears necessary for success, with a significant reduction in pregnancy rates when the inseminated is count is lower than 5-10 million (in other words, in most cases one should consider 5 million a lower limit for success, 10 million for cost-effective). Higher success rates are with washed counts over 20-30 million, while increasing counts over 50 million did not appear to offer advantage. Advanced Fertility has a chart of success rates for one month of various treatments.
Q: How many IUIs should I try before moving on to IVF?
A: It depends on what you can afford and what meds you are doing. One might do 3-4 IUIs on Clomid before moving on to injectables, then do 3-4 cycles on injectables. If one doesn't have success after four good ovulatory cycles on injectables with well-timed IUI, it would be time to consider IVF.
Q: Is bleeding common after an IUI?
A: It doesn't usually happen, but it isn't uncommon. It is most common to have some bleeding if the doctor had trouble reaching the cervix. Some women also have light bleeding with ovulation.
Q: How long after IUI should implantation occur?
A: Implantation generally takes place 6-12 days after ovulation — so 6-12 days after a well-timed IUI. See abstract.
Q: What kind of monitoring is usually done for an IUI cycle?
A; This depends mostly on how the female is being treated. A natural cycle is often timed to over the counter ovulation prediction kits,. The use of clomiphene citrate can increase the monitoring, but many doctors don't do ultrasounds or settle for one u/s around cycle day 12. Gonadotropins increase both medication costs and the necessity of ultrasounds and bloodwork.
Q: At what size are follicles considered mature?
A: Many doctors monitor follicle development during IUI cycles. Most trigger when the dominant follicle is within a certain size range. While there is always some difference in doctor preference, the norms are unmedicated 20-24mm, clomiphene citrate 20-24mm, FSH-only meds 17 or 18mm minimum, and FSH+LH would be 16 or 17mm minimum. It is possible for slightly smaller follicles, 14-15mm, to contain a viable egg. Also, follicles continue to grow until they release, usually at a rate of about 1-2 mm per day. A woman may ovulate more than one follicle in a cycle, but the releases will occur within 24 hours. When hCG is not used, only follicles close in size are likely to release. The use of hCG induces ovulation in about 95 percent of women, and will get most mature follicles to rupture.
Q: What should estradiol (E2) level be at time of hCG trigger?
A: The E2 level should be 200-600pg/ml per 18mm follicle. Some doctors are content with a minimum level of 150, but higher tends to be better.
Q: What are the risks involved in IUI?
Q: The main risks are some discomfort such as cramping, minor injury to the cervix that leads to bleeding or spotting, or introduction of infection (including sexually transmitted disease from the sperm itself — it helps to be sure of the known donor's health, or use carefully monitored frozen specimens). There are also risks of hyperstimulation associated with the use of ovulation induction medications such as clomiphene citrate (low risk) and gonadotropin therapy (higher risk). Proper technique and adequate monitoring reduce risks.
Q: Can I take pain medications before or after the procedure?
A: Most women don't need medication for pain associated with IUI. If there is cramping, it is best to avoid medications such as ibuprofen and naproxen (NSAIDS), but Tylenol is considered safe (but maybe not that helpful for cramps).
Q: What does "sperm washing" mean?
A: It is sometimes also called sperm preparation or spinning. It is a laboratory technique for separating sperm from semen, and separating motile sperm from non-motile sperm, for use in assisted reproduction (IUI, IVF).
The washing technique for near normal specimens is mixing the ejaculate after liquefaction with the appropriate washing medium followed by centrifugation. (A centrifuge is a machine that separates materials with different densities by spinning them at high speed.) The supernatant is discarded and the sediment (sperm rich fraction) is re-suspended in more washing medium. This process is repeated 2-3 times maximum. In the final wash, the sediment is re-suspended in 0.5 cc of medium, loaded into a syringe and deposited in the uterus.
The "Sperm Rise" or "Swim-up" technique is one in which two to five cc of medium are carefully layered on top of 0.2-0.5 cc of semen. Motile sperm cells "swim-up" into the culture medium. After some time (30-90 minutes) the medium (containing motile sperm cells) is carefully harvested and centrifuged. If necessary, fresh medium is layered on top of the seminal fluid again to harvest more sperm cells.
The discontinuous gradient centrifugation technique utilizes a dense liquid phase to separate sperm cells from seminal fluid and debris. There are different compounds commercially available that may be used. Semen is deposited on top of this fluid and subjected to centrifugation. Motile sperm cells migrate to the bottom of the tube, which are used for IUI after further washing.
Q: How soon after an IUI can I go swimming?
A: Since the vagina doesn't open unless something pushes it, it is OK to swim shortly after your IUI . . . but because of how much one has invested in getting pregnant, it probably makes sense to wait 48 hours after your IUIs to go swimming.
Q: Can IUI work after tubal ligation (having "tubes tied")?
A: No. A tubal ligation is effective birth control because it prevents the sperm and egg from meeting. The process that leads to pregnancy is having an egg released from a follicle in the ovary and then beginning the journey to the uterus through the fallopian tube. Sperm will travel from the vagina, through the cervix, through the uterus, into the tube where fertilization occurs. IUI bypasses the need for the sperm to travel through the cervix, but that's it. It doesn't get the egg to the other side of the obstruction, so fertilization won't take place. The only way to get pregnant after tubal ligation is by having reversal surgery or an assisted reproduction technology that includes egg retrieval, such as in vitro fertilization (IVF).