Intrauterine Insemination IUI

Definition

Sperm are inserted into the uterine cavity around the time of ovulation.

IUI can be done in

A natural cycle
Stimulated Cycle

The ovaries are stimulated with

Antioestrogens: a course of tablets for 5 days
Gonadotrophins: a course fertility injections every day for 6 to 9 days or longer

Ovarian response is monitored by vaginal ultrasound.

Human Chorionic Gonadotrophin injection is given to trigger ovulation; when one to three ovarian follicles are seen to have developed to the required size, usually with one dominate follicle.

Prepared sperm is inseminated 24 to 36 hours later. Insemination may be withheld if 2 or more mature follicles are seen to reduce the risk of multiple pregnancies.

IUI has been used in:

Unexplained infertility
Mild endometriosis
Mild male-factor infertility
Disability (physical or psychological) preventing vaginal sexual intercourse
After sperm washing in a couple where the male is HIV positive
Donor insemination

The primary outcome is live full-term singleton births, as this allow clinicians to inform couples of their chances of safely having a healthy baby.
When this is not available then live birth had to be used as a proxy, but the quality of the evidence was downgraded.
Clinical pregnancy rates are more commonly recorded than live birth rates and are therefore used as a proxy for live full-term singleton birth where live birth rates are not reported.

Multiple births

Is the main risk to a mother and the baby and is linked to

Increased rates of preterm birth
Low birth weight and neonatal mortality in the baby
Pre-eclampsia in the mother.
Multiple pregnancies lead to multiple births.

Adverse Outcomes:

Ovarian HyperStimulation Syndrome OHSS is a potentially life threatening condition and one of the main reasons that ovulation induction treatment is stopped or cancelled.

Other adverse events are:

Miscarriage
Stillbirth
Ectopic pregnancies

There is significantly higher live birth rates with IUI with stimulation compared with IUI without stimulation, but also there were associated higher multiple pregnancy rates.

In Vitro Fertilisation IVF is an alternative to IUI with stimulation.

Several cycles of IUI with stimulation were required to match live birth rates achieved by a single IVF cycle, but with disadvantage of higher multiple birth rates as there was less control over the number of embryos produced.

In conclusion

IUI with stimulation should not be recommended in any situation.

IUI without stimulation is no better than expectant management.

IUI with stimulation is better than expectant management in all groups of women,but it significantly increases the risk of multiple pregnancies.

IUI with or without stimulation should not be routinely offered.

In certain groups where vaginal sex is inappropriate or not possible; IUI without stimulation with sperm from a male partner or donor would be the first-line approach.

Expectant management for two groups of women with unexplained infertility “mild endometriosis or mild male factor infertility” does not involve active clinical or therapeutic interventions and consist of:

Support to an individual or couple

Provide information and advice about the regularity and timing of intercourse

Advice any lifestyle changes which might improve their chances of conceiving

Unprotected regular vaginal intercourse

Eighty per cent of couples where the women is age 39 years or less will conceive within 12 months.

Over 85% of couples where the woman is less than 35 years will conceive within 12 months.

In couples with unexplained infertility for 2 years ‘including the year before testing and diagnosis’ IVF should be considered to reduce anxiety and depression.

The additional cumulative success rates in the third year would be very small. Success rates decline with the age of the woman. This information should be explained early on to women with the diagnosis of unexplained infertility.

Donor Insemination DI in Unexplained Infertility (mild endometriosis or mild male factor infertility)

The cumulative success rates with intra cervical insemination (ICI) and Intra Uterine Insemination (IUI) in women who are 35 years or less is shown in the table:

Semen Type	Insemination Type	Pregnancy after 6 cycles of DI	Pregnancy after 12 cycles of DI
Thawed	ICI	›40%	›60%
Fresh	ICI	›50%	›70%
Thawed	IUI	›60%	›80%

Women in same sex relationships with a diagnosis of unexplained infertility “mild endometriosis or mild male factor infertility” should have up to 12 cycles of donor insemination. This would be equivalent to expectant management for that group ‘unexplained infertility’ in couples.

Other groups requiring special consideration

IUI using partner or donor sperm without ovarian stimulation would be appropriate treatment for up to 12 cycles:

If vaginal intercourse is not possible or very difficult (physical disability or psychosexual problem).
In couples where the male is HIV positive requiring sperm washing.
If there is an objection to IVF (social, cultural or religious)

Recommendation

Unstimulated Intrauterine Insemination is considered as a treatment option in the following groups as an alternative to vaginal sexual intercourse:

If vaginal intercourse is not possible or very difficult (physical disability or psychosexual problem) using partner or donor sperm.
In couples where the male is HIV positive requiring sperm washing.
People in same sex relationships.

For people in the above groups who have not conceived after 6 cycles of donor or partner insemination, despite evidence of normal ovulation, tubal patency(not blocked} and normal semen analysis, further 6 cycles of unstimulated intrauterine insemination could be offered before IVF is considered.

In people with Unexplained Infertility “mild endometriosis or mild male factor infertility” who are having regular unprotected sexual intercourse Intrauterine Insemination, either with or without ovarian stimulation is not routinely offered (exceptional circumstances include, social, cultural or religious objections to IVF).

The advice is to try to conceive for a total of 2 years (including the one year prior to infertility investigations) before IVF is usually considered. However many circumstances including the age of the woman, the individual request and other reasons should be taken into consideration and IVF should be offered earlier.