Difference Between Intrauterine Insemination and In Vitro Fertilization

Assisted Reproductive Technology (ART) Cycles

All examinations that the woman and man undergo before, during, and after an IVF cycle are performed at the facility. Depending on the causes of the couple's infertility, different techniques can be used. These should be applied progressively, starting with the least invasive, from the first to the third level:

• First level: intrauterine insemination;
• Second and third levels: in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI);

Intrauterine Insemination

How does intrauterine insemination work?

Intrauterine insemination is a first-level method in an ART cycle in which the partner's sperm are inserted directly into the uterine cavity to facilitate their meeting with the female gametes (oocytes). Mild multiple follicular growth (maximum 3-4 follicles) is induced by subcutaneous injection of low doses of gonadotropins (follicle-stimulating hormone) or, in some cases, by oral administration of clomiphene citrate. After a few days of treatment, the woman begins ultrasound monitoring of ovulation to assess the number and size of the follicles and, if deemed necessary, a dosage of plasma estradiol and progesterone. Once a correct follicular diameter is reached (approximately 18 mm), the doctor induces ovulation by subcutaneous or intramuscular injection of HCG, and insemination is performed (approximately 36 hours later). This involves transferring sperm, previously treated in the laboratory to make them more capable of reaching the oocyte, into the uterus.

What to do after intrauterine insemination?

Intrauterine insemination takes place in an outpatient clinic, using a flexible catheter inserted through the vagina and cervix.

After intrauterine insemination, the woman remains lying on the gynecological table for a few minutes, then gets up and can resume her normal activities.

Generally, from the evening of the intrauterine insemination, the doctor starts treatment to support the luteal phase by taking progesterone for 14 days after the insemination. The aim of taking progesterone is to support the endometrium (the lining of the uterine cavity) and make it more conducive to the implantation of a pregnancy. 14 days after the procedure, the woman is asked to have a blood test to detect HCG and thus assess a possible pregnancy. If the pregnancy test is negative, the procedure can be repeated several times, without interruption between one stimulation cycle and the next, provided a control ultrasound is performed to verify that there is no obstacle to continuing the procedure.

In Vitro Fertilization (IVF)

The second and third levels of the ART pathway involve in vitro fertilization (also called IVF). This is the technique by which the woman's cells (oocytes) are aspirated from the envelope containing them (follicle) and fertilized in vitro, i.e., "outside the body", with the man's sperm, i.e., in a laboratory.

There are several options for in vitro fertilization:

• IVF: with this method, the oocytes and sperm are placed together in a dish with a suitable culture medium, and the sperm are allowed to naturally penetrate the oocyte;
• ICSI: involves the microinjection of a single sperm directly into the ovum. It is reserved for cases where simple insemination of the oocyte is feared to pose problems in obtaining fertilization, and is considered a level III ART when it is necessary to use sperm surgically collected from the testicle;

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Intracytoplasmic Sperm Injection (ICSI)

Intracytoplasmic sperm injection (ICSI) involves injecting a single sperm, or its precursor, directly into the oocyte (cytoplasm).

ICSI is a technique used to resolve infertility cases mainly due to a severe male factor, but it is also indicated in cases of previous IVF failure and when the number of oocytes available for insemination is limited. There are no major differences in the preparation of an ICSI cycle compared to traditional IVF, except for the laboratory procedures. This technique involves mechanically removing all barriers from the ovum, consisting of cumulus cells and the corona radiata, and introducing a single selected sperm directly into the ovum's cytoplasm. This procedure requires a laboratory instrument called a micromanipulator. ICSI has the enormous advantage of being able to observe and select the gametes (oocytes and sperm) before they are used, in order to choose the best "candidates". The ICSI procedure is similar to that of IVF, except that ICSI overcomes the obstacles to oocyte fertilization. While in IVF, the oocyte is brought into contact with sperm, one of which spontaneously penetrates the oocyte in vitro, in ICSI, the sperm are microinjected under microscopic guidance into the oocyte via the micromanipulator.

IVF or ICSI?

There is no single answer to this question, which is answered differently depending on the specific and subjective case.

The choice between IVF and ICSI depends not only on the characteristics of the seminal fluid but also on various factors such as:

• the woman's age;
• the number of oocytes retrieved;
• whether the problem concerns the woman, the man, or both;
• the couple's request to cryopreserve the oocytes;

Of course, the doctor will assess the situation and advise you on the specific method best suited to your case. The necessary surgical procedures are minimally invasive and painless and are considered to have a low risk (serious complications are very rare). For a woman to be able to go through an ART cycle serenely, doctors advise leading a normal life before, during, and even after treatment.

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