How does intrauterine insemination work?

Intrauterine Insemination: What is it?

Intrauterine insemination (IUI) is an assisted reproductive technology (ART) that involves directly introducing prepared sperm into a woman's uterus at the time of ovulation. This procedure is used to increase the chances of conception in couples who have difficulty conceiving naturally, such as those with mild to moderate fertility problems, sperm motility issues, or cervical mucus problems. IUI is often considered a first step in fertility treatments, before moving on to more complex treatments such as in vitro fertilization (IVF). IUI is a relatively simple, non-invasive, and less expensive procedure compared to other ART techniques, and can be performed in a doctor's office.

When to use intrauterine insemination?

What are the indications for intrauterine insemination?

Intrauterine insemination is indicated in cases of:

• unexplained infertility;
• mild to moderate male infertility;
• Stage I-II endometriosis and some cases of Stage III-IV according to the American Fertility Society (AFS) classification, particularly after surgery;
• repeated failures of pregnancy induction through ovulation stimulation and timed intercourse;
• sexual and coital pathologies that have not benefited from simple intracervical insemination;
• cervical factor;

What are the conditions for successful intrauterine insemination?

Essential conditions for successful intrauterine insemination are:

• semen sample with mild/moderate oligoasthenospermia;
• fallopian tube function;

The chances of pregnancy vary from 10 to 20% per attempt depending on the underlying pathology and the patient's age.

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What is involved in intrauterine insemination?

Intrauterine insemination involves moderate pharmacological stimulation (gonadotropins) for multiple follicular growth. Ultrasound monitoring and hormone assays are performed to monitor ovulation during treatment.

The first ultrasound scan, as well as a blood test to measure FSH, LH and ESTRADIOL, are performed on the second or third day of the cycle: it is on this day that we decide whether the patient can continue the stimulation, by calling the gynecologist in the afternoon, who will communicate the values of the hormonal tests performed in the morning. Subsequent ultrasound checks will be decided by the gynecologist.

At the time of ovulation, the male partner will produce a semen sample which, after being capacitated, will be introduced into the uterine cavity via a flexible catheter. This technique is completely painless for the patient and is performed in our PMA department.

How is intrauterine insemination performed?

The phases of intrauterine insemination (IUI) are:

• Pharmacological treatment to induce the maturation of two or three follicles;
• Ultrasound monitoring to assess follicle growth using transvaginal ultrasound and any hormonal assays;
• Semen preparation and introduction of sperm into the uterine cavity;
• Luteal phase control;

Since the hormones used for this purpose can induce the production of different follicles, continuous monitoring is very important in order to avoid side effects and multiple pregnancies. The treatment is followed by a series of ultrasounds to evaluate the development of the follicles and, if necessary, by the measurement of the concentration of certain hormones in the blood.

Ovulation induction in intrauterine insemination differs from that performed in IVF. In the former, the intention is to stimulate the growth of only the dominant follicle, while in the latter, the production of more follicles is induced for fertilization in the laboratory. When two or three follicles reach the appropriate size, ovulation is induced by a further injection of hormone (human chorionic gonadotropin or hCG).

Shortly before or immediately after ovulation, a fresh sperm sample (obtained the same day by masturbation) is prepared using different techniques to allow the sperm to penetrate directly into the uterine cavity, through a catheter, thus avoiding any problem of antibodies present at the level of the cervix. Intrauterine insemination is a simple, outpatient procedure that does not require anesthesia.

Using a fine cannula, a volume of 0.3 to 0.5 ml of treated seminal fluid is placed in the cervix and injected slowly. If it is not easy to pass through the cervical canal, slight traction can be exerted on the neck using forceps and an anxiolytic and/or an antispasmodic can be administered.  

Preliminary medical examinations

For the couple

• Hormone assays;
• Genetic investigations;
• Immunological tests for the presence of anti-sperm antibodies;

For the man

• Semen analysis (examination of seminal fluid to assess its fertilization capacity and other fundamental functions, such as the number, morphology and percentage of motile sperm);
• Semen culture (analysis of semen to assess the presence of infectious agents in the genital organs);

For women

• Hysterosalpingography (to check the condition of the fallopian tubes and their patency);
• Ultrasound of the uterus and ovaries (to check ovulation, the number of oocytes, the presence of any cysts, fibroids or other formations);
• Hysteroscopy (endoscopic examination of the uterine cavity);
• Pap test (cytological examination that checks for the presence of a lesion due to HPV and cell alterations in the cervix);
• Search for infectious agents (e.g., vaginal swab to look for common pathogens such as Chlamydia and Candida);

What are the risks of intrauterine insemination?

Intrauterine insemination has limited risks. If more than three follicles reach a certain size, there may be a risk of multiple pregnancy and the procedure may be abandoned. Generally, if pregnancy does not occur after 2 or 3 cycles of insemination, the case should be reassessed in order to move on to an in vitro technique.

Success rate of intrauterine insemination

Intrauterine insemination is relatively simple and yields good results. The probability of triggering a pregnancy with this technique is 10 to 15% per cycle. The success rates of this technique vary depending on the causes of infertility present in the couple, the age of the patient, the values of the seminal fluid and the type of stimulation performed.

Generally, if pregnancy does not occur after 3-4 cycles of insemination, the case should be reassessed and more sophisticated procedures, such as in vitro fertilization, should be considered.

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