What is Intrauterine Insemination (IUI)?
Intrauterine insemination (IUI) is a fertility treatment in which a concentrated sample of motile sperm is placed directly into the uterine cavity. An IUI is often performed in conjunction with ovarian stimulation for ovulation induction, although it can also be done following a natural cycle. If oral or injectable medication is used for ovulation induction, monitoring of your hormone levels and follicle growth may be necessary during your cycle.
However, even with careful monitoring, there are risks associated with ovarian stimulation and IUI that are not as common with more advanced reproductive technologies, like in vitro fertilization (IVF). It’s important that you understand the risks and know when it is appropriate to cancel an IUI cycle.
How Does Ovulation Induction and IUI Work?
Ovulation induction usually starts at the beginning of your menstrual cycle. Here are more details on the procedure and the timing:
Oral medications such as Clomiphene Citrate (Clomid) or Letrozole, or injectable hormones like Gonal-F, Follistim or Menopur can be used to help if you do not ovulate, or if you ovulate infrequently.
Two weeks into your cycle, your fertility doctor will verify the number of mature follicles on ultrasound and determine if you are ready to take a human chorionic gonadotropin (hCG) injection, which triggers ovulation to occur approximately 36 hours later.
After taking the hCG, you will then be scheduled for an IUI appointment within that time frame.
Prior to your IUI appointment, a semen sample is collected from your partner, or thawed if a frozen donor sperm sample is being used.
The sample is then washed so a high concentration of motile sperm is available for insemination.
The procedure, which takes just a few minutes, is performed in the office using a small, flexible catheter that is placed into the uterine cavity. Following the procedure, you can resume daily activities.
Please note that IUI success rates vary by age and diagnosis.
What Are the Risks Associated with Ovarian Stimulation and IUI?
When fertility medications are used, it’s possible for more than one follicle to develop. As a result, there’s a higher chance of superovulation (ovulating more than one mature egg), and also fertilization of more than one egg. With a greater number of mature follicles, the risk of having a multiple pregnancy increases.
The likelihood of having a multiple pregnancy also depends on the type of ovarian stimulation used:
- The risk of having a twin pregnancy following use of oral ovulation induction agents is approximately 8%.
- The risk of having a twin pregnancy following the use of injectable hormones and IUI is about 20%.
- Triplets or more occur in less than 1% of IUI cycles.
While there is no definitive evidence regarding the exact number of follicles that increases the risk of a multiple pregnancy, most providers exhibit caution with 3 or more mature follicles. However, in some cases, depending on age and treatment history, triggering ovulation of 3 or more follicles may be warranted. You should discuss the risks and benefits of triggering ovulation with your provider, based on your history and ultrasound findings.
Why is a Multiple Pregnancy Considered to be a Risk?
Multiple pregnancies (twins, triplets, or higher) have an increased risk of harm to both the mother and babies. Multiple gestations can cause health issues for the mother, such as:
- High blood pressure.
- Need for a cesarean section.
- Delivery complications.
There are also complications for the babies, including:
- Preterm delivery
- Low birth weight
- Delayed lung development
- Neurological issues
These health risks increase with high order multiples (triplets or more). Therefore, if you are pregnant with triplets or more, you should consider a consultation with a high-risk obstetrician/maternal fetal medicine doctor to discuss the option of selective reduction of the pregnancy. While a selection reduction may be beneficial in terms of minimizing medical risks to both mother and babies, it does however have an increased risk of miscarriage of the entire pregnancy. Therefore, it should only be performed by a highly-specialized and experienced physician.
When Should I Cancel My IUI?
You should weigh the risks and benefits of triggering ovulation with 3 or more mature follicles with your doctor. If you and your fertility doctor agree to cancel your IUI due to the risk of a multiple pregnancy, you should abstain from intercourse and allow ovulation to occur naturally until your next cycle. You and your doctor may also discuss alternative regimens for ovulation induction, to minimize risk in future cycles.
Dr. Alan Copperman is a board-certified reproductive endocrinologist and infertility specialist with a long history of success in treating infertility and applying fertility preservation technologies. He serves as Medical Director of Progyny, a leading fertility benefits management company, and co-founded and serves as Medical Director of RMA of New York, one of the largest and most prestigious IVF centers in the country. Dr. Copperman is also the Vice Chairman and Director of Infertility for the Icahn School of Medicine at Mount Sinai, and Chief Medical Officer of Sema4, a health information company. Dr. Copperman has been named to New York magazine’s list of Best Doctors 17 years in a row. He has been recognized by his peers and patient advocacy organizations for his commitment to patient-focused and data-driven care. He has published more than 100 original manuscripts and book chapters on reproductive medicine and has co-authored over 300 scientific abstracts on infertility, in vitro fertilization, egg freezing, ovum donation, and reproductive genetics.