Procedure for intrauterine insemination (IUI) using processed sperm
- Elizabeth S Ginsburg, MD
Elizabeth S Ginsburg, MD
- Associate Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Intrauterine insemination (IUI) is a procedure in which processed and concentrated motile sperm are placed directly into the uterine cavity.
Intravaginal insemination is a low cost, low resource alternative to IUI that is sometimes used by couples who are unable to have, or choose to avoid, vaginal intercourse (table 1).
Clinical use of intrauterine insemination (IUI) is based on the hypothesis that placing a large number of sperm high in the reproductive tract enhances the likelihood of conception. The minimum requirements for performing the procedure are ovulation in the IUI cycle, patency of at least one fallopian tube, inseminate with an adequate number of motile sperm, and absence of documented or suspected active cervical, intrauterine, or pelvic infection.
Because coitus can be avoided, IUI is particularly useful in couples with some types of severe sexual dysfunction (eg, severe vaginismus, ejaculatory dysfunction) or discordant for sexually transmitted disease carriage (eg, human immunodeficiency virus [HIV], hepatitis). For cervical factor or mild male factor infertility, IUI allows sperm to bypass potentially hostile cervical factors, thus increasing the number of sperm that gain access to the uterine cavity (and oocyte). For women undergoing ovulation induction, including those with unexplained infertility or minimal or mild endometriosis, pregnancy rates are thought to be higher when IUI is used as an adjunctive procedure instead of timed natural intercourse. In these couples, IUI is often used as an intermediate level and cost-effective intervention prior to proceeding to in vitro fertilization (IVF). The pregnancy rate after IUI depends on male factors, female factors, and technical factors.
Clinical use of IUI is discussed in more detail separately:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Jurema MW, Vieira AD, Bankowski B, et al. Effect of ejaculatory abstinence period on the pregnancy rate after intrauterine insemination. Fertil Steril 2005; 84:678.
- Marshburn PB, Alanis M, Matthews ML, et al. A short period of ejaculatory abstinence before intrauterine insemination is associated with higher pregnancy rates. Fertil Steril 2010; 93:286.
- Agarwal A, Deepinder F, Cocuzza M, et al. Effect of vaginal lubricants on sperm motility and chromatin integrity: a prospective comparative study. Fertil Steril 2008; 89:375.
- Anderson L, Lewis SE, McClure N. The effects of coital lubricants on sperm motility in vitro. Hum Reprod 1998; 13:3351.
- Boomsma CM, Heineman MJ, Cohlen BJ, Farquhar C. Semen preparation techniques for intrauterine insemination. Cochrane Database Syst Rev 2007; :CD004507.
- Morshedi M, Duran HE, Taylor S, Oehninger S. Efficacy and pregnancy outcome of two methods of semen preparation for intrauterine insemination: a prospective randomized study. Fertil Steril 2003; 79 Suppl 3:1625.
- Pasqualotto EB, Daitch JA, Hendin BN, et al. Relationship of total motile sperm count and percentage motile sperm to successful pregnancy rates following intrauterine insemination. J Assist Reprod Genet 1999; 16:476.
- van Weert JM, Repping S, Van Voorhis BJ, et al. Performance of the postwash total motile sperm count as a predictor of pregnancy at the time of intrauterine insemination: a meta-analysis. Fertil Steril 2004; 82:612.
- Van Voorhis BJ, Barnett M, Sparks AE, et al. Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization. Fertil Steril 2001; 75:661.
- Miller DC, Hollenbeck BK, Smith GD, et al. Processed total motile sperm count correlates with pregnancy outcome after intrauterine insemination. Urology 2002; 60:497.
- Huang HY, Lee CL, Lai YM, et al. The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa. J Assist Reprod Genet 1996; 13:56.
- Wainer R, Albert M, Dorion A, et al. Influence of the number of motile spermatozoa inseminated and of their morphology on the success of intrauterine insemination. Hum Reprod 2004; 19:2060.
- Cantineau AE, Janssen MJ, Cohlen BJ. Synchronised approach for intrauterine insemination in subfertile couples. Cochrane Database Syst Rev 2010; :CD006942.
- Osuna C, Matorras R, Pijoan JI, Rodríguez-Escudero FJ. One versus two inseminations per cycle in intrauterine insemination with sperm from patients' husbands: a systematic review of the literature. Fertil Steril 2004; 82:17.
- Cantineau AE, Heineman MJ, Cohlen BJ. Single versus double intrauterine insemination (IUI) in stimulated cycles for subfertile couples. Cochrane Database Syst Rev 2003; :CD003854.
- Bagis T, Haydardedeoglu B, Kilicdag EB, et al. Single versus double intrauterine insemination in multi-follicular ovarian hyperstimulation cycles: a randomized trial. Hum Reprod 2010; 25:1684.
- Rahman SM, Karmakar D, Malhotra N, Kumar S. Timing of intrauterine insemination: an attempt to unravel the enigma. Arch Gynecol Obstet 2011; 284:1023.
- Tonguc E, Var T, Onalan G, et al. Comparison of the effectiveness of single versus double intrauterine insemination with three different timing regimens. Fertil Steril 2010; 94:1267.
- Kyrou D, Kolibianakis EM, Fatemi HM, et al. Spontaneous triggering of ovulation versus HCG administration in patients undergoing IUI: a prospective randomized study. Reprod Biomed Online 2012; 25:278.
- Dankert T, Kremer JA, Cohlen BJ, et al. A randomized clinical trial of clomiphene citrate versus low dose recombinant FSH for ovarian hyperstimulation in intrauterine insemination cycles for unexplained and male subfertility. Hum Reprod 2007; 22:792.
- Diamond MP, Legro RS, Coutifaris C, et al. Letrozole, Gonadotropin, or Clomiphene for Unexplained Infertility. N Engl J Med 2015; 373:1230.
- Badawy A, Elnashar A, Totongy M. Clomiphene citrate or aromatase inhibitors for superovulation in women with unexplained infertility undergoing intrauterine insemination: a prospective randomized trial. Fertil Steril 2009; 92:1355.
- NIH/NICHD Reproductive Medicine Network. Fertility and Infertility Branch, Eunice Kennedy Shriver. Effect of letrozole versus clomiphene on live birth in women with anovulatory infertility due to PCOS: a randomized double-blind multicenter trial. Fertil Steril 2013; 100:S51.
- Veltman-Verhulst SM, Cohlen BJ, Hughes E, Heineman MJ. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev 2012; :CD001838.
- Reindollar RH, Regan MM, Neumann PJ, et al. A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial. Fertil Steril 2010; 94:888.
- Kosmas IP, Tatsioni A, Fatemi HM, et al. Human chorionic gonadotropin administration vs. luteinizing monitoring for intrauterine insemination timing, after administration of clomiphene citrate: a meta-analysis. Fertil Steril 2007; 87:607.
- Matorras R, Diaz T, Corcostegui B, et al. Ovarian stimulation in intrauterine insemination with donor sperm: a randomized study comparing clomiphene citrate in fixed protocol versus highly purified urinary FSH. Hum Reprod 2002; 17:2107.
- Matorras R, Osuna C, Exposito A, et al. Recombinant FSH versus highly purified FSH in intrauterine insemination: systematic review and metaanalysis. Fertil Steril 2011; 95:1937.
- Ghosh C, Buck G, Priore R, et al. Follicular response and pregnancy among infertile women undergoing ovulation induction and intrauterine insemination. Fertil Steril 2003; 80:328.
- Silverberg KM, Olive DL, Burns WN, et al. Follicular size at the time of human chorionic gonadotropin administration predicts ovulation outcome in human menopausal gonadotropin-stimulated cycles. Fertil Steril 1991; 56:296.
- Palatnik A, Strawn E, Szabo A, Robb P. What is the optimal follicular size before triggering ovulation in intrauterine insemination cycles with clomiphene citrate or letrozole? An analysis of 988 cycles. Fertil Steril 2012; 97:1089.
- Farhi J, Orvieto R, Gavish O, Homburg R. The association between follicular size on human chorionic gonadotropin day and pregnancy rate in clomiphene citrate treated polycystic ovary syndrome patients. Gynecol Endocrinol 2010; 26:546.
- Bakas P, Konidaris S, Liapis A, et al. Role of gonadotropin-releasing hormone antagonist in the management of subfertile couples with intrauterine insemination and controlled ovarian stimulation. Fertil Steril 2011; 95:2024.
- Gómez-Palomares JL, Acevedo-Martín B, Chávez M, et al. Multifollicular recruitment in combination with gonadotropin-releasing hormone antagonist increased pregnancy rates in intrauterine insemination cycles. Fertil Steril 2008; 89:620.
- Checa MA, Prat M, Robles A, Carreras R. Use of gonadotropin-releasing hormone antagonists to overcome the drawbacks of intrauterine insemination on weekends. Fertil Steril 2006; 85:573.
- Arab-Zozani M, Nastri CO. Single versus double intrauterine insemination (IUI) for pregnancy: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2017; 215:75.
- van der Poel N, Farquhar C, Abou-Setta AM, et al. Soft versus firm catheters for intrauterine insemination. Cochrane Database Syst Rev 2010; :CD006225.
- Lavie O, Margalioth EJ, Geva-Eldar T, Ben-Chetrit A. Ultrasonographic endometrial changes after intrauterine insemination: a comparison of two catheters. Fertil Steril 1997; 68:731.
- Settlage DS, Motoshima M, Tredway DR. Sperm transport from the external cervical os to the fallopian tubes in women: a time and quantitation study. Fertil Steril 1973; 24:655.
- Saleh A, Tan SL, Biljan MM, Tulandi T. A randomized study of the effect of 10 minutes of bed rest after intrauterine insemination. Fertil Steril 2000; 74:509.
- Hill MJ, Whitcomb BW, Lewis TD, et al. Progesterone luteal support after ovulation induction and intrauterine insemination: a systematic review and meta-analysis. Fertil Steril 2013; 100:1373.
- Smith JF, Eisenberg ML, Millstein SG, et al. Fertility treatments and outcomes among couples seeking fertility care: data from a prospective fertility cohort in the United States. Fertil Steril 2011; 95:79.
- Haagen EC, Hermens RP, Nelen WL, et al. Subfertility guidelines in Europe: the quantity and quality of intrauterine insemination guidelines. Hum Reprod 2006; 21:2103.
- CLINICAL USE
- SPERM COLLECTION AND PROCESSING
- Semen collection
- Sperm processing
- TIMING THE INSEMINATION
- Unstimulated cycles
- Stimulated cycles
- - Clomiphene citrate
- - Gonadotropin and hCG
- IUI PROCEDURE
- Patient preparation
- Postprocedure care
- NUMBER OF IUI CYCLES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS