Hi. My name's Kurt Peterson. I'm a board-certified
reproductive endocrinologist and infertility specialist.
I work at Nevada Fertility Center and today we will be talking about IUI.
What is IUI?
IUI stands for intrauterine insemination.
It's a process by which we place sperm up higher
in the reproductive tract in order to optimize the number
of good sperm in the right place at the right time -
hoping to increase your pregnancy chances.
For a typical IUI, we bring patients in for a baseline ultrasound
to verify that the ovaries are resting and then we start them on medications,
typically Letrozole or Clomid.
An IUI cycle takes place over a typical menstrual cycle -
roughly one month.
It is broken down into roughly 2 weeks of meds, monitoring,
and an insemination procedure,
followed by 2 weeks of waiting to test for pregnancy.
You'll typically do a baseline ultrasound around
Cycle Days 3 through 5 to verify
that your ovaries are resting. Then you'll be given
oral medications for about 5 days
to help recruit growth of eggs in what we call "follicles" -
these are fluid-filled spaces within your ovaries
each containing an egg. You'll likely return
around Cycle Day 10-13
for a follicular ultrasound to track recruitment
and growth of these follicles.
Once they reach an appropriate size,
we initiate the ovulation process by giving you
an injection we call the trigger shot.
An intrauterine insemination, or IUI
is typically done 24-36 hours after
the trigger shot, to ensure that motile sperm are present
in the uterus near the time of ovulation.
We're basically optimizing the number of good sperm
in the right place at the right time
by controlling key events of the cycle.
So the average patient will need maybe 2 to 3 ultrasounds
to monitor throughout the process for an IUI cycle.
After the insemination
the patient will wait 14 days before we do a pregnancy test
to verify that it was successful.
So, good candidates for an IUI cycle are patients
who have adequate ovarian reserve,
they have normal uterine testing, meaning a cavity
without any problems inside of it, open fallopian tubes,
and a partner or a sperm source with adequate sperm parameters.
So patients who tend to do well with IUIs are those who don't actually have
a history of infertility but require an IUI for one reason or another.
Sometimes our same-sex couples or those who need
donor sperm insemination for a variety of reasons.
Other patients who tend to do really well with IUIs,
are those who have issues with anovulation
where we can easily induce ovulation with medications -
they tend to have higher success rates with IUI cycles.
So, patients with unexplained infertility,
meaning their testing was normal, but for some reason
or another they are not getting pregnant on their own
do you see improved pregnancy rates with IUI
although, it is more limited - maybe 7% to 10% per cycle
if they have unexplained infertility.
Patients that don't do as well with IUI cycles, may be patients
who have diminished ovarian reserve in combination with advanced age.
So patients over the age of 40 tend to have lower success rates with IUI.
It doesn't mean they can't do them, but we do have lower expectations
for success.
How much sperm do you need for IUI?
Many practices use a total motile count
before the wash to determine whether it's adequate for an IUI.
A pre-wash
total motile count of 10 million is a fair estimate
for adequate sperm for an IUI. And I say estimate
because it does have to go through a wash process
and we expect to lose about 30% to 50%
of the total motile count after the wash.
The hope is that you have greater than 5 million after the wash.
Can people get pregnant with total motile
counts less than 5 million after the wash?
Absolutely. It happens all the time.
But there does arise a question of cost-benefit
when we have sperm counts below 5 million.
Why do some patients go
through timed intercourse before going through IUI?
In patients where the male has a total motile sperm count
greater than 75 million, it's unclear
whether IUI adds any benefit. Some may choose to do timed
intercourse cycles as opposed to an IUI to save on the extra cost
if there is no perceived benefit.
So general success rates for IUI for the first, second and third cycles
are largely going to depend on the diagnosis.
But if we're talking about average pregnancy rates for IUI cycles
being between 10% to 20%,
if you were to do three cycles - over three cycles,
you would expect 30% to 60% of patients to become pregnant.
The pregnancy rates per cycle
stay relatively constant for the first three cycles,
but after the third cycle you start to see a drop in the pregnancy
rates per cycle.
So Letrozole and Clomid have different mechanisms of action
but result in largely the same effect, which is
they cause your brain to release more FSH from the pituitary
and recruit follicles in the ovaries.
Clomid is a selective estrogen receptor modulator,
which basically just tricks your brain into thinking that you don't have estrogen.
So you release more FSH from the pituitary,
resulting in follicular recruitment.
Letrozole works by blocking
an enzyme in your adipose tissue called aromatase.
By doing
so, it creates a sensable reduction in estrogen levels.
And so your brain will release more FSH to recruit follicles.
For questions
in relation to Letrozole versus Clomid, they can essentially be used
interchangeably without affecting the pregnancy rate by very much.
There are some nuances.
In Letrozole, for patients with anovulation or PCOS,
it tends to work a little bit better.
Clomid may have a small advantage in patients with unexplained
infertility, where our goal is to recruit multiple follicles.
So how many IUI cycles should one try before moving on to IVF?
After about 3 to 4 cycles, we see a decline in the benefit from IUI
cycles.
In fact, after 6 cycles of IUI
we see no benefit over trying on your own.
So after 3 to 4 cycles, it's
a great time to start considering whether you should move on to IVF.
Is the IUI procedure painful?
To perform
an IUI, your physician has to place the speculum
inside the vagina and pass a catheter through the cervix.
So under normal circumstances,
one shouldn't feel more than mild discomfort with the procedure.
Do you have to lay down after an IUI?
No. Numerous studies have shown that whether a patient lies down
for a period of time or they get up and move around immediately,
neither has an effect on the success rates of an IUI.
Can you workout after an IUI?
Yes.
There are no restrictions on activity after an IUI.
Going through fertility treatments can be riddled with anxiety and stress.
Exercise can be a great stress reliever.
Can you take a bath or swim after an IUI?
There are some centers that recommend a 24 to 48 hour
wait before bathing or swimming.
There are, however, no data to suggest that this is necessary.
So yes, you can.
So what if you only have
one blocked [fallopian] tube and one open [fallopian] tube? Can you still do IUI?
Yes, you can.
Practitioners usually will want to focus on
ovulating from the side where the tube is open.
If you ovulate from the
opposite side, it may reduce your chances of pregnancy.
How much? We don't know.
So depending on who your practitioner is, they may recommend cancelling
if you develop a follicle on the side of the closed [fallopian] tube.
Or they may say we can go forward
understanding that it may not be optimal.
But one thing to keep in mind is that if you do have one blocked tube
whatever process caused it to be blocked
may have also caused damage to the function of the other tube
that remains open and it could reduce your chances overall.
Can a patient do anything to increase their success with IUI?
Most recommendations in this category are going to be
general opinion regarding
general health and well-being.
So I would recommend doing whatever helps you feel the best
and not stress yourself out with hearsay,
wives tales, or unproven treatments that you read about on social media.
Reassure yourself that you're doing evidence-based
practice with your physician doing an IUI
and trust that you'll have the success rates that are expected.