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Getting Pregnant With IUI: What You Need to Know
Intrauterine insemination is a fertility procedure that is typically quick and painless. But success rates can vary.
Credit... Simone Noronha
This guide was originally published on July 24, 2019 in NYT Parenting.
It was the night before my first IUI and I couldn't sleep. I had made the mistake of going down a Google rabbit hole, plumbing the depths of parenting forums for any personal stories about intrauterine insemination — especially the negative ones.
I wanted to mentally prepare myself. Would it hurt? Would there be a lot of cramping afterward? Could something unexpectedly go awry?
Like most people, I would have much preferred to avoid a fertility clinic altogether. But I'm married to a woman, so we had little choice in the matter.
We had considered the possibility of intracervical insemination, or ICI, sometimes referred to as the "turkey baster" method. That's where you use a disposable, needleless syringe (NOT an actual turkey baster) to deposit sperm into the vagina. It can easily be done at home.
But with IUI, the sperm is deposited directly into the uterus, so its journey to the fallopian tubes is much shorter than it is with intracervical insemination. I came to think of IUI as kind of like the FastPass tickets at Disneyland. (And when a single vial of donor sperm costs anywhere from $700 to $1,000, you want to be sure the sperm quickly arrive exactly where you need them to.)
For this guide, I spoke with doctors from three of the top fertility centers in the country and examined some of the best available research on IUI. As with any medical procedure, it's best to discuss it with your doctor. But this can serve as a starting point for those new to IUI or who just want to learn more.
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What is IUI?
Although it may sound a bit daunting, intrauterine insemination, or IUI, is one of the least invasive fertility procedures — especially when compared with in-vitro fertilization, or I.V.F.
During I.V.F., a woman's eggs are surgically retrieved from her ovaries; fertilized and developed into embryos in a lab; and then transferred back into her uterus. But IUI is much simpler. Sperm — whether from your partner or a donor — is prepared and then inserted into the uterus through a soft catheter. Most women (myself included) don't feel a thing, and it only takes a few minutes.
What happens during an IUI cycle at a fertility clinic?
A typical IUI cycle begins at the start of your period and ends when you take a blood pregnancy test, about two weeks after your IUI.
First, you'll get a blood test on the second or third day of your period to confirm that you aren't already pregnant. Your doctors will often perform a transvaginal ultrasound to examine your uterine lining and your ovarian follicles (the small, fluid-filled sacs in your ovaries that typically contain one immature, microscopic egg).
During the weeks before ovulation, your doctor will perform additional ultrasounds to make sure that your uterine lining is thickening and your follicles are growing.
When at least one mature follicle on the ultrasound measures over 20 millimeters, ovulation is likely to happen soon. At this point, your doctor might instruct you to take an hCG trigger shot (which induces ovulation about 36 hours after the injection) and will schedule your IUI.
Or, your doctor might tell you to continue measuring the level of luteinizing hormone (which peaks 24 to 48 hours before ovulation) in your urine with an at-home test. When the test indicates that your LH levels have peaked, the IUI is typically performed the following day.
If you are using sperm from a male partner, he will come to the clinic on the day of your IUI to deposit a sample, and the fertility clinic will prepare it for insemination. This process involves washing it to remove unwanted substances like non-motile sperm, white blood cells and prostaglandins (hormone-like chemicals that can cause painful cramping when deposited into the uterus).
If you're using frozen donor sperm, your clinic will thaw it on the morning of your IUI.
During the IUI, your doctor will insert a speculum into your vagina and thread a thin, flexible catheter through your cervix to deposit sperm into your uterus.
The entire process usually takes about 5 minutes. Your doctor will likely advise you to lie down for about 10 minutes after the procedure to prevent you from feeling lightheaded or dizzy.
About a week later, many fertility clinics will check your progesterone levels with a blood test to determine whether you actually ovulated around the time of the procedure. (If you didn't, the procedure is much less likely to be successful.)
About two weeks after your IUI, you'll take a blood test to see if you're pregnant. For most women, this "two-week wait" is the hardest part of the IUI cycle. It can be tempting to read into every symptom you experience. Do your sore breasts mean you're about to get your period? Or does it mean that you're pregnant? Only the blood test will offer official confirmation.
Is medication necessary? And if so, which one(s) will I need to take?
If you don't have any known fertility problems — if your doctor has determined that your partner has male-factor infertility, for example, or if you're getting the procedure because you're a single mother by choice or in a same-sex relationship — you may not need medication during your initial IUI cycles.
But if you've had trouble getting pregnant — either with past partners or with previous IUI cycles — your doctor may recommend certain oral or injectable medications that can help you release more eggs.
In the past, women undergoing IUI were sometimes prescribed gonadotropin injections that would stimulate the ovaries to release multiple follicles, but studies have shown that there is a higher likelihood of multiples with gonadotropins than there is with two of the more commonly used ovulation-inducing drugs, clomiphene citrate or letrozole.
Clomiphene (Clomid or Serophene), is currently the only oral drug that is approved to induce ovulation. It prompts egg growth by stimulating follicles in the ovaries.
But studies have found that letrozole (Femara), a breast cancer medication that's taken orally, can be an effective off-label drug for inducing ovulation. In fact, some studies have suggested that it is more effective than clomiphene in women who have polycystic ovary syndrome, or PCOS. As a result, letrozole is widely used for ovulation induction.
Another commonly prescribed medication is the human chorionic gonadotropin shot, also referred to as a hCG trigger shot (Ovidrel). It's injected under the skin about 12 to 36 hours before your IUI procedure, and mimics the surge of luteinizing hormone, which tells your body to ovulate.
For many women undergoing IUI, these drugs can be a game changer. A seminal study published in the New England Journal of Medicine in 1999, for instance, found that of 932 couples with unexplained infertility, those who received follicle-stimulating hormone with their IUI were nearly twice as likely to become pregnant than those who had IUI without the drugs.
It's important, however, to discuss the potential side effects and risks of these medications with your doctor. The hCG trigger shot, for instance, can cause ovarian hyperstimulation syndrome, a condition that can result in painful, swollen ovaries. Your doctor can help you weigh the potential benefits of medication against the possible risks.
Will IUI hurt?
IUI is not supposed to hurt.
"For most women, it's really very straightforward," said Dr. Martha Noel, M.D., an assistant professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco. "You shouldn't feel anything."
Some women may find the speculum, which usually isn't lubricated, to be uncomfortable. Occasionally, the catheter can create some discomfort as well, especially if you have cervical stenosis and the passageway through the cervix is narrow, or if the tilt of your uterus makes insertion more challenging.
If you've been told that your uterus is anteverted, meaning that it points forward toward your abdomen, having a full bladder during the procedure can help make it easier for the doctors to insert the catheter, Dr. Noel said.
After the IUI, it's normal to experience mild cramping.
Can I resume normal activities after an IUI?
After an IUI, you can do nearly everything you used to do with two exceptions. It's best to avoid alcohol, hot tubs and saunas for the two weeks before your pregnancy test because they can be harmful to a developing embryo, said Dr. Paula C. Brady, M.D., a reproductive endocrinologist and infertility specialist at the NewYork-Presbyterian/Columbia University Irving Medical Center.
The exercise you normally do is "totally fine," she added, unless your doctor tells you otherwise.
Having sex and drinking one cup of coffee or tea per day is also O.K.
If the IUI does not work, it's tempting to scrutinize everything you did afterward, wondering if it could have had an effect. Don't.
There isn't anything you can do during the two-week wait to boost your odds, said Antonio R. Gargiulo, M.D., a reproductive endocrinology and infertility specialist at the Center for Infertility and Reproductive Surgery at Brigham and Women's Hospital in Boston. "It's just luck, honestly," he added.
What are the success rates of IUI?
There isn't a clear-cut answer to this question. It will depend largely on your age and why you're getting an IUI in the first place.
"Actual data on IUI success rates are surprisingly hard to find, because studies include different patient populations, ages, infertility diagnoses, etc.," said Dr. Brady.
But we do know that while IUI is less invasive and less expensive than I.V.F., it tends to be less effective. Research suggests that women with unexplained infertility have about a 20-to-25-percent chance of getting pregnant over a few cycles. Women under 35 who choose to do IUI because they aren't getting periods regularly can see success rates as high as 50 percent across three to six cycles, Dr. Brady said.
If you've tried the procedure three times with no luck, it's best to have another conversation with your doctor, Dr. Brady added. At that point, it might be more efficient and cost-effective to move on to I.V.F.
Can the procedure be successful for women in their 40s?
Yes, but the chances of becoming and staying pregnant are lower than they are for women in their 20s or 30s.
According to Dr. Gargiulo, the average age of the patients at Brigham and Women's Hospital is 38.5 years old. But there's very little published material on the success rates of IUI for women over age 35, he said.
Part of the reason why women in their 40s tend have less success with IUI than those who are younger is because at least 30 percent of pregnancies in women in their early 40s result in miscarriage, Dr. Brady said.
With most patients, "I do set clear limits that we definitely need to sit down after three cycles if it hasn't worked to decide if we want to keep doing this, and we should not do any more than six cycles," she added.
In fact, studies suggest that it might even behoove women in their 40s to go straight to I.V.F. instead of trying IUI first.
Still, "I really think it is for patients to decide," Dr. Brady said. "I.V.F. is expensive and invasive and it's often not where people want to start."
Does IUI increase your chance of having twins?
Yes, but only if you're taking ovary-stimulating medication, which can result in the ovulation of more than one egg.
One study of 900 women with unexplained fertility between the ages of 18 and 40 and published in the New England Journal of Medicine in 2015, for instance, found that among women who took gonadotropic injections, the rate of multiples was 32 percent. With clomiphene it was 9 percent and with letrozole it was 13 percent.
Does IUI come with any other risks?
The IUI procedure carries few risks. While there's a "theoretical" risk of infection with any procedure that involves "introducing something through the vagina and the cervix and into the uterus," Dr. Noel said, infections are rare.
There is, however, the risk of becoming discouraged given the relatively low success rates, according to Dr. Gargiulo.
"I think the main risk to IUI is that the couple may lose stamina and drop off having not even begun effective medical treatment for infertility," said Dr. Gargiulo. "You've got to be ready for a negative pregnancy test nine out of 10 times. If you're ready for that, then IUI is definitely the first way to go for many of our patients."
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Source: https://www.nytimes.com/article/getting-pregnant-iui.html