Intra Uterine Insemination (IUI)

What is IUI/DI?

Intrauterine insemination is a technique for enhancing the chance of pregnancy. It makes sure that sperm are present at the right place at the right time. By monitoring the growth of the follicles (containing eggs) inside the ovaries, and placing a high number of motile sperm in the uterus at the time of ovulation, we make sure that the conditions are perfect for achieving a pregnancy.

When donor sperm is used, the treatment may be referred to as donor insemination (DI). If you are having treatment with donor sperm, please also read Sperm Donation – Information for Recipients.

IUI/DI can be performed in a natural cycle, without hormones, or with low doses of hormones with the aim of producing 1-2 oocytes.

Why has IUI/DI been suggested?

IUI may be appropriate if:

• The woman does not have blocked fallopian tubes, internal scarring or endometriosis
• The male partner's sperm sample is good or borderline
• The infertility is unexplained

DI may be appropriate if:

• The woman to be treated has minimal or no female infertility factors
  and
• The male partner lacks sperm, has poor sperm quality or is a carrier of a genetic disorder that is not desirable to pass on to a child
  or
• The woman to be treated has no male partner, or has a female partner

Is treatment available on the NHS?

NHS funded treatment is generally not available for IUI or DI for most couples. However, the availability of funding and the criteria for funding may vary between different areas/Health Authorities. These issues will be discussed with you at the time of referral.

What is the cost of treatment?

If you are not eligible for NHS treatment or do not wish to wait for treatment, you may self-fund treatment. Charges include all treatment consultations, procedures, early pregnancy monitoring and counselling.

Important: please note that the cost of the Donor Insemination cycle is charged separately each time and is additional to the price of donor sperm.

What happens before treatment starts?

Investigations
Fertility investigations will have been carried out in the fertility clinic prior to referral. These investigations may involve hormone tests during your menstrual cycle to ensure that you are able to produce oocytes, tests to check that your uterus and your ovaries are normal, your tubes are patent, and a semen analysis for your partner, if applicable. Further investigations may be required and these will be fully discussed with you.

Why do we need tests for HIV and Hepatitis?
For your own safety, the HFEA ruled in 2001 that all individuals undergoing IUI, DI and IVF need a blood test to screen for HIV and Hepatitis B and C. This is to rule out the very small chance of any cross contamination of the viruses in the laboratory and in gamete/embryo storage vessels. Both partners are tested if you are having IUI and just the woman to be treated if you are having DI. If you have a positive test, we will provide counselling and referral to a specialist for advice about your future health. These tests need to be done prior to you starting any treatment, within 3 months of commencement of the treatment itself. If you are not coming through the NHS pathway, you may have to pay for some of these tests. Please clarify this with the doctors/nurses at the fertility centre.

Legal requirements

Confidentiality
Under the terms of the Human Fertilisation and Embryology Act (HFEA) we cannot pass on details of your treatment to anyone not covered by a treatment licence. This means that we cannot tell your GP or referring doctor about your treatment. However, we can pass on details if you provide us with written consent to disclosure. We will ask you to sign a form specifying what information may be passed on and to whom. Usually, this will be your GP, referring doctor and other people directly connected to your treatment or ongoing medical care.

During the course of treatment we have a legal obligation to collect information, including personal details, such as your name(s), date(s) of birth and some medical details. For DI treatment, but not for partner IUI, this information is passed to the HFEA.

The HFEA keeps a register because it has a legal obligation to tell adults, who may ask in the future, whether they were born as a result of a licensed treatment (IVF or treatment with donor sperm, oocytes or embryos).

Consent to treatment
Before beginning treatment we must also obtain your written informed consent. This means that you have been given information about the procedures, had the opportunity to receive counselling and had time to think about your decision. You may choose to change or withdraw your consent at any time before sperm is inseminated.

Welfare of the child
Before offering treatment, we are required by law to consider the welfare of any child who may be born as a result of treatment.

Preconception advice

In order to maximise the chances of conception, to help general health and improve pregnancy outcome should you conceive, you should consider the following aspects of preconception care:

• Folic acid. Supplementation has been shown to reduce the occurrence of Spina Bifida. You should take Folic Acid 400 micrograms daily for three months before conception and continue this until the 12th week of pregnancy. There are special formulations of tablets for women wanting to become pregnant and these contain other vitamins, which may be useful. See your pharmacist for further advice.
• Rubella. You should make sure that your immunity to Rubella has been checked recently. Your GP will usually be able to arrange this, or it may be done through us.
• Cervical Smear. Please make sure that you are up to date with your cervical smears.
• Weight. Women who are overweight may have a reduced chance of success and you should try and make sure your weight is within normal limits before treatment. Similarly, women who are underweight have a reduced chance of success and there are additional problems posed to a pregnancy if they do conceive. A BMI of between 19 and 30 is recommended.
• Smoking. If you smoke you are advised to stop before treatment, not only because it may reduce the chance of treatment working, but also because of the potential effects on a pregnancy. This also applies to male partners as smoking affects sperm quality.
• Alcohol. The effect of modest alcohol consumption is not really known, but you are advised to limit yourself to less than five units a week (spread out over the week).
• Medications. If you are taking any medications, whether prescribed or not, you must tell us before treatment so we can ensure that they do not interact with any of the medications we will give you and that they will not harm a pregnancy. Please do not take any herbal or "alternative" remedies without checking with us first.

First appointment

At this visit the doctor will review your medical history and investigations to ensure that IUI/DI is appropriate for you. The doctor will also explain what is involved in the treatment, what the chances of success are and the risks of treatment.

Nurse consultation

If you wish to proceed with IUI/DI, an appointment will be arranged with a fertility nurse. The purpose of this appointment is to discuss the treatment further (in particular, the timetable for treatment), be trained in how to give injections and arrange a date to commence treatment. The nurse will ensure that all necessary consent forms have been signed. We ask that both partners attend the appointments with the doctor and nurse.

Counselling

All patients are offered counselling at any point of their treatment. You may want to see our fertility counsellor before beginning treatment to help decide whether IUI/DI is the right treatment for you, or to help you with stress or anxiety. All patients using donor sperm must have implications counselling, please see Sperm Donation – Information for Recipients.

How many treatment cycles will be offered?

After three treatment cycles of IUI/DI it is recommended that you have an appointment to see the doctor to discuss whether more IUI/DI is appropriate or if you should consider IVF treatment. However, you may have a review appointment after each attempt if you wish. We will also discuss with you whether there is any NHS funding available for further treatment.

What happens in a treatment cycle?

The following section describes the stages in an IUI/DI treatment cycle.

Start of treatment cycle
The treatment starts shortly after you have started your period. You will come to the centre for a baseline pelvic ultrasound scan. All scans are internal (transvaginal). If you are having a stimulated cycle, you will now start to administer your injections. The injections contain low doses of Follicle Stimulation Hormone (FSH) which stimulates the ovaries to produce follicles. The oocytes are formed inside the follicles. If you are having a natural cycle, your own hormone production should cause a single follicle to grow.

The only thing you will need to remember is to call us on day 1 of your period in order to book the baseline scan. Following this all instructions will be written down for you.

Monitoring the cycle
The growth of the follicles inside the ovaries is monitored carefully with regular vaginal ultrasound scans, normally 2 or 3 times a week.

If too many follicles are developing and the chances of a multiple pregnancy in that particular cycle are considered high, it may be necessary to stop treatment and possibly start again on a lower dose of FSH with your next period. Equally, sometimes a follicle will not grow, and the treatment may be cancelled and restarted, on a slightly different regime.

Triggering ovulation
Ovulation is triggered using a different hormone injection. When 1-2 follicles are at the correct size (usually after 10 to 14 days), a final hormone injection is given which releases the egg(s) from the follicle (ovulation).

The final hormone injection is carefully timed approximately 38 hours before the insemination. As inseminations are usually performed in the morning, this last injection is given late at night two days before. Occasionally, for a variety of reasons, the doctor may request that the time between the trigger injection and insemination is shorter than usual. The reason will be explained to you.

Sperm collection
On the day of the insemination, the male partner will be asked to produce a sperm sample. We have a private room in a quiet part of the clinic for sperm production. He should abstain from ejaculation for 2-5 days prior to the insemination, to maximise both the quantity and quality of the sperm. If donor sperm is to be used, this will be thawed on the day of the insemination. The sample is then prepared to concentrate the motile sperm.

The insemination
The insemination of partner or donor sperm occurs at a maximum of two days after the trigger injection. The procedure is quick and simple and usually completely painless.

The technique used for insemination is similar to having a smear test. A speculum, like that used for a smear, is inserted into the vagina and the cervix and vagina are gently cleaned. A very fine plastic tube is then inserted into the uterus via the cervical canal. This allows the sperm to be deposited in the upper part of the uterine cavity where they will have straightforward access to the egg(s).

Hormone support
In the second half of the cycle the lining of the uterus (endometrium) may be supported with progesterone to help the embryo implant in the uterus. This is called luteal phase support and ensures that the endometrium undergoes the necessary changes to allow implantation of an embryo. The progesterone (luteal phase support) is inserted into the vagina each night starting on the night of the insemination and continuing until the day of the urine pregnancy test two weeks later.

Pregnancy test
We will ask you to do a urine pregnancy test at home two weeks after the insemination. This will test for a hormone called human Chorionic Gonadotrophin (hCG) which is produced during pregnancy. Please telephone us to report the result!

What happens if the test result is positive?

Pregnancy scans
You will be asked to attend for a vaginal scan about three weeks after your pregnancy test (this is equivalent to about seven weeks of pregnancy).

This scan is important to ensure that the pregnancy is in the correct place, that it is developing normally and to confirm how many pregnancy sacs there are. At this stage, the pregnancy should be clearly visible inside the uterus as a small sac with a tiny fetus within. It should be possible to identify a heartbeat at this stage.

If all is progressing normally, you will be asked to attend antenatal care. If problems are identified during these scans we will discuss the findings with you and make appropriate plans.

You should continue taking folic acid until 12 weeks of pregnancy.

Pregnancy outcome
We are required by law to notify the HFEA of the outcome of all treatment cycles. Please report the outcome of the pregnancy back to us. More information regarding this will be given to you when a pregnancy is confirmed.

What happens if the test result is negative?

A negative result means that pregnancy has not occurred this time. We realise that you may be very disappointed and the staff of the clinic are always available to offer support and advice. The counsellor is also available should you wish to have an appointment.

Issues to Consider with IUI/DI

What is the chance of success?
Your own chance of success will be influenced by a number of factors and may be different to the overall chances of success. For up to date national statistics please refer to www.hfea.gov.uk. Important factors affecting the chance of success include the following:

• The age of the woman. The main influence on the success of treatment is the age of the woman. The chance of success decreases with age.
• Previous pregnancies. Women who have been pregnant before, or who have had a previous birth, have a higher chance of conceiving with IUI/DI treatment.
• The duration of infertility. The live birth rate is lower the longer a couple has been infertile. This effect is most marked in long-standing infertility, whatever the age of the woman.
• Previous IUI/DI attempts. The live birth rate is highest during the first two to three attempts of IUI. For this reason we advise that treatment is reviewed after three cycles, or earlier if required.

Is there an increased risk of a multiple pregnancy?
When undergoing stimulated IUI/DI treatment, the chance of a multiple pregnancy is higher than when using no hormones. While the prospect of twins or triplets may seem attractive, there are many serious risks associated with a multiple pregnancy. Research has shown that multiple pregnancies can lead to a higher risk of:

• Complications during pregnancy
• Premature birth and low birth weight
• Disability
• Death of infants within 28 days of birth (known as neonatal death)

In addition to the serious risk to the babies' health, a multiple birth can create enormous strain for the parents, including financial difficulties as well as emotional and physical exhaustion. In some cases, the joys of parenthood are greatly reduced by these problems.

Where can you get further information?

We hope that this information leaflet has given you all the information that you require before your treatment. Please do not hesitate to contact us if you need further information or if you do not understand anything. We welcome any suggestions you may have on improving our leaflets.

The staff of the clinic are always available should you require any further information and this includes 24 hour out-of-hours cover should you have a more serious problem.

A list of national and local Infertility Support groups is available in the clinic.

Further information can be also obtained from the Human Fertilisation & Embryology Authority (HFEA). Please visit www.hfea.gov.uk for information on infertility, treatment and advice on how to choose your fertility clinic.