When you are unable to conceive naturally, you have several options. One of the least invasive and least costly options is known as artificial insemination (AI), also referred to as intrauterine insemination or IUI. This procedure is typically one of the first methods used in the event that a couple is unable to conceive naturally after 12 months of actively trying. Before this treatment is considered suitable for a couple, certain criteria need to be met in order for it to have a reasonable chance at success.

Artificial Insemination or IUI is the process of inseminating a woman with collected fresh or frozen ejaculated sperm. The prepared sperm is directly placed in the uterus which eliminates the need for the sperm to travel very far, although they do need to travel up the fallopian tubes to the end, where fertilization often occurs.

This treatment may be appropriate if:

• Ovulation is not occurring and simpler treatments (oral ovulation tablets) have not worked
• Semen analysis shows mild abnormalities
• The cause of infertility is unexplained
• When donor sperm is needed to achieve a pregnancy
• You have at least one patent fallopian tube

Even though artificial insemination is one of the first procedures attempted for infertility, it is not always the right procedure for everyone. The most common cases for IUI are those with a partner with a low sperm count or with sperm that do not have the strength to swim through the cervix and fallopian tubes, making their way to the uterus where the mature egg is waiting to be fertilized. IUI can also be used for women with certain reproductive issues, including any type of obstruction that would give the sperm a difficult time getting through to the uterus, or women that have cervical mucus that does not provide a conducive environment for the sperm to survive.

In order for artificial insemination to be successful, a receptive environment needs to be created. This means that the woman has at least one ovary that produces eggs and a fallopian tube that is patent. In addition, the man needs to be able to produce a semen sample that is suitable to be used in the process. Before you undergo any of the steps for IUI, your fertility specialist will perform tests to determine if your fallopian tubes are clear, your ovaries are producing eggs, and the sperm count and motility is adequate.

The process for IUI is simple and takes place in a series of 6 steps described below. The ultimate goal is to help you produce at least one egg (more is sometimes recommended or needed for success). The semen that is produced will be directly inseminated where it needs to be to promote fertilization and afterwards, you will be continually monitored and given appropriate medications to create an environment that is conducive for a pregnancy to occur.

Step 1. Stimulation

Stimulation of the ovaries is the first, necessary step for the process of artificial insemination. This step can be skipped for some patients if it is determined that egg production is not a problem. This will be determined with a series of blood tests and ultrasounds during menstrual cycles preceding the IUI cycle. If it is determined that you do not regularly produce eggs, stimulating hormones will be provided. These hormones can be provided either orally or via injection. In most cases, the oral hormone, Clomiphene citrate or Letrozole, is used first as it is the most gentle hormone that will not produce an excessive amount of eggs. Women that respond well to oral medication might produce enough good eggs to make the process successful.

Women that do not respond well to oral medication may be given FSH (follicle stimulating hormone) injections. This is usually done in very small doses (which is different from the IVF process) in order to stimulate the ovaries, but not overstimulate them. The goal during the IUI process is to create a situation for one or two follicles to be released from the ovaries, but no more than that. During IVF (in vitro fertilization) the process is different and the more follicles released, the better the chances of the process being successful.

If you suffer from Polycystic Ovary Syndrome, a process called ovary drilling may be used to encourage follicles to be released. Ovary drilling is a surgical procedure which allows the surgeon to gain access to the ovary via a small hole in your belly button (laparoscopy). Once the doctor has access to the ovary, holes are drilled with electric current, in a process called diathermy. This often enables a woman with PCOS to release her own follicles or to respond to administered hormones, such as Clomid.

Step 2. Cycle Monitoring

Cycle monitoring should occur during every IUI attempt whether you use medications or ovulate on your own. Monitoring shows exactly where you are in your cycle; everything is an exact science when it comes to pinpointing the optimum time for egg fertilization.

During the monitoring process you will have blood drawn to test your levels of your oestradiol, luetinizing and progesterone levels, which signifies whether or not you are producing and releasing eggs. You will also undergo some ultrasounds to see the follicles developing in your ovary.

The ultrasound is performed transvaginally, as opposed to over the abdomen, in order to get a close-up view of the ovary. When you look at the screen, you will see black circles which signify the follicles. As ultrasounds are performed throughout your cycle, you should see the follicles getting larger, which could mean that they are producing an egg. A mature follicle is usually around 17mm, sometimes slightly larger.

Step 3. Releasing the Eggs

Once there is evidence that there are one or more follicles that are ready to release an egg, a trigger shot may be administered if you are not showing signs of spontaneous ovulation. This shot provides the luteinizing hormone, which is what triggers ovulation.

Once the LH shot is administered, insemination will need to take place the day of the trigger shot or at the latest, the day after, in order to time the release of the egg and the placement of the sperm to encourage fertilization and a pregnancy.

If you show natural signs of ovulation (an LH surge in your blood or urine) then insemination will occur on the same day as the surge or at the latest, the next day.

Step 4. Preparing the Semen

Now that the female’s body is prepared to accept the semen, it is time to prepare the semen sample to enhance the success of the procedure. The sample is provided to the lab where it is prepared for insemination. Semen/sperm collected directly from the testes (known as surgical sperm collections) are NOT suitable to be used for IUI. Regardless of the origin of the semen, it needs to be collected in a sterile manner.

Recent research has suggested that men should be ejaculating 2-3 times a week for at least 2-3 months prior to treatment. The more frequent ejaculation (2-3 times/week) occurs, the less likely there is damage to the sperm because it has been stored in the testes for too long. The same applies to preparation before an insemination treatment cycle.

On the day of the insemination, you will be asked to produce a fresh sample of semen (collected by masturbation) to a scientist at the Fertility Solutions clinic at a prearranged time. The sample should be produced no earlier than 1 hour prior to the time you are required to take it to the clinic for processing.

You may choose to produce your sample at home or in a dedicated, private room at Fertility Solutions. If you anticipate that the semen collection will be difficult for you, please discuss this with us and we may be able to organize alternative arrangements.

After the sample is prepared, it will be evaluated for its ability to assist you in achieving pregnancy. Any slow moving or abnormal sperm are removed during the washing process; the remaining sperm are placed into a solution that is sperm friendly and then inseminated into the uterus via the cervix.

The semen goes through a preparation process, which is called “washing.” This eliminates any unnecessary compounds present in the semen that could hinder the success of the process. Any sperm that are not moving vigorously are washed out of the sample, along with some compounds normally found in semen that can cause strong cramping in the uterus. The remaining sperm are concentrated into a very small volume of culture medium ready to be used for the insemination. This process takes around 2 hours. The sperm are taken from its current state and liquefied. After a short period of time, the semen is then sorted, in order to locate the most active sperm, increasing the chance of success for the procedure. The most active sperm are then collected in a centrifuge to be used for the insemination process.

Step 5. IUI Procedure

Once all aspects of the IUI process have been prepared, it is time for the insemination – the time you have waited to happen!

The procedure itself is virtually painless and only takes a short amount of time. Most people liken it to having a pap smear. The prepared sperm will need to be placed through your cervix allowing access to the uterus. You are comfortably sat in a chair that angles the lower half of your body in a way that allows for the administration of the sperm; a speculum is then used to open up your vagina, providing the access needed to place the sperm in the uterus.

Once the sperm is placed in your uterus, the procedure is complete, and you are free to go on with your day. The only precautions you should take following the procedure are to stay away from saunas or anything else that would extremely alter your temperature, eat a healthy diet, avoid alcohol and avoid any excessive work (heavy lifting).

Step 6. Maintaining the Proper Environment for a Pregnancy

In a normal pregnancy, the body produces progesterone, which helps to thicken and maintain the uterine lining, which is needed to support a pregnancy. If there is not enough progesterone produced by your body, the uterus cannot hold onto a pregnancy because the lining sheds, as normally occurs every month during the menstrual period. In some cases of IUI, extra progesterone is necessary in order to ensure the proper environment for a fertilized egg.

Progesterone can be administered as a vaginal gel or pessary. The injections are administered several times throughout the process in order to keep the lining thick. Progesterone is easily absorbed, which makes vaginal gel/pessaries a viable option, but you should be prepared to wear a panty liner and to deal with overflow in your underwear as your body uses what it needs and discards the rest.

Progesterone, in either method, is continuously administered until it is determined whether or not the procedure was a success. If it is determined that the procedure was a success, blood tests will determine if you are producing enough progesterone on your own or if the administration needs to continue in order to support the early pregnancy.

It is important to understand that you may not get a normal menstrual period, even if you are not pregnant if you are taking progesterone supplements. They are designed to maintain the lining of the uterus so it does not shed. It is best to wait until you have had an official pregnancy test with a blood draw, to test your hCG levels to determine if pregnancy has occurred.

As with any medical procedure, there are a few issues that can occur that you should understand. The risks are very minimal, but being informed about the risks will help you to be aware of what you should expect.

• Difficulty inserting the catheter – In some cases, the catheter is difficult to maneuver through the cervix. This issue is typically resolved by changing the position of the chair or filling/emptying your bladder
• Cramping – Many women experience cramping shortly after the procedure. It usually does not last long and with a little rest and elevation of your feet, the cramping will subside.
• Infection – The most worrisome issue with an IUI is the risk of infection. This occurs when germs that reside in the vagina are pushed into the uterus. The symptoms of an infection include chills, fever, odorous discharge and an overall feeling of sickness. This complication is very rare.

If you have any questions about your IUI Cycle, you are encouraged to contact your specialist, nurse or a scientist.