Jun 23, 2022

The Definitive Guide to Intrauterine Insemination (IUI)

Like any fertility treatment, intrauterine insemination (IUI) has a steep learning curve. Whether you're uncertain about the costs of the procedure or wondering how your age affects your likelihood of success, navigating all the details can be overwhelming.

When considering fertility treatments, nearly everyone feels an unsettling combination of possibility and nervous anticipation. While the prospect of starting fertility treatments can feel exciting, jumping in too quickly, and facing health or financial hurdles can add unnecessary stress and complexity.

For this reason, it’s essential to strike a balance between "analysis paralysis," where you're learning so much about a topic you struggle to take action and moving so quickly that you overlook important details.

This guide covers everything you should know about IUI, a non-invasive assisted reproductive technology (ART) with a long history of use in medicine. If you're wondering about how IUI is done, its risks, likelihood of success, and more, this guide is for you.

Intrauterine insemination (IUI) in a nutshell: An overview

IUI is done by placing a highly concentrated sperm sample directly into the uterus around the time of ovulation. By bypassing the cervix and vagina, the goal of IUI is to reduce the amount of distance healthy sperm has to travel to fertilize an egg.

After preparing the sperm for insemination, a practitioner places the sperm concentrate through the cervix using a catheter, a sterilized, thin and flexible tube. After the procedure, conception proceeds as it would with natural fertilization. Many people repeat IUI cycles until it results in pregnancy, usually undergoing no more than three to four cycles.

The process is non-invasive and painless, with the most common symptom being light cramping after the procedure.

When is IUI the right choice?

Thanks to its straightforward timeline and process, the medical community regards IUI as a non-invasive, low-complexity procedure best done before more intensive and costly interventions, such as in-vitro fertilization (IVF).

Fertility specialists usually recommend IUI to heterosexual couples struggling to get pregnant after a year of regular unprotected sex. Conversely, IUI is often the first choice for same-sex couples or single women interested in conceiving a child.

If you have any of the following diagnoses, you may want to investigate IUI.

Unexplained infertility: Certain aspects of IUI, such as sperm washing, can increase the chances of pregnancy with or without medication. The sperm washing process strips away fluids, enzymes, proteins, and other features of sperm that can interfere with fertilization.

Oligospermia (low sperm count), ejaculation issues, etc: The health of a male partner's sperm can be a driving force behind fertility issues in some cases. IUI mitigates problems with sperm movement (motility), quantity, and/or shape abnormalities, improving the likelihood of pregnancy.

Inhospitable cervix: IUI also helps in instances where the cervix may create a barrier to pregnancy. During ovulation, the cervix produces mucus to create an environment where sperm can travel seamlessly from the vagina and into the fallopian tubes. Thick cervical mucus or cervical scarring can cause the cervix to thicken and obstruct the sperm’s passage. By inserting sperm directly into the uterus, IUI can allow a person to become pregnant by bypassing the cervix.

Endometriosis-caused infertility: Endometriosis causes tissue similar to the lining of the uterus to grow where it shouldn't; for example, around the ovaries or intestines. Infertility affects a large percentage of people with endometriosis. In mild cases, IUI combined with fertility medications has helped individuals increase their chances of pregnancy.

IUI is ultimately an assistant to, rather than a replacement for, natural conception. Because sperm still needs to travel through the fallopian tube, fertilize an egg, then implant within the uterus, certain health conditions are incompatible with IUI, including:

  • Moderate to severe endometriosis
  • Moderate to severe male factor infertility
  • Diseases of the fallopian tubes

Types of IUI

Your reason for doing IUI determines whether your procedure will be natural or stimulated. Since fertility issues aren't always the motivating force behind same-sex couples seeking IUI, they often do a natural IUI, meaning that they don't use medication to induce follicle growth and ovulation. In these cases, clinicians time the IUI procedure according to an individual's natural ovulation cycle.

However, even in natural IUIs, your fertility specialist may recommend that you use human chorionic gonadotropin (hCG) hormone, such as Ovidrel (an injectable medication), to increase the chances of implantation by synchronizing egg release with the introduction of sperm during IUI.

Fertility specialists often prescribe oral medications like Clomid or off-label letrozole as well as gonadotropins, a class of injectable medications that help stimulate egg development. Your doctor will prescribe these medications shortly after your period begins, monitoring for signs of ovulation to determine the best time for the IUI.

IUI risks

As with nearly any medical procedure, IUI comes with a small risk of infection. However, your doctors will sterilize their instruments before your IUI, which greatly minimizes the risk of infection.

Multiple pregnancies: Some fertility medications, namely gonadotropins, may increase the chances that you'll release multiple eggs at once, leading to twins, triplets, and beyond. Since multiple pregnancies pose risks to both mother and child, your doctor will prescribe an appropriate dose with this risk in mind, monitoring for signs of overstimulation through bloodwork and ultrasounds. In circumstances where the chance for multiples is high, cycle cancellation may be considered.

Ovarian hyperstimulation: On rare occasions, fertility medication may also lead your ovaries to become hyper-responsive, causing a phenomenon known as ovarian hyperstimulation syndrome (OHSS). In very rare cases, this syndrome can cause issues with blood clotting, kidney problems, or fluid build-up in the abdomen. Report symptoms like severe abdominal pain, shortness of breath, dizziness, and lightheadedness when taking fertility medication.

IUI alternatives

IUI vs. IVF. Whereas the earliest recorded IUI procedure occurred in the 18th century, in-vitro fertilization (IVF) is only around 40 years old. IVF is a more invasive, higher-tech series of procedures.

A physician collects eggs directly from an individual's ovaries before fertilizing them with sperm in a lab. One or two fertilized eggs, now embryos, are then transferred into the uterus. Excess embryos may be frozen for future use. IVF is the most effective form of ART, but it's also the most time-consuming and costly.

IVF may be better than IUI for people with the following conditions:

  • Severe male-factor infertility
  • Blocked fallopian tubes
  • Multiple miscarriages
  • Severe endometriosis

IVF has an increased rate of success over IUI, but it should be noted that individual success rates vary depending on age, diagnosis, as well as other factors. However, IVF is also significantly more expensive than IUI.

The cost of an IVF cycle can be around $12,000 to $20,000, while the medications can average between $2,000 and $6,000. Depending on your circumstances, fertility specialists usually recommend trying three to four IUI cycles before moving on to IVF treatment.

IUI vs. timed intercourse. Another alternative to IUI is timed intercourse. A couple can increase their chance of pregnancy by timing intercourse during the ovulation window, a six-day period in a menstrual cycle where pregnancy becomes most likely.

Working with a fertility specialist to devise a plan to time intercourse, or tracking your cycle with a fertility monitoring device, are two straightforward and cost-effective ways to get pregnant if fertility isn't an issue.

What to expect during IUI: The psychological, the financial, and the logistical

Before starting their journey, many people understandably want to know what to expect from IUI on a day-by-day or appointment-by-appointment basis. Anticipating the IUI process from a logistical, financial, and psychological standpoint will help your experience flow much smoother.

Logistical IUI: testing and timing

The first step when considering IUI is consulting with a fertility specialist. They'll take you through a series of fertility tests measuring your hormone levels, assessing your ovarian reserve, monitoring for structural abnormalities within the uterus or fallopian tubes, and if relevant, checking your partner's sperm health.

For people seeking IUI for fertility issues, these tests provide insight into the causes behind your struggle to get pregnant. Before you and your doctor confirm that you're a good candidate for IUI, you'll do some of the following infertility testing:

Ovarian reserve testing: These tests measure what's known as your ovarian reserve, aka your remaining egg supply. Lab testing includes measuring the amount of follicle-stimulating hormone (FSH) in the bloodstream on day three of the menstrual cycle, along with an anti-mullerian hormone (AMH) level. Your physician can also do an ultrasound where they can count the number of eggs (seen as follicles) in the ovaries in a given month.

Testing for Structural Abnormalities: If your fallopian tubes are blocked, missing, or dilated, it's impossible to do an IUI. A hysterosalpingogram (HSG), an ultrasound-guided X-ray of the uterus or pelvis, is a fundamental part of testing: it lets your doctor know whether your fallopian tubes are capable of transporting eggs from the ovaries to the uterus to result in pregnancy.

An HSG will also help to identify issues within the uterine cavity, such as polyps, scar tissue, fibroids, or other structural abnormalities (such as a uterine septum), all of which can impact and interfere with implantation. Practitioners might also recommend that a saline sonohysterogram (SIS) or hysteroscopy be used in place of the HSG. Your doctor will determine which test is right for your circumstances.

Thyroid testing: One driver of infertility is thyroid dysfunction. Your provider will test for abnormalities with a thyroid-stimulating hormone (TSH) level and a prolactin level. Issues with either of these hormones can interfere with ovulation and contribute to infertility.

Semen analysis: Sperm quality or health depends on factors like sperm count and motility and is an important puzzle piece in diagnosing the source of your fertility issues.

Testing is primarily relevant to people seeking IUI for fertility or other reproductive health-related challenges. Same-sex couples or single women may choose not to undergo the same tests. They can obtain donor sperm from certified labs, which will be frozen and thawed shortly before the procedure.

For individuals using sperm from a male partner, your partner will provide a sperm sample after two but no more than five days of abstinence to evaluate sperm count, health, and motility.

Sperm washing

Sperm washing is a fundamental part of IUI, regardless of your reason for getting the procedure. The process mimics events that occur during natural conception. Before meeting the eggs, healthy sperm swim through cervical mucus after entering the vagina through semen.

Similarly, the washing procedure separates dead or non-motile sperm, fluids, proteins, enzymes, and other materials from viable, healthy sperm. After the separation process, specialists concentrate it into a medium known as human tubal fluid (HTF), which protects and preserves the sperm before fertilization.

The procedure

IUI itself takes no more than a few minutes. Like a pap smear or an IUD insertion, you'll lie on an exam table with your legs in stirrups. Using a speculum, the doctor or nurse attaches a vial with the sperm concentrate to a catheter, a long thin tube. The catheter is inserted through the cervix and sperm is placed directly into the uterus.

After the practitioner removes the catheter and speculum, you'll lie down for a brief observation. You can then carry on with your day as you normally would. The visit typically only takes 15-20 minutes.

The psychology of IUI: Timing your pregnancy test

If your IUI is successful, the fertilized egg will travel through one of the fallopian tubes and implant within the uterus, just as it does after sex. The transition from fertilization to implantation typically takes six to 12 days.

Thanks to this gap, the hardest part of IUI may come after the procedure and during the "two-week wait," or the period between ovulation and the earliest you can expect an accurate pregnancy test.

When you're taking fertility medication, carefully timing your pregnancy test becomes even more critical. To enhance the timing of your IUI, your doctor may prescribe a trigger shot, which stimulates the ovaries to release mature eggs in preparation for an IUI. They contain human chorionic gonadotropin (hCG), the pregnancy-detection hormone used in pregnancy tests.

Trigger shots are helpful for people who don't ovulate or in cases where you want control over ovulation timing. Physicians normally instruct the trigger shot to be taken 36 hours before the IUI procedure. The injection may be done in a doctor's office or self-administered at home. Since trigger shots contain hCG, taking a home pregnancy test too early after the IUI may result in a false-positive result.

Pregnancy tests measure levels of the hormone hCG in the urine. It's important to note that these tests can only detect hCG when it reaches a certain threshold, or approximately between 20 to 25 milli-international units per milliliter (mIU/mL).

Even after the six to 12-day period, your hCG levels might not reach that threshold until a few days after implantation. Testing too soon can create false positives, putting a deeper sting into an initial failed try, or false negatives, causing you to become disappointed only to find a few days later that you are, in fact, pregnant.

During the "two-week wait," many people become hyper-aware of every sensation, wondering whether their symptoms are signs of pregnancy or just hormonal changes from their fertility treatments. If you're feeling tense during the two-week wait, remember that you're not alone: you’re experiencing emotions shared by almost everyone at some point along their fertility treatment journey.

The following mind-body practices can help support emotional balance during this time.

Breathing exercises. Most people have heard instructions to "take a deep breath" when they're feeling anxious, but did you know the length of your exhales affects the way you feel the most? Slowing down the rate of your exhales compared to your inhales reduces your heart rate, engaging the parasympathetic or "rest-and-digest" branch of your nervous system.

During moments of anxiety or tension, set a 10-minute timer, and focus on your breathing, extending your exhales for about twice as long as your inhales. As you continue, you'll feel more peaceful and grounded in your body.

Emotional Freedom Techniques (EFT). EFT, also known as tapping, can soothe your mind and body during times of emotional turmoil. Based on the idea that negative emotions interfere with energy meridians throughout the body, EFT is like acupuncture without the needles, a practice with a great deal of anecdotal use in relieving fertility-related stress. It focuses on illuminating hidden layers of emotion behind physical and psychological pain. Read more about tapping here.

The financial side of IUI: The costs

For many people, IUI is an excellent first-choice fertility treatment because it’s non-invasive and relatively affordable. However, the costs of IUI can range widely, costing anywhere from a few hundred to thousands for a single cycle. The cost of IUI varies based on whether testing, monitoring, and medication are part of your protocol.

Foundational IUI

In every case, IUI involves two key steps: sperm washing and insemination. These foundational steps cost between $150 to $500. For those doing natural IUI, these may be the only costs associated with the procedure. But couples or individuals using donor sperm may incur separate costs for that procedure at the donor agency of their choice.

For individuals and families using IUI as a treatment for infertility, the factors that impact cost include:

Medication: Providers will prescribe meditation to stimulate ovulation and egg growth. Medication costs depend on the overall protocol you've chosen and on your provider. Some individuals choose to take just one oral fertility medication, such as letrozole or Clomid, which can range from $30 to $100 per cycle.

For people with more significant fertility issues, gonadotropins can cost up to $6,000, while trigger shots typically cost anywhere from $50 to $250.

Monitoring: If you're taking fertility medications, your doctor will monitor for multiple pregnancies or ovarian hyper-stimulation. Pricing models depend on your insurance but generally cost between $500 and $1,000 per cycle.

Does insurance cover IUI?

In many cases, insurance will cover parts of IUI they consider medically necessary. For instance, insurance providers might cover things like medications, testing, and blood work even if they don't cover the costs of the IUI procedure itself.

The following factors can factor into whether insurance covers your IUI:

  • State of residence
  • Medication types: In some cases, an insurance company will cover IUI if it does or does not include specific fertility drugs
  • Gender: Some insurance will cover the costs of the sperm wash, but not the procedure itself
  • Origin of sperm: Many insurance providers cover the cost of donor sperm but not sperm washing

Will it work for you? IUI success rates

Understanding IUI success rates can be tricky. Measures of success vary across studies and depend on a variety of factors. Researchers also study success rates using different variables, such as the live birth rate or pregnancy. However, the following are some of the most pivotal keys to a successful IUI.

Age. Fertility specialists usually don't recommend IUI after age 40. Pregnancy at age 40 becomes more difficult and brings with it a higher likelihood of pregnancy loss. That said, age is just one of many factors, and it may still be worth talking to your doctor about how you can raise your chances of success by optimizing your diet and lifestyle.

Health conditions: IUI increases the chance of pregnancy by placing concentrated sperm directly into the uterus, but it still requires a natural conception process. As a result, pre-existing diagnoses that interfere with implantation, such as uterine polyps or scar tissue, for example, affect the likelihood of success with IUI and may require you to try more extensive procedures, such as IVF.

Cycle quantity. The majority of success with IUI occurs within the first three to four cycles. If you're struggling to get pregnant after four IUIs, exploring other options might be more cost-effective.

If any of the above factors pertain to you, you might find it worthwhile to explore lifestyle optimizations that can increase your chances of success with IUI. Some factors you may want to consider:

Diet: A study in Obstetrics & Gynecology analyzed the diets of 17,544 women for eight years as they attempted to become pregnant. The authors found that participants who ate plant-based protein, mono-unsaturated fat, vegetables, and full-fat dairy, while avoiding processed foods and trans fats, had higher fertility rates.

Thanks to the link between infertility and vitamin D deficiency, eating foods high in vitamin D, such as salmon, egg yolks, or mushrooms, may also improve success rates with IUI. Your doctor may also recommend that you take a vitamin D supplement. Recent research in Advances in Nutrition also points to the positive impact of diets rich in fiber, omega-3 fatty acids, and vegetable proteins, vitamins, and minerals (like the Mediterranean diet) on fertility.

Consistent sleep: The hormones responsible for ovulation in women and sperm maturation in men are also involved with the body's sleep-wake patterns. Research has shown that inconsistent sleep habits can disrupt the menstrual cycle. Going to sleep and waking up at the same time every day are critical for immune, cellular, and hormonal regulation. As an added benefit, sleep and wake cycle consistency also reduces grogginess and insomnia.

How Future Family can support your fertility journey

If you're interested in IUI, Future Family can help you navigate the process with a customized plan designed for your unique situation. You can keep track of and pay for all the costs and procedures associated with your IUI treatment within a single online dashboard.

Our Fertility Coaches can also provide emotional and practical support throughout your journey. Fertility treatments aren't just daunting for price alone: the logistics, time, and other complexities can prevent people from taking action, causing them to delay their dreams of starting or growing a family.

As Registered Nurses (RNs) with over a decade of experience in the fertility field, our Fertility Coaches can give you a big picture outlook on your entire IUI treatment journey. Think of your coach as a personal nurse navigator: they’re easily accessible and able to answer all your questions related to your fertility journey.  

Our nurses have all worked in clinical fertility settings before becoming coaches at Future Family. From helping you understand your treatment results to video chatting with you 1:1, our nurses do it all!

Still, our coaches aren’t here to replace the amazing team you’re already working with at your clinic. Instead, think of our coaches as an additional layer of support. Here are just a few of the services our coaches provide:

  • Medication training & support
  • Fertility education to help you interpret your test results
  • Someone to lean on for support during the emotional up and downs of treatment
  • Support groups, which are hosted bi-monthly

Our coaches are here to help you focus on what matters most: optimizing your health and mindset so you have as stress-free a journey as possible.

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