‘The sisterhood of the traveling sperm’ or do IUI’s really work?

May 27, 2010Carole 19 Comments »

One of my sisters sent me a link to this NY Times article about three women who got pregnant on their own, just as they were on the brink of using Donor 8282’s sperm which they passed around among the three of them like some weird sperm chain letter. As I read the article, it struck me that the “Lucky Sperm” vial was not very lucky because the  fourth woman who actually used the seven vials of Donor  8282’s sperm was the only one who never became pregnant! Apparently it was lucky to plan to use it but not to actually use it.

My mind immediately wandered off down lab director lane— how often was the donor sample fedexed around, risking thawing??? Was it damaged in transit or improperly stored?? But then I wandered over to the bigger question, just how effective are intrauterine insemination (IUI) cycles? Most of the time, we see the patients for whom the IUI didn’t work and have “graduated” to IVF, so my personal experience tends to be biased against IUI’s.  But I recognize that lots of patients have had their children from IUIs so what makes this procedure work for some women and not others?

The European Society for Human Reproduction and Embryology published a Workshop report on Intrauterine Insemination which nicely summarizes the worldwide experience with insemination cycles. Basically the report boils it down to four factors that are crucial to the success of IUI:

  • Maternal age (younger age is better)
  • Duration of sub-fertility  (the age thing again, because maternal age has been increasing while you have been TTC.)
  • Sperm quality (if sperm count is really low or if sperm can’t swim well, IUI’s don’t work)
  • Open Fallopian tubes (fertilization happens in the tubes so if tubes are blocked, IUI can not work)

The other interesting fact was that the success rates tended to increase when ovarian simulation was also used. For example, natural cycles with insemination did not significantly increase pregnancy rates over intercourse. So if you are using IUI alone without ovarian stimulation to treat infertility, IUI is less likely to work if you have some fertility issues. On the other hand, if you are using donor sperm and IUI because you are a single woman or part of  a lesbian couple without fertility problems, it should work about as well as intercourse.

Adding ovarian stimulation to increase the number of follicles and eggs produced did increase the pregnancy rate but also increased the risk of getting pregnant with twins, triplets or more. IVF gets a bad rap for producing a lot of high-risk multiple pregnancies which too often end badly. The truth is, if used responsibly, IVF actually can decrease the multiple rate because you can decide to transfer only one embryo. With IUI’s you might have an idea how many follicles developed from the  ultrasound exam but you have no idea how many eggs will ovulate and present themselves to be fertilized. Most multiples come from IUI surprises when all six follicles actually have eggs, get fertilized and implant. Gulp! I think it’s cruel to ask someone who has been desperately trying to get pregnant to suddenly have to think about selective reduction to try to bring at least one baby home safe. How do you wrap your head around that? It’s better to avoid the situation all together.

You might be thinking, “Okay, Carole, that’s fine and dandy but IVF is terribly expensive and we can only afford IUI which costs two-thirds less”.  ESHRE found in their review of IUI and IVF outcomes that IVF was seven times as effective as IUI, so if IVF costs three times as much but is seven times as effective, the economic advantage of multiple IUI’s becomes questionable. Having said that, almost every patient will try at least one, and sometimes three cycles of IUI before moving on so–

How can you increase the odds that your first IUI will work for you?

Insist that your partner have a semen analysis. This seems obvious but you might be shocked to know that this is not always part of the fertility work-up. If your guy had kids with someone else or with you years ago, your doctor may be quick to give him a pass because his sperm should be good, right? Not necessarily. Fertility can decline over time and the guy who was fertile a year ago can be less fertile or sterile now. We have seen sperm counts decline from month to month due to underlying urologic conditions or even cancer. If he has developed chronic medical conditions since he last fathered kids, his medications may be decreasing his sperm count.

What is a minimal sperm count for IUI? This is a tricky question because every clinic has their tale of the amazing conception with a terrible sample. However, a good rule of thumb is to look at what commercial sperm banks guarantee as minimum count and motility after thawing.  Sperm banks have an economic incentive to determine the minimum sperm number needed for conception. Think about it. If they put too much sperm in the vial, they dilute their profits. if they put too few, they will have too many angry customers. California Cryobank, one of the nation’s biggest sperm cryobanks guarantees that their sperm vials contain AT LEAST ten million motile sperm after thawing. You need to know that sperm count by itself is meaningless- sperm need to be more than just present, they need to be alive and strongly swimming forward. Freezing and thawing is hard on sperm. Preparation procedures like washing and centrifugation can reduce the functional number and motility of the final sample. So when all is said and done, you want to have at least ten million swimming sperm  in the insemination catheter to enter the IUI race. You might have to use your diplomatic skills here but if your partner’s fresh processed IUI sample is not at least as good as a thawed donor sample, you may not want to spend too much time with IUIs.

If you are using commercial donor sperm, insist that the lab do a count and tell you if the thawed sample contained the minimum count and motility guaranteed by the sperm bank. If the sample is worse than promised, you can often get your money back from the sperm bank on sub-standard samples. ObGyns who do IUIs in their office often don’t count the sperm because they don’t have a lab license to perform high complexity testing. This is another argument for going to a board certified REI fertility specialist with a lab for your IUIs, you are more likely to get a semen analysis report on the sample that is used for your IUI.

The other big issue is knowing whether your Fallopian tubes are open or blocked. If  your Fallopian tubes are blocked, the sperm that was deposited in your uterus can’t get to the egg to fertilize it. End of story. A hysterosalpingogram (HSG) is one procedure your doctor can perform to see if your tubes are open. Some doctors use a saline infusion with ultrasound method to visualize the tubes. Again, most ObGyns probably don’t offer these procedures and you might need to go to a REI to get this done. A complete work up may cost the same as the first IUI cycle but unless you get pregnant on that first IUI, your doctor will probably (hopefully) want to do some diagnosis to see why the first cycle didn’t work. If you find out your dearly beloved has five sperm, you can skip that first IUI altogether and head straight to IVF with sperm injection to give his sperm a fighting chance.

A cautionary tale. We had one referring doctor who kept sending us the same couple for sperm processing for IUI. We would process the sperm for IUI, give it back to the couple and they would go back to the doctor’s office for the actual insemination.  I am not sure why this doctor  wanted us to process this sperm for them because every time we also provided the doctor with a semen analysis which showed that the semen sample was well below effective levels for IUI every single time. I am not sure if this poor guy ever had a million sperm in the original ejaculate, let alone after processing. It drove us crazy in the lab because we aren’t allowed to offer medical advice to patients.  To be fair, we didn’t  know what the back story was. Maybe there was some good reason we didn’t understand  to keep doing IUIs over and over that had a poor chance of success. We never found out if they ever got pregnant but we were relieved when they stopped coming because we didn’t like  to feel like accomplices in what looked like poor medical care to us. But hey, we’re just the lab rats. What do we know?

The bottom line is that you have more influence over your care than you may realize because you are not just the patient but also the customer. If something doesn’t make sense to you, question it. Maybe there is a good explanation, but if not, move on. It’s your money, your emotions and your life.

© 2010, Carole. All rights reserved.

19 Responses to this entry

  • Anonymous Says:

    For men with poor sperm motility, can sperm be placed in the fallopian tubes instead of the uterus to improve the chances of fertilization?

  • Carole Says:

    In the GIFT procedure which is an acronym for Gamete Intra Fallopian Transfer, sperm and eggs are collected and processed separately in the lab, then placed in the Fallopian tubes via a second surgical procedure for the woman later on the same day. So this is an example of placing sperm (with eggs) into the Fallopian tube, but this is not usually done if sperm quality is poor because the sperm still need to have good motility to find, attach to and penetrate the egg so I wouldn’t classify this procedure as one that is done for men with poor sperm quality. GIFT is usually performed to bypass religious objections to IVF since fertilization of the eggs with GIFT occurs inside the body.

  • Anonymous Says:

    How many eggs are typically planned to be retrieved in the GIFT procedure?

    Are the egg and sperm any closer or farther in GIFT than IVF incubation? In other words, if a certain low quality sperm can fertilize an egg in incubation IVF, can it do any worse or better in GIFT?

    I am unable to trust the criteria set for sperm quality for the various ART procedures because we were told that my husband’s sperm is so terrible that we have to go for ICSI. But 1 of the 2 incubated fertilized (and 6 that were injected did not fertilize, but ofcourse that was due to bad eggs according the clinic).

  • Carole Says:

    I don’t think I can speak to ideal number of eggs for GIFT because in my programs, we did zero or perhaps one GIFT cycle a year and only for religious reasons or insurance reasons. (A patient had a very unusual plan which covered GIFT but not IVF). GIFT asks a lot more from low quality sperm than IVF, because ICSI can not be used with GIFT. ICSI is the great equalizer for men with poor quality sperm. I really can’t comment on your specific results. Please discuss with your physician. If your physician can’t or won’t explain things to your satisfaction, you have the option to look for a program that suits you better.

  • Anonymous Says:

    If cumulus cells are required for sperm to bind, penetrate and fertilize an egg, what kind of processing is performed on eggs that are retrieved for GIFT?

    Regardless of sperm quality or success rate, is the sperm closer (distance-wise) to the egg in GIFT or IVF incubation?

    Thanks!

  • Carole Says:

    In preparation for GIFT, the cumulus-oocyte complex is kept intact and rinsed free of any red blood cells that came along with the retrieval fluid. If the cumulus is exceptionally large, it might be trimmed somewhat to make handling easier but this is not required. The catheter is loaded with a few eggs, followed by an air space as a temporary barrier and finally the sperm sample. Actually, you can probably reverse the order, sperm first, followed by egg. The air space barrier is to prevent any mixing outside the body- again for religious reasons. When the entire catheter contents are released into the Fallopian tube, everything is mixed together. As far as distance, volumes are kept fairly small in either situation so “distance” to the egg is not an issue if the sperm are normally motile. Any other embryologists who do more GIFT please feel free to comment.

  • me Says:

    here in canada IUI is around $300-$500 and IVF is $10,000 plus…..so the 3 x more calculation is not correct for us! therefore its much better for us to try multiples IUI’s before moving on.
    I heard Kate Plus 8 had IUI with injectables when she got her 6 so I agree with your comments on multiples.

  • Joanie Says:

    Hi there, we have had 4 IUI’s (unsuccessful) with Donor Sperm at our clinic here in NZ. Each IUI has had between 3 million and 4.6 million sperm used. The clinic keeps telling us that anything over 1 million is good. But the more I research the more I find out that the numbers we are receiving for the IUI are low! I questioned the Nurse doing the IUI today and she didn’t know anything about a minimum number required and she asked the Lab person who wasn’t aware of this either. Which is very worrying to us! What are your thoughts? Thanks.

  • Carole Says:

    Dear Joanie,
    I think it’s time to see another physician for a second opinion. Those sperm counts are low. Are they actually performing a sperm count at thaw or are they simply eyeballing the sperm? Most reputable sperm banks will refund your money if the sperm at thaw are less than what they guarantee. But they require evidence that the sperm was thawed correctly and counted. Good Luck. Carole

  • Theresa Says:

    Hi,

    I am 35 years old, been trying for the past 10 years to get pregnant (unsuccessful). I had surgery at age 26 for blocked fallopian tubes – the gynecologist says i still have about 70 % chance in 1 tube – however I have read that about 1 in 5 women become pregnant after surgery to fallopian tubes.

    IVF is very expensive. Is there anything else I can try ?

    Thank you

  • Carole Says:

    Hi Theresa,
    One of the very frustrating things for me is how expensive IVF is but good programs are able to deliver 50% or better pregnancy rates with IVF so it is still the most effective method for bypassing tube problems. I wrote about how to stretch the infertility dollar in a previous post http://fertilitylabinsider.com/2010/07/stretching-the-infertility-dollar/ which might be helpful. Some programs offer discounts to patients in special categories (eg. service men and women). You might arrange an appointment with an IVF doctor to discuss options. Find out in advance how much the preliminary visit is. Some REs may not charge at all. Some will charge $200. It may be worth it to find out more. Don’t ever agree to proceed without a written estimate of everything you would owe in advance. I assume you have exhausted all IUI tries or have been told the risk of ectopic is too high with IUI and damaged tubes. IUI is less expensive but often less effective as well.

    You may hear about an experimental product called Invocell which I discussed in two previous posts.http://fertilitylabinsider.com/?s=invocell I am not a fan of Invocell which has annoyed some readers who see it as a cheap alternative to IVF. The biggest problem with Invocell for me is that it is still not as effective as a good IVF lab and does not rule out abnormally fertilized eggs because the whole contraption resides in your vagina for a few days without anyone looking whether the egg is fertilized. Some cases of abnormally fertilized eggs (3PNs) look like normal embryos but then if transferred can cause a molar pregnancy which is a serious abnormal pregnancy condition that can be cancerous. I’m told, don’t worry, this outcome is infrequent; be happy, this is a cheap alternative. But when it doesn’t have the safeguards we expect for patients, I don’t think it is good enough. IVF is still a safer alternative, IMO. I wish I had better news. Readers from overseas who have national health care with IVF coverage are horrified by how hard it is for patients here. Some patients go overseas for IVF looking for more affordable treatment. Good Luck!! Carole

  • jyothsna Says:

    i am 27, i am trying to conceive but not yet, i just want to know, if a female has blocked tubes both the side, mature follicle will it move to uters.

  • Carole Says:

    Hi jyothana,
    If tubes are blocked on both sides, the site of fertilization (in the tubes) is blocked and the connection between the ovaries and the uterus that the fertilized egg must travel is blocked, so pregnancy from IUI or intercourse is impossible. Blocked tubes is the original problem for which iVF was invented because eggs could be fertilized in the lab, grown to embryos, and then returned to the uterus where they belong without relying on the tubes for any of this. If one tube is blocked, then there is still a chance that the egg from the unblocked side will be fertilized and move through to the uterus but the chances of pregnancy are significantly reduced. Hope that helps. Carole

  • Fertility Lab Insider - Lessons learned from over fifteen years of working inside fertility labs. » Blog Archive » ASRM 2013 Update: Patient Communication Poster from Reader’s Feedback Says:

    […] topics of interest where related to IUIs and how well they work , when to stop IVF, financial issues, fertilization failure, no sperm on retrieval day, medications […]

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  • OVD Says:

    Thank you for your article.
    We were using donor sperm for IUI and bought it from Cryos Denmark. They’ve put STOP notice and it’s been 8 months and still temporary notice.
    We decided to move on and using another donor.
    I’ve requested refund and they say that they don’t refund.
    Do you know if we can argue that?
    We only used one sample out of 5, plus delivery from Denmark to the UK, so it’s a bit sad if we cannot get it back.
    Many Thanks

  • Carole Says:

    Dear OVD,
    I am not familiar with that bank and what rules may apply in Denmark. Can someone with experience using this company please comment? Good Luck!!

  • brook Says:

    I had both blocked tubes due to fluid in them at ends. I had surgery to remove the fluid, after that the doctor told me one tube was not function,and other had 40% function. My question is can iui work for me or should I move right to ivf?, he said i can become pregant naturally just would take much longer, please advise me.

  • Carole Says:

    Hi Brook,
    Having only one tube functioning at 40% will certainly decrease your chances for conception to a very low probability. If you are under 35 years old, you may be able to spend some time trying intercourse which will cost you no $, only time. But IUIs aren’t free. The ovarian stim drugs will cost about the same for either IVF or IUI and you will also have lab expenses. After you have done 3 IUIs, you will have probably spent as much as one IVF will cost you. If you go to a good IVF program and are under 35, your chances of pregnancy are likely to be very good. If you are over 35, I wouldn’t spend any time on IUIs, because every year after 35 reduces your fertility–IVF is the better bet if you are over 35. I wish you much good luck no matter what you decide.

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