Intrauterine Insemination (IUI): Essential Questions and Answers

May 26, 2024 Bryan McColgan, MD

One avenue for assisted reproduction that has not yet been discussed on BabyMoon Family is intrauterine insemination (IUI). In this article, I wanted to provide essential information regarding IUI, so that if this is an option for you, you can know what is involved and how it differs from other forms of assisted reproductive technology (ART) for rainbow family building.

What is IUI?

IUI is a fertility procedure where sperm is placed directly into the uterus using a small catheter. The reason this procedure is performed is it increases the number and probability of healthy sperm being able to travel down the fallopian tubes to fertilize the ovaries (1).

Who is IUI for?

For heterosexuals, IUI is used when couples have medical infertility due to the following reasons (2):

Endometriosis. Endometriosis is when there is uterine tissue outside of the uterus itself, which can be exceedingly painful and cause fertility issues that IUI can sometimes overcome.
Male infertility. Given that IUI makes it easier for high quality sperm to reach the ovaries, it makes sense that any issue with sperm motility, size, shape, and/or amount can sometimes be mitigated with IUI.
Cervical infertility. The cervix is the opening between the vagina and uterus, and it creates mucus during ovulation that is meant to help sperm travel to the ovaries. However, this mucus can be too thick, or the cervical opening can be too small or scarred from previous biopsies or other procedures. IUI bypasses the cervix, preventing any potential complications with this area.
Ovulatory infertility. If a woman has issues ovulating or producing and releasing eggs, this can also be mitigated with IUI as the sperm are placed closer to the ovaries and so there is less of a need for maximum ovulation.
Semen allergy. Some people have semen allergies, which can cause redness, irritation, and pain on contact with semen. IUI can prevent the painful vaginal irritation from a semen allergy, as it bypasses this area, and many of the proteins and components of semen that cause the allergy are removed before the sperm are inserted.

For queer people, IUI serves additional reproductive purposes:

Queer single women and couples. With donor sperm, queer single women and couples can undergo IUI and become pregnant. Given the lower complexity and costs (discussed more below), this is an attractive option for queer women building families.
Queer women and men who want to coparent. Rainbow families come in all shapes and formations. I have friends who are gay men who wanted to have children, and they decided to pursue parenthood with their lesbian friends. IUI is a way to allow these family units to form.

How is IUI different from IVF?

In vitro fertilization (IVF) is a much more common acronym in fertility parlance, and it has some key differences from IUI.

As described above, IUI takes and processes sperm, and then injects the sperm directly into the uterus, in sync with a woman’s menstrual cycle. This synchronization can take place naturally, in what is termed a ‘natural cycle’ IUI procedure, or it can be done in a ‘medicated cycle’ IUI procedure where the woman is given medications to promote ovulation (3).

For IVF, women also undergo a ‘medical cycle’ of ovarian stimulation. I have discussed this previously in an article about the procedures egg donors undergo (https://www.babymoonfamily.com/original-articles/egg-donation-procedure).

However, in IVF, the goal is to remove the ovaries in order to fertilize them with sperm outside the body in a lab. These embryos are then allowed to develop for around 6 days before being implanted into the uterus.

By contrast, the fertilization and immediate development of the embryo in IUI occurs in the women’s body. This comparison between IUI and IVF is shown in the image here.

(4)

Lastly, IVF allows for the development and then freezing of additional embryos. These embryos can then be selected later for future implementations and additional children. For IUI, the procedure is either successful and results in a pregnancy, or else the entire procedure has to be repeated.

How much does IUI cost?

For those in the United States, the good news is that IUI may be covered by insurance. All insurances are different, so it’s important to check with your specific provider, but fertility medications and the procedure itself can be covered. Also, insurers may actually insist that IUI be attempted before IVF can be considered for reimbursement because of its lower cost (5).

For those in the United Kingdom, the NHS will cover IUI if you qualify for one of the following and are willing to endure what can be an exceedingly long wait time (6):

You're unable to have vaginal sex – for example, because of a physical disability or psychosexual problem.
You have a condition that means you need specific help to conceive. For example, if 1 of you has HIV and it's not safe to have unprotected sex.
You're in a same-sex relationship and have not become pregnant after up to 6 cycles of IUI using donor sperm from a licensed fertility unit.

For queer women and couples, the last point is interesting and will be discussed more in the ‘Can IUI be done at home?’ section below.

Out of pocket, there is no one estimated cost for IUI, but it is generally considered to cost between about $300 to $1,000 without insurance in the United States (7).

This is significantly less than the costs for IVF in the United States. In 2023, a single IVF cycle - defined as ovarian stimulation, egg retrieval and embryo transfer - can range from $15,000 to $30,000, depending on the center and the patient’s individual medication needs (8).

How successful is IUI?

IUI success rates will vary depending on the fertility reason a person or couple is pursuing IUI.

In 2021, a study was published that compared pregnancy success rates between heterosexual women with medical infertility and healthy lesbian women undergoing IUI (9).

The study included 11,870 IUI cycles, of which 393 were in lesbian women using donor sperm and 11,477 were in heterosexual women with infertility using either partner or donor sperm. The procedures were performed at two academic medical centers in the United States, and included both ‘natural cycle’ and ‘medicated cycle’ IUI procedures.

The results compared clinical pregnancy, live birth, and clinical miscarriage rates between the two groups:

Clinical pregnancy: 13.2% for lesbians vs. 11.1% for heterosexuals
Live birth: 10.4% for lesbians vs. 8.3% for heterosexuals
Clinical miscarriage: 15.4% for lesbians vs. 23.8% for heterosexuals

After additional adjustments and statistical analyses, the authors concluded that the healthy lesbians had significantly higher rates for clinical pregnancy and live births compared to the medically infertile heterosexuals.

Overall, the rate of live birth for queer women undergoing IUI appears to be around 10%.

This is in comparison to IVF, which changes significantly with age and medical situation, but a CDC report estimated that the American national average for women younger than 35 to become pregnant by IVF on the first try is 55.1% (10).

Can IUI be done at home?

Short answer: Yes and no.

Because IUI requires insertion of a catheter through the cervix into the uterus, this requires instrumentation and expertise of a trained medical professional. It is possible that a midwife could do a home visit and perform IUI, but it is more common that a person or couple without medical experience will actually perform a different type of artificial insemination at home: Intracervical insemination (ICI).

ICI is what would happen during normal vaginal intercourse, when the sperm would be ejaculated into the vagina (11). This can be done without the need to insert a catheter through the cervix and so can be performed by lay people on themselves or their partner.

Success rates for a single cycle of ICI are reported to be between 5 and 10% (12). However, this rate defines a ‘single cycle’ as the women’s ovulation cycle and does not limit the amount of times she/they introduce sperm.

As with IUI, ICI should be timed with a woman's ovulation to maximize effectiveness. This can also be further enhanced with ovarian stimulation medication, but that would have to be done with the supervision of a physician. However, since ICI can be done at home, women can introduce sperm as often as they want, increasing the chances of a successful pregnancy.

In addition to timing, it is important to note that at-home insemination requires people to be diligent with regard to the health and safety of the sperm donor. Known sperm donors should be tested for sexually transmitted infections (STIs) prior to insemination, and anonymous sperm donations should be obtained from a reputable sperm bank with thorough testing procedures.

IUI and ICI offer a less expensive avenue for reproduction for queer women compared to IVF. While they have lower success rates in terms of pregnancy compared to IVF, they can be covered by insurance or even performed within the comfort of your own home. In my opinion, these procedures are a great first step toward rainbow family building for queer women.

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