What is intrauterine insemination (IUI) and how does it work?

Intrauterine insemination (IUI) involves a laboratory procedure to separate fast moving sperm from more sluggish or non-moving sperm.

The fast moving sperm are then placed into the woman’s womb close to the time of ovulation when the egg is released from the ovary in the middle of the monthly cycle

Is IUI for me?

Your clinic may recommend IUI if:

There is unexplained infertility
There are ovulation problems
The male partner experiences impotence or premature ejaculation

Patency health tests

It is essential that your fallopian tubes are known to be open and healthy before the IUI process begins. A tubal patency test is usually carried out as part of your assessment by the fertility clinic.

The typical method for assessing the health of your pelvis and the patency of your fallopian tubes is laparoscopy and dye testing.

At laparoscopy a direct view of the pelvis is obtained by inserting a telescope into the abdomen.

When the pelvis and tubes are healthy, dye passes freely through both tubes. There should be no adhesions present that might prevent an egg from having access to either tube from the ovaries. This is performed under a short general anaesthetic.

The test may show that you only have one open healthy tube although you may have both ovaries. IUI treatment can then only be carried out when there is evidence that ovulation is about to occur from the ovary that is on the same side as the open tube.

The second essential requirement is that there is no significant problem with sperm numbers or sperm quality.

How does IUI work?

For women:

Step 1. If you are not using fertility drugs IUI is done between day 12 and day 16 of your monthly cycle – with day one being the first day of your period. You are given blood or urine tests to identify when you are about to ovulate.

Many clinics will provide you with an ovulation predictor kit to detect the hormone surge that signals imminent ovulation.

- or -

If you use fertility drugs to stimulate ovulation, vaginal ultrasound scans are used to track the development of your eggs. As soon as an egg is mature, you are given a hormone injection to stimulate its release.

Fertility drugs

Step 2. The sperm are inserted 36 to 40 hours later. To do this, the doctor first
inserts a speculum (a special instrument that keeps your vaginal walls apart) into your vagina (as for a cervical smear test).

The sperm are inserted 36 to 40 hours later. To do this, the doctor first inserts a speculum (a special instrument that keeps your vaginal walls apart) into your vagina (as for a cervical smear test).

A small catheter (a soft, flexible tube) is then threaded into your womb via your cervix. The best quality sperm are selected and inserted through the catheter.

The whole process takes just a few minutes and is usually a painless procedure but some women may experience a temporary, menstrual-like cramping.

Step 3. You may wish to rest for a short time before going home – ask your clinic what they recommend.

For men:
Step 1. You will be asked to produce a sperm sample on the day the treatment takes place.

Step 2. The sperm are washed to remove the fluid surrounding them and the rapidly moving sperm separated out.

Step 3. The rapidly moving sperm are placed in a small catheter (tube) to be inserted into the womb.

What is donor insemination (DI) and how does it work?

What is DI?

Donor insemination (DI) uses sperm from a donor to help the woman become pregnant.

Sperm donors are screened for sexually transmitted diseases and some genetic disorders. In DI, sperm from the donor is placed into the neck of the womb (cervix) at the time when the woman ovulates

DI - IUI uses intrauterine insemination with donor sperm.

Donor sperm can also be used for in vitro fertilisation (IVF).

Is DI for me?

Your doctor or clinic may recommend this treatment if:

your partner is unable to produce sperm
your partner’s sperm count or quality is so poor that it is unlikely to result in the conception of a baby, unless intra-cytoplasmic sperm injection (ICSI) is carried out
your partner has a high risk of passing on an inherited disease

IVF - What is in vitro fertilisation (IVF) and how does it work?

What is IVF?

In vitro fertilisation (IVF) literally means ‘fertilisation in glass’ giving us the familiar term ‘test tube baby’.

During the IVF process, eggs are removed from the ovaries and fertilised with sperm in the laboratory. The fertilised egg (embryo) is later placed in the woman’s womb.

Is IVF for me?

A clinic may recommend IVF as your best treatment option if:

you have been diagnosed with unexplained infertility
your fallopian tubes are blocked
you have been unsuccessful with other techniques like using fertility drugs or intrauterine insemination (IUI)
there is a minor degree of male subfertility - more severe problems are treated with intra-cytoplasmic sperm injection (ICSI).

How does IVF work?

IVF techniques can differ from clinic to clinic, often depending on your individual circumstances.
A typical IVF treatment may involve:

For women:

Step 1. Suppressing the natural monthly hormone cycle

As a first step of the IVF process you may be given a drug to suppress your natural cycle.

Treatment is given either as a daily injection (which is normally self-administered unless you are not able to do this yourself) . This continues for about two weeks.

Step 2. Boosting the egg supply

After the natural cycle is suppressed you are given a fertility hormone called FSH (or Follicle Stimulating Hormone). This is usually taken as a daily injection for around 12 days.

This hormone will increase the number of eggs you produce - meaning that more eggs can be fertilised. With more fertilised eggs, the clinic has a greater choice of embryos to use in your treatment.

Step 3. Checking on progress

Throughout the drug treatment, the clinic will monitor your progress. This is done by vaginal ultrasound scans and, possibly, blood tests.

34–38 hours before your eggs are due to be collected you have a hormone injection to help your eggs mature.

Step 4. Collecting the eggs

In the IVF process eggs are usually collected by ultrasound guidance under sedation. This involves a needle being inserted into the scanning probe and into each ovary.

The eggs are, in turn, collected through the needle.

Cramping and a small amount of vaginal bleeding can occur after the procedure.

Step 5. Fertilising the eggs

Your eggs are mixed with your partner’s or the donor’s sperm and cultured in the laboratory for 16–20 hours. They are then checked to see if any have fertilised.

Those that have been fertilised (now called embryos) are grown in the laboratory incubator for another one - two days before being checked again. The best one or two embryos will then be chosen for transfer.

After egg collection, you are given medication to help prepare the lining of the womb for embryo transfer. This is given as pessaries, injection or gel.

Step 6. Embryo transfer

For women under the age of 40, one or two embryos can be transferred. If you are 40, or over, a maximum of three can be used.

The number of embryos is restricted because of the risks associated with multiple births. Remaining embryos may be frozen for future IVF attempts, if they are suitable.

Step 7. Other treatments

Some clinics may also offer blastocyst transfer, where the fertilised eggs are left to mature for five to six days and then transferred.

For men:

Step 1. Collecting sperm

Around the time your partner’s eggs are collected, you are asked to produce a fresh sample of sperm.

This is stored for a short time before the sperm are washed and spun at a high speed. This is so the healthiest and most active sperm can be selected.

If you are using donated sperm, it is removed from frozen storage, thawed and prepared in the same way.

What is intra-cytoplasmic sperm injection (ICSI) and how does it work?

Intra-cytoplasmic sperm injection (ICSI) involves injecting a single sperm directly into an egg in order to fertilise it. The fertilised egg (embryo) is then transferred to the woman’s womb.

The major development of ICSI means that as long as some sperm can be obtained (even in very low numbers), fertilisation is possible.

Is ICSI for me?

ICSI is often recommended if:

The male partner has a very low sperm count
Other problems with the sperm have been identified, such as poor morphology (abnormally shaped) and/or poor motility (poor swimmers)
At previous attempts at in vitro fertilisation (IVF) there was either failure of fertilisation or an unexpectedly low fertilisation rate
The male partner has had a vasectomy and sperm have been collected from the testicles or epididymis (sperm reservoir)
Other situations where the sperm count is zero and donor insemination is not wanted
The male partner does not ejaculate any sperm but sperm have been collected from the testicles
The male partner has had problems obtaining an erection and ejaculating. This includes men with spinal cord injuries, diabetes and other disorders.

How does ICSI work?

The procedure for ICSI is similar to that for IVF, but instead of fertilisation taking place in a dish, the embryologist selects sperm from the sample and a single sperm is injected directly into each egg.

For women

Step 1.
You take fertility drugs to stimulate your ovaries to produce more eggs, as for IVF.

Step 2.
The eggs are then collected and each egg is injected with a single sperm from your partner or a donor. After two to three days in the laboratory, those that are fertilised are transferred to your womb in the same way as for conventional IVF.

Any suitable remaining embryos can be frozen for future use.

Step 3.
Some clinics may also offer blastocyst transfer, where the fertilised eggs are left to mature for five to six days and then transferred.

Step 4.
After the treatment, your clinic will arrange a date with you for your pregnancy test.

For men

Step 1.
An embryologist will examine your sperm under a microscope and decide whether ICSI could increase your chances of fathering a baby.

Step 2.
The next step depends on whether you are able to provide sperm without medical intervention:

If you can, you produce a fresh sperm sample on the same day as your partner’s eggs are collected.

–or–

Sperm can be collected directly from the epididymis (a narrow tube inside the scrotum, where sperm are stored and matured) using a type of fine syringe. This is known as ‘percutaneous epididymal sperm aspiration’ or PESA.

Sperm can also be retrieved from the testicles, a process known as ‘testicular sperm aspiration’ or TESA.

It is also possible to remove tiny quantities of testicular tissue from which sperm can be extracted. This procedure is called ‘testicular sperm extraction’ or TESE.

For more information about PESA, TESA and TESE, speak to your doctor.

Step 3.
A single sperm is injected into each egg. This does not mean that the egg is fertilised, but ICSI now gives an opportunity for that complex process to commence. ICSI is not a guarantee that fertilisation will take place.

Step 4.
Subsequently one - three of the best quality embryos are transferred to the womb.

In case of zero sperm count

If you have a zero sperm count (other than caused by vasectomy), the chances of retrieving sperm surgically by PESA, TESA or TESE may be very low or at least uncertain.

In this situation, consider having a surgical retrieval such as a ‘dummy run’ and store any sperm that are obtained. If no sperm are retrieved the options of having Donor insemination (DI) or In vitro fertilisation (IVF) with donor sperm can be considered instead.

Preserving your fertility

Fertility preservation involves freezing and storing eggs, sperm, or embryos for use in a person’s future fertility treatment. In rarer cases, this can involve freezing and storing ovarian or testicular tissue.

If you wish to preserve your fertility there may be a number of options available to you, including:

Reasons for preserving your fertility

Both men and women may wish to preserve their fertility for a number of reasons. You may wish to preserve your fertility:

To delay parenthood until a date at which you are ready to start a family
To allow treatment of a medical condition which may affect your future fertility, such as prior to some cancer treatments
In cases where you are at risk of injury or death

Preserving your fertility to delay parenthood

You may decide to freeze and store your eggs or embryos to delay having children. A woman’s chance of conceiving naturally declines with age as the quantity and quality of her eggs diminish, so women who store their frozen eggs or embryos when they are younger may have a better chance of a successful pregnancy in the future.

What is embryo freezing and storage?

During in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) treatment, fertility drugs are used to stimulate the ovaries to produce more eggs than usual. These are then fertilised with your partner’s, or a donor’s sperm to create embryos.

Because there is normally a number of unused embryos, some people choose to freeze the good quality unused embryos for use in later treatment cycles or for donation.

Is embryo storage for me?

You may consider freezing your unused embryos for the following reasons:

It gives you the option of using the embryos in future IVF or ICSI cycles, without having to go through the risks, expense and inconvenience of using fertility drugs and undergoing egg collection again.
If your treatment needs to be cancelled after egg collection (for example, if you have a bad reaction to fertility drugs), you may still be able to store your embryos for future use.
You want to donate your unused embryos for the treatment of other women or for research.
You are facing medical treatment, such as for cancer, that may affect your fertility, (embryo freezing is currently the most effective way for women to preserve their fertility).

What are the risks of freezing embryos?

Not all embryos will survive freezing and eventual thawing when they come to be used. Very occasionally no embryos will survive.

It is not uncommon for those embryos that do survive freezing and thawing to lose a cell or two. Ideally the embryos should continue to divide between thawing and transfer.

As embryo transfer is involved in using frozen embryos, the same risks apply.

What is blastocyst transfer?

A blastocyst is an embryo that has developed for five to six days after fertilisation.

With blastocyst transfer, embryos are cultured in the laboratory incubator to the blastocyst stage before they are transferred to the womb.

At this time, one or two of the best quality blastocysts are selected and then implanted into the woman’s womb. A blastocyst must successfully attach itself to the wall of the womb for a woman to become pregnant.

Is blastocyst transfer for me?

Many clinics are now offering blastocyst transfer as a means of improving chances of pregnancy after single embryo transfer. This is particularly useful for younger women with a good prognosis for pregnancy from in vitro fertilisation (IVF).

Your doctor may also suggest you try blastocyst transfer if you have produced good quality embryos in a previous IVF cycle but they failed to implant in the womb.

It is not normally recommended if you produce fewer than normal healthy eggs.

How does blastocyst transfer work?

The procedure for blastocyst transfer is similar to that for normal embryo transfer, but instead of being implanted into the womb after two or three days, the embryos are allowed to develop for five to six days before transfer.

What are the risks of blastocyst transfer?

Not all embryos will develop to produce blastocysts in the laboratory. Embryos can stop developing at the four-cell stage (day two) and progress no further.

The embryologist may advise your consultant that in your case it is safer to consider a day two-three embryo transfer than risk having no blastocyst to transfer on day five-six.

As with normal embryo transfer, due to the risks of a multiple birth if more than one blastocyst is transferred, you may want to consider single blastocyst transfer.

For more information on the problems involved in multiple births, speak to your clinician and see the following information:

How does assisted hatching work?

Before an embryo can attach to the wall of the womb, it has to break out or ‘hatch’ from its outer layer called the zona pellucida.

It has been suggested that making a hole in or thinning this outer layer may help embryos to ‘hatch’, increasing the chances of the woman becoming pregnant in some cases.

However, assisted hatching does not improve the quality of embryos.

What is assisted hatching?

Assisted hatching is done while the embryo is in the laboratory.

Before being transferred back to the womb a hole is made in the outer layer of the embryo or it is thinned, using acid, laser or mechanical methods.

A typical procedure is:

On day three of embryo development, the embryologist uses either weak acid in a fine glass pipette, a microlaser or a microtool to thin or cut a hole in the outer layer of the embryo.

What is my chance of having a baby with assisted hatching?

Some clinicians believe that the use of assisted hatching results in higher pregnancy rates in selected cases. For example, it has been noted that in the older woman the zona pellucida around the embryo can appear to be thickened. The making of a ‘weak point’ in the zona may help implantation.

Others feel that there is no convincing evidence that it helps to improve chances of pregnancy.

What are the risks of assisted hatching?

Current research suggests that this treatment is no more likely to cause an abnormality to the baby than IVF without assisted hatching. As it is only the outer layer that is affected by this procedure, the embryo should remain unharmed.

There is always some risk of damage with any procedure of this type.

If you have more than one embryo transferred, this may increase the risk of multiple births.

What is surrogacy?

Surrogacy is when another woman carries and gives birth to a baby for the couple who want to have a child.

Is surrogacy for me?

Surrogacy may be appropriate if you have a medical condition that makes it impossible or dangerous to get pregnant and to give birth.

The type of medical conditions that might make surrogacy necessary for you include:

absence or malformation of the womb
recurrent pregnancy loss
repeated in vitro fertilisation (IVF) implantation failures.

How does surrogacy work?

Full surrogacy

Full surrogacy involves the implantation of an embryo created using either:

the eggs and sperm of the intended parents
a donated egg fertilised with sperm from the intended father
an embryo created using donor eggs and sperm.