Treatment Spotlight:

• Intrauterine insemination (IUI) is a minimally invasive fertility treatment.
• It involves a concentrated sample of sperm being deposited into the uterus at the time of ovulation, with the help of a small, thin tube (a catheter).
• IUI can be used as part of a natural menstrual cycle, or as part of a stimulated cycle where hormone medication is used to stimulate the ovaries - similar to IVF.
• For certain groups, including female same sex couples and couples where unprotected sex is not advised, IUI can be fully or part-funded by the NHS.

IUI is an assisted reproductive technique (ART) that gives sperm a better chance of fertilising an egg. It's the most direct form of artificial insemination, and involves placing the sperm directly into the uterus with the help of a catheter. This way, sperm bypasses the vagina and the cervix, and gets a head start on its journey to the egg.

IUI is less invasive than IVF, and fertilisation takes place inside the body - unlike in IVF, where fertilisation takes place in a lab.

There are two types of IUI:

• Stimulated IUI involves taking medication to promote egg growth, and a trigger shot is used to start ovulation.

• Unstimulated IUI doesn't involve medication. Instead, an ovulation test is taken to time insemination at the right point of ovulation within a natural menstrual cycle.

IUI is usually not the preferred treatment for those suffering with infertility. However, IUI is used regularly when:

• Donor sperm is being used. Where a person is single, a partner doesn't produce sperm or overall sperm quality is low, IUI is a common procedure to help people fall pregnant with donor sperm.

• Infertility is unexplained. IUI is often the first treatment recommended to individuals and couples where there is no confirmed reason for infertility.

• Where unprotected sex isn't an option. This could be for physical or emotional reasons, such as an allergy to semen (it happens!), or a pre-existing condition like HIV.

• Where IVF isn't an option - there could be cultural or religious reasons that rule out IVF as well as physical reasons, like the fact that you don't respond well to hormone medication.

• IUI is most commonly used as an alternative to sex. IUI is less demanding than IVF, which is why it is often used as an alternative to sex for people who are otherwise fertile, but who are unable to have sex. However, some people do choose to try IUI before IVF because it is less invasive.

• It's cheaper than IVF (kind of), but less successful per cycle. Some people decide to use IUI to treat infertility rather than IVF because it's cheaper per cycle. The average advertised package cost of an IUI cycle is £1,265, compared to £3,898 for a single cycle package for IVF. However, multiple cycles of IUI may be required, and if you're using donor sperm, costs can creep up significantly.

• IUI is time consuming. With IUI, timing is everything. Your cycle needs to be closely monitored to ensure that insemination happens at exactly the right time. This is especially true with Stimulated IUI, where you'll spend a lot of time at your clinic for pre-treatment tests and scans.

• It's not for everyone. IUI won't be successful if you have been diagnosed with male factor infertility, fallopian tube blockages or any issues with ovulation.

Time: Varies, but approx. 2 weeks

Location: Clinic

For females, or those assigned female at birth (AFAB), your clinic will run pre-treatment blood tests and ultrasound scans. These predict your body's response to treatment and help to understand the number and quality of eggs available (this is known as your ovarian reserve) [1].

Tests include:

• Blood tests for Anti-Müllerian Hormone (AMH) and Follicle Stimulating Hormone (FSH). These are used to understand the number of eggs you have available.

• A pelvic scan, which involves an Antral Follicle Count (AFC). This looks at the number of immature follicles that can be matured (and develop eggs) in the IVF cycle.

For men, tests check the quantity and quality of sperm. This is measured as motility (movement) and morphology (shape). Depending on the results, you may need additional treatments, such as intracytoplasmic sperm injections (ICSI).

Both partners undergo mandatory screening for blood-borne viruses, like HIV and hepatitis [2].

Next, you'll need a follow-up consultation with a doctor to discuss the results and prepare your cycle.

Time: 2 weeks

Location: Home, with minimal clinic visits

Even if you're following an unstimulated natural cycle, this will still need to be tracked to optimise the timing of insemination. You can do this through blood and urine tests performed at your clinic - so be prepared to visit your clinic multiple times over your predicted week of ovulation (days 10-16 of your menstrual cycle). Alternatively, you can use an ovulation prediction kit at home.

Time: 2-4 weeks

Location: Home, with in-clinic monitoring

Now it's time to begin your treatment - or protocol.

Most protocols start on day 1-2 of your period, directly after your bleed. This is when you will begin stimulation. The process typically takes two weeks, during which you inject medication into your abdomen. This encourages follicles in your ovaries to grow and develop multiple eggs at the same rate, increasing your chances of conception. This is different to a natural cycle, where only a 'lead' follicle develops an egg.

The size of the follicle is how your doctor determines whether the egg is ready (since eggs are too small to assess otherwise). To monitor the development of your follicles, the doctor will use hormonal blood tests and a trans-vaginal ultrasound.

Time: A few hours, just prior to insemination

Location: Clinic

On the morning of the IUI procedure, the male partner needs to produce a sperm sample. This can be a previously frozen sample.

The sample is then 'washed' in the lab to create a higher quality, concentrated sperm package. This process also removes naturally occurring substances in the semen that can prevent fertilisation, and removes any pathogens, like a sexually transmitted diseases, that could be passed on.

If you're using donor sperm, the sample will arrive at your clinic frozen and already washed.

Time: 5 minutes

Location: Clinic

The insemination procedure is very quick, and is usually carried out without anaesthesia or sedation.

A catheter is inserted into the uterus via the vagina, and the prepared sperm is sent through this fine tube into the uterus. Your doctor will use an ultrasound to guide the catheter, and to help them visualise it clearly, you will be asked to arrive at your appointment with a full bladder.

Time: 2 weeks

Location: Home

After insemination, fertilisation and implantation will hopefully be successful. The 'two week wait' refers to the period you'll need to wait until a pregnancy test can be taken to provide you with a reliable result.

Typical timeline: 6 weeks

This is based on a single round of IUI, from pre-treatment to taking a pregnancy test.

The length of your IUI treatment is the same, whether you opt for stimulated or unstimulated IUI.

The time it takes to complete pre-treatment tests may vary depending on whether your doctor feels it necessary to run further tests, and you may choose to take a break between this phase and starting treatment. Regardless, you'll need to wait until the start of your next menstrual cycle to begin treatment.

If you need further cycles, you won't necessarily need to run the same tests as the first time, bringing the treatment timeline for any subsequent IUI cycles to around 4 weeks.

Like other fertility treatments, success rates are not the same for everyone. Age, the IUI method you use, any underlying conditions, and the quality of care at your clinic all play a big factor.

However, IUI success rates typically range between 5-15% per cycle for women up to 40 years old, making it about a third as successful as IVF. This is why IUI is often carried out as an alternative to sex in those with no evidence of infertility, rather than as a treatment for infertility. This is because if someone is suffering from infertility this would only further reduce the chance of success with IUI.

There's a higher cumulative success rate with IUI compared to a per cycle success rate. That means your chances of conceiving via IUI increase for every additional cycle after your last - with the highest success rates typically seen in the 3rd and 4th cycles.

Up to 37 years of age, stimulated IUI cycles are generally considered more effective. The success rate of stimulated cycles is 13%, compared to 6.5% for unstimulated cycles.

However, for anyone over 37, unstimulated cycles tend to lead to a greater chance of pregnancy than a stimulated cycle (12% versus 8.5%) [3].

Women are born with all the eggs they will ever have. Unlike other cells in the body, like skin cells, eggs don't regenerate. This means our eggs age like the rest of us, reducing the number and quality of eggs available over time.

But it's not just women who experience an age-related decline in fertility.

Emerging research shows age affects sperm. Men over 30 are more likely to have decreased sperm motility compared to younger men, and men over 40 are more likely to have lower sperm counts.

There's also mounting evidence that sperm quality has been declining generally over recent generations. The exact cause is unknown, but thought to be caused by greater levels of pollutants, changing diets and increased stress levels.

Life after IUI looks different for everyone.

If your cycle was unsuccessful, it can be heartbreaking. Many people may feel the need to take a break before trying another cycle, while others go straight back into planning. Your clinic should provide follow up appointments and counselling sessions to help support you.

While the chance of success increases with every IUI cycle, it's important to contact your GP if you aren't getting anywhere. When accessing care on the NHS, failed IUI cycles can be used to demonstrate infertility, and may help you become eligible for IVF treatment.

Like IVF, IUI can be a lonely process - and multiple cycles can make it even more isolating. While your clinic can offer excellent support along the way, connecting with the fertility community online or offline can offer invaluable friendship, connection and support.

Overall, IUI is pretty safe because its minimally invasive, and if you're using donor sperm, all sperm is screened to exclude certain diseases - like HIV, hepatitis, and syphilis. However, there are some risks to be aware of:

• Cramping and spotting. While IUI treatment shouldn't be painful, some people experience cramping after the treatment. Similarly, a small amount of vaginal bleeding - called spotting - may occur. This is usually the result of placing the catheter during treatment, and usually doesn't affect the chances of pregnancy.

• Infection. There is a small chance of infection following IUI treatment.

• Ovarian Hyperstimulation Syndrome (OHSS) - if following stimulated IUI. OHSS occurs when your ovaries become overactive in response to hormonal medication, and start releasing their own chemicals. This is very rare, and in the case of stimulated IUI, the course of hormone medication is shorter than for IVF - making OHSS rarer still. If it does occur, OHSS can usually be treated at home. In rare cases, it can lead to hospitalisation and pregnancy complications.

• Multiple pregnancy - if following stimulated IUI. Hormone medication used in stimulated IUI increases the number of mature eggs released in a cycle, which each have the possibility of being fertilised. A 2020 study found that if the number of mature follicles was increased from 1 to 5 at the time of IUI, the chance of multiple pregnancy per cycle increased from 0.6% to 6.5% [4]. Multiple pregnancies are associated with a heightened risk of health problems for both mother and babies - such as late miscarriage, premature delivery, gestational diabetes, stillbirth and death. Unstimulated cycles do not increase the chance of having a multiple pregnancy.

The NHS may fund IUI as an alternative to natural conception, for certain groups who cannot safely have sex. These groups include:

• Those who are physically or psychologically unable to have vaginal intercourse

• Couples who may be unable to have unprotected sex (for example, where one partner has HIV)

• Female same-sex couples

Funding for IUI is depends on your postcode and determined by your local Integrated Care Board - the number of rounds of IUI that your ICB will fund can vary from 0-12. To find out your eligibility, use our NHS Fertility Funding Calculator.

IVF may later be accessed if these cycles are not successful. The number of unsuccessful cycles that are required before accessing IVF varies depending on where you live.

IUI may also be offered as an alternative to IVF, where individuals have cultural or religious objections to IVF.

On average, an advertised package price of IUI is £1,265 - but can range from £550 to £2,310, and vary significantly between clinics.

If donor sperm is used, whether from a bank or a known donor, the sperm must be screened and prepared for the process. This will add to the total cost of your IUI treatment. The average price of donor sperm at a fertility clinic is advertised as £1,230 per sample, and you may also have to pay an additional £37.50 per cycle to cover the HFEA fee associated with donor insemination.

Given the chance of conceiving with IUI is around 5-15% per cycle, some clinics offer multi-cycle packages, but remember: whether you purchase a single or multi-cycle package, these are unlikely to include the cost of initial tests, consultations or any medication required.

IUI is a relatively non-invasive way to help people fall pregnant. It's the most successful form of artificial insemination, making it a popular alternative to sexual intercourse.

However, it's not necessarily the most effective option to treat infertility. And you'll need to keep an eye on costs - if you plan to use donor sperm or require multiple cycles, costs can increase quickly.