What to Expect at Your IUI: The Process, the Math, and the Reality

IUI is simple—but the expectations, emotions, and math behind it definitely aren’t. In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols walks you through exactly what to expect during an IUI cycle, from the first ultrasound to the trigger shot to the quick, 30-second insemination appointment. You’ll learn who IUI works best for, why success rates aren’t as straightforward as they seem, and how your odds really build with each cycle. Whether you’re preparing for your first IUI or deciding whether to keep going, this episode gives you the clarity, context, and confidence you need to make informed decisions on your fertility journey.

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Transcript

0:01

Today we talk about what to expect during your IUI treatment and what the actual math says about your chances of success. I'm, Dr. Marc Emils, and this is Taco about Fertility Tuesday. So you've done your initial consult, or maybe you followed up, and now you've talked about going ahead with iui, with your doctor. The question is, what is this, and what's this process like? Well, basically, an iui, which stands for intrauterine insemination, also known as artificial insemination, is basically taking the best sperm and then putting them into the uterus. It's like putting them at the front door of a house and saying, hey, I'm coming in. The great thing about it is it's simple. It's not surgery. There's no anesthesia. There's no drama. It's just getting everything a little bit closer together. Now, essentially, most artificial insemination IUI cycles are going to start with some type of baseline ultrasound that's going to make sure there's no cyst before you start the process. So that way, later on when you go to look to see how the follicles grew, you can know that that's an actual follicle versus a cyst that was there before. There are multiple ways to medicate this cycle. You could just naturally develop one follicle. You can take meds like Clomid or Letrozole, which is also known as Femara, and you can even add injections. Those injections can even make more eggs. Usually you'll start these medications on the third day of your menstrual cycle. Then you take that medicine, usually up to about day seven, and they'll set up an ultrasound somewhere between about day 8 and day 10. Now, this next ultrasound, we call it the monitoring ultrasound. This is basically now where we're looking to see which follicles grew and did too many grow or did not enough grow for different ages? We're shooting for different numbers. If you are, let's say, 41, I'm happy if we can get like three to four eggs, maybe even five. But if you're 40, 30, I may only want two eggs because I don't want you to end up being quatromom. Then when we look at that ultrasound on day 10, or maybe 11 to 12, whatever that day is, they'll determine either if you're ready to take what's called a trigger shot, or if you need another ultrasound or even more medication, if you need another ultrasound, then they'll bring you back. Let's Say in two days. And at that point they're going to reassess. Now, eventually the follicles are going to be a size where they're ready to be released. Now some clinics may verify that the eggs are mature by checking the estrogen level. Others may just use the size of the follicle and call it good. When the follicle is ready, they're going to give you a trigger shot. And this is basically to hit the timing button. So that way you're going to ovulate in about the next 36 hours. Now some places will either have you do the IUI at 24 hours or we'll have you do it at 36 hours. Both are, correct. It's important to understand the trigger shot itself is not making you more pregnant, it's just making the time of ovulation more predictable. So now if you have a few follicles that are mature, you've taken your trigger shot. Amazing. So what comes next? Well, during this next 36 hours, a couple things will happen. They're usually going to set the time for your artificial insemination, IUI time. And about an hour and a half prior to that, they're going to set up the semen preparation by either having your partner come into the clinic to give a sample or dropping off the sample, or if you're using frozen sperm, a, time that they're going to thaw that sample. Now when they get that sample, what they're going to do is they're going to have to clean that sample. They do that through various ways. Sometimes they use centrifuges, sometimes they use a swim up method. There's even what are called microfluidic devices that can actually separate the sperm. The point is what they do is they go through the sperm and try to get the best of the best sperm. And they do this by removing the dead sperm, the abnormal shaped sperm, and then put it into a small medium so that way it can be placed into uterus. And this media is about maybe half a milliliter of fluid. And this is important because when you see the fluids, you're gonna be like, that's not the sperm I normally see. And that's true because what you're seeing is you're seeing a media that is compatible with going into your uterus that has a sperm in it. It's important to remember that sperm is actually very small. If a man has a vasectomy, you're not gonna notice any difference in the amount of his ejaculate. Because the amount of sperm being released is very little. Most of that fluid is going to be semovesical fluid and prostatic fluid. So don't be surprised if it doesn't seem like a lot. There's actually millions of sperm in that small amount of fluid. Now, what usually happens is on the day of the iui, you'll come into the clinic, they'll put you in a room, and they'll usually verify the sample with you, making sure that the sperm, name is correct, your name is correct. Once that's verified, the doctor will come in, usually will check again with you to make sure everything's correct. And then they'll start by placing a speculum. Now, the goal here is to get the cervix in view. Once the cervix is in view, they'll usually draw the sample into a syringe that's attached to a catheter. That catheter then is put through the cervix and usually brought to the top of the uterus or just to the lower uterine segment. At that point, they inject the sperm in. The whole thing should only take about 20 to 30 seconds, a lot quicker than most people expect. Now, there are times that it can be a little difficult to get the catheter to go in. And, sometimes they have to use a device called an OS finder so they can figure out the path of the cervix because they can't see past the opening of the cervix, so they can't tell if it's turning left or right or up and down. So that device can help them figure out what the path is. There are other times that's actually closed and they have to use that device to dilate the cervix. And there's even other times they have to put what's called the tenaculum on the cervix, which holds the cervix while they try to place the catheter through it. It's not very common, but it can be used. But most of the time it goes very simple with no issues, is usually done in less than a minute. For most patients, there's not going to be any pain. Sometimes you might get some mild cramps. And again, if you had that special situation where there was issues, it might be more uncomfortable for most people. They don't even realize the IUI has been done. Additionally, a lot of times they'll have you lay there for about 10 minutes. It's not technically necessary, but it's usually a common thing that people will do just to kind of let everything settle and then you'll sit on up. The great thing about an IUI is, as I mentioned earlier, there's no anesthesia. So you can go right back to work and go back to your life. It's not like when you have anesthesia and you have to be done for the day, you're not in any severe pain, where you're not going to want to work. You can just go back and do whatever you want, but you can also take the day off as well. Most of the time. Clinics will have you also take progesterone after the iui, usually starting the day of, or a, next day or two. And the other thing that will usually happen is they'll talk about your partner abstaining for about two to five days before the iui. But each clinic's a little bit different, so it may vary. So this gives you at least a general idea of what to expect. As I mentioned, it's pretty simple. I think one of the hardest things is the idea of how could it not work when you inject the sperm in. And that's because there are many things actually affect the success of the IUI. I honestly believe a lot of people do IUIs that shouldn't be. And so hopefully your doctor is making sure this is a good option for you people. It's not a good option for is if, let's say you're 38 and you want six kids, not a good option. If you had severe sperm quality, again, not a good option if you're over 40, rarely are IUI a good option unless you're only wanting one kid. Another situation is if you are only wanting a singleton and not wanting twins and you want no risk of twins. Again, IUI becomes more difficult because we can't make more eggs. And then the last situation would be, is obviously if your tubes are blocked, IUIs wouldn't make sense. But those are kind of the big players that affect IUI success. Age, sperm count, timing, medicated versus natural cycles and tubes. And what I mean by that is as you get older, the rate goes down for success. As the sperm quality is lower, it lowers the success rate when it comes to timing. If you miss timing, it's also going to be lower chances because the sperm's not there when it needs to be. When I talked about medicated versus natural cycles, the less aggressive you are, meaning the blessed eggs you bake, the lower the chances. And then again the tubes are pretty self explanatory now, what is the real math, though? This is going to depend a little bit on your clinic and how aggressive they are. So let's just start with something generic like, let's say Clomid or Letrozole. And then the most you get to is, let's say, injectables. So for using both of those, the minimum, let's say, is going to be 10, and the maximum would be 22. So that's the type of range I'm going to give. And you can know the bottom number is the lower similar treatment and the top number is the more aggressive treatment. So if you're under 35, it's about 10 to 22% chance. That doesn't sound like a lot, but keep in mind, if you've been trying for a year, your chances of getting pregnant are less than 5% anyways. Now, as soon as you move up to about 35 to 37 years of age, that kind of drops a little bit. Now you're somewhere between about 10 and 15%. By 38 to 40, that drops down to about 5 to 10% chance of success per cycle. And over 40 is about 2 to 5%. Now, again, these are averages. They're not prophetic. So it could be different in your situation, again, especially if you increase the dosage and increase the number of eggs you're making. Now, where the math gets a little weird is what are your chances after each cycle? You would think it would just add up additively, but realistically it's cumulative. Meaning if your first chance is 15%, your second one doesn't become 30. If your chances were 15% each time, your first cycle would be about 15% chance. Your second would be 28. Your third cycle would be 38, your fourth cycle, 48. And by your sixth cycle, you're around 62%. So your odds aren't actually decreasing. It's just how math works. When you have a finite amount you can get up to, which is 100%, for this reason, most clinics will only do about three IUIs. And at that point they'll say either move on or go on the IVF. And that's because if you look at IUIs and say, well, listen, M, if I look at everyone who got pregnant during the IUIs, you would find that of the people who got pregnant, 90% of them were pregnant in the first three cycles. Not 90% pregnancy rate, but 90% of the people who got pregnant were in the first three cycles. Honestly, I think one of the things that's important about IUIs and to increase the success rate is the right people doing them. I feel a lot of times the wrong patients are doing IUIs because there's a couple things frustrating about IUIs when they fail. One is you have no idea why it failed. I mean, everything looked good. You had the perfect follicle, a beautiful lining. The sperm was literally Brad Pitt esque, the timing was perfect, and yet a negative pregnancy test. So what are some of those reasons? Well, it could be for lots of things. The most common is going to be the egg was probably chromosomally abnormal. That's why as you get older, the chances go down because more eggs are abnormal. But there's other reasons as well. The tube may fail to pick up the egg, or there can be something wrong with the sperm not fertilizing the egg. There can be luteal phase defects or ovulation issues that we're not realizing. Sometimes it could just be bad luck. The important part is one failed IUI does not diagnose infertility. It's just math. The problem with math is it doesn't mean it's not emotional. And as I mentioned, after, you do the iui, you're going to overanalyze everything. Every little twinge, every little pregnancy test that you're trying to see if maybe it's positive or not. And then when it doesn't work, you're gonna be so disappointed, you're gonna start thinking, what did I do wrong? And the important part is, you didn't. It's just not that high of success. As I talked about, there's a better chance of it not working than working on the first iui. So when the IUI fails, especially in the first one, it's not a sign something is wrong. It's just a sign that probabilities aren't always on our side. The biggest tech way is IUIs are good for some patients, such as people with mild m sperm issues, or maybe people who have not tried for that long. But anytime there are issues, such as advanced age, you've had failed IUIs in the past. Sperm M count is severely low, tubes are not reliable, or basically even just being burnt out and you're ready to move on to something more aggressive, then it might make more sense to start with ivf. I tend to when patients have been trying for over two to three years, I do proceed straight to ivf unless there is a reason why they're not getting pregnant, such as ovulation issues, or if the sperm does have some issues, like motility issues, then it might make sense to do IUIs. But if it's unexplained and I can't find the cause, usually I recommend doing IVF because I find IUIs don't always work in that situation. So the takeaway will be an IUI can work and for many couples it does. But it's going to work best when you understand the process, the probabilities to the point where it makes sense to pivot. Hopefully this episode was helpful for you and maybe you have a friend who's going through iui. You just saw a fertility doctor and wondered what is the IUI going to be like? Hopefully this was able to help you. It is not to discourage you to do IUIs. It is it's just important to ask questions. As I always say, talk to your doctor. It's never wrong to say your doctor, hey, is this really the best thing for me? Or in the reverse, if they say you should do the IVF and say, well, why can't I do IUI if it's just a mild sperm problem? Being educated allows you to be an advocate for yourself and you can always ask questions. As I always say, if your doctor doesn't want you to ask questions, it's probably not the right doctor. You should always be be able to ask questions. As always. If you like this episode, please tell your friends about it. Give us a five star review on your favorite medium, but most of all, keep coming back. I look forward to talking again next week on Taco Belt Fertility Tuesday.