IUI Protocol with Donor Sperm
Women undergoing IUI with donor sperm should receive intrauterine insemination rather than intracervical insemination, combined with ovarian stimulation using low-dose gonadotropins (≤75 IU/day), clomiphene citrate, or tamoxifen, with single insemination performed 24-40 hours after hCG trigger or 1 day after spontaneous LH surge. 1
Route of Insemination
Intrauterine insemination (IUI) is superior to intracervical insemination (ICI) for donor sperm treatment, significantly improving both live birth rates (OR 1.98,95% CI 1.02-3.86) and pregnancy rates (OR 3.37,95% CI 1.90-5.96) after 6 cycles using cryopreserved sperm in stimulated cycles. 2
IUI results in higher clinical pregnancy rates than ICI in both natural cycles (OR 6.18,95% CI 1.91-20.03) and gonadotropin-stimulated cycles (OR 2.83,95% CI 1.38-5.78). 3
Ovarian Stimulation Protocol
Ovarian stimulation should be combined with IUI to improve live birth rates, particularly in women with good prognosis. 1
Use low-dose gonadotropins (≤75 IU/day starting dose), clomiphene citrate (100 mg/day from cycle days 5-10), or tamoxifen as acceptable first-line options. 1, 4
Gonadotropin stimulation (starting at 150 IU FSH) produces higher per-cycle pregnancy rates (14.4%) compared to clomiphene citrate fixed protocol (6.1%), though clomiphene has lower multiple pregnancy rates (12.5% vs 20%). 4
Do not add GnRH agonists to gonadotropins as they increase multiple pregnancy rates and costs without improving pregnancy rates. 1
Cycle Monitoring and Timing
Cancel the cycle if >2 follicles >15 mm OR >5 follicles >10 mm are present at time of hCG injection or LH surge to prevent high-order multiple pregnancies. 1
Aim for 2-4 preovulatory follicles, which significantly improves pregnancy rates (34.4% for two follicles, 31.5% for 3-4 follicles) compared to single follicle (20.9%). 5
Perform single IUI 24-40 hours after hCG trigger in stimulated cycles, or 1 day after spontaneous LH surge in natural cycles. 1
Double insemination per cycle does not improve pregnancy rates over single insemination and should not be performed. 1
Sperm Preparation
Use any standard preparation technique (swim-up, gradient centrifugation, or wash and centrifugation) as there is no evidence that one method is superior to another. 1
Ensure at least 0.75 million motile spermatozoa are inseminated, as this threshold significantly impacts both clinical pregnancy (25.9% vs 17.3%) and live birth rates (21.0% vs 13.0%). 6
Post-Insemination Care
- Apply 10-15 minutes of bed rest immediately after insemination. 1
Number of Cycles
Perform at least 3 consecutive IUI cycles before considering transition to IVF/ICSI, as pregnancy rates continue to increase through multiple cycles. 1
After 3 failed IUI cycles with ovarian stimulation, transition to IVF/ICSI is the most cost-effective next step. 7
Age-Related Considerations
Success rates are significantly higher in women ≤35 years (30.5% per cycle) compared to women >35 years (18.1% per cycle). 5
Women's age is negatively associated with live birth rates and should be factored into counseling about expected success. 6
Infection Screening
- Screen both partners for infectious agents (including HIV, hepatitis) based on local, regional, and national standards before initiating treatment. 1
Risk Counseling
Inform patients about increased risk of preterm birth and low birthweight in IUI-conceived pregnancies compared to spontaneous conception, even in singleton pregnancies. 1
Multiple pregnancy risk is 10-20% with gonadotropin stimulation but can be minimized through strict cycle cancellation criteria. 1, 3