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IVF Alternatives: A Closer Look at IUI vs ICI

Colourful bubble representing the cells involved in fertility treatments such as ICI, IUI and IVF, all of which compete for the title of 'best fertility treatment'.

For the title of best fertility treatment, there are many contenders. IVF is the best know, but what about the less famous alternatives to IVF, chiefly IUI and ICI?.

If you’re like us, your sex-ed curriculum at school taught you one great myth: if you have sex, you will get pregnant right away. This information is not particularly helpful when you later decide to have a baby. You’ll do all the right things, track your ovulation, have regular sex, time sex with your ovulation, but somehow you still don’t get pregnant. The urge to google, ‘how to get pregnant’ may be strong, but try to resist as you’ll be taken straight to the pages of various clinics, all offering IVF, in vitro fertilisation. The holy grail of fertility treatments, costing an average of £5000 per round in the UK (don’t even ask about pricing in the US). All this will likely leave you wondering, “Is there an alternative to IVF?” The answer is yes…

What does ICI stand for?

Intracervical insemination. Essentially, it is a form of artificial insemination that involves keeping semen held against the cervix for an extended amount of time (usually 4-12 hours).

This is usually done using a small silicone cup, something like a menstrual cup (often called a ‘cervical cap’). The cervical cap holds semen in place. This is why you’ll sometimes see ICI – intracervical insemination – referred to as CCI, Cervical Cup Insemination, or Cervical Cap Insemination.

Whatever it’s called, the goal of intracervical insemination is to concentrate semen in the cervical mucus, to increase the number of sperm which make it through and into the uterus, towards the egg.

Cervical mucus is magic. It is what allows sperm to swim up through the cervix and into the uterus. It provides the perfect home for sperm to live in whilst in the vagina (at the right pH level), it filters out irregularly shaped sperm cells, it even provides sustenance for the sperm as they make their way heroically to the egg, a veritable picnic.

By concentrating sperm in this magical fluid for an extended period of time, we increase the probability of sperm making it into the uterus, and eventually, to the egg.

As fertility treatments go, ICI is natural, non-invasive, and proven through decades of clinical research, all of which make it an attractive alternative to IVF. Scientific papers and records from physicians show that ICI used to be the de facto clinical treatment from as early as 1940, to around 1980.

Where did ICI go?

In the 1970’s there was a significant technological advancement that allowed scientists to ‘wash’ semen – sperm washing involves processing a semen sample in a laboratory, removing healthy sperm from the semen fluid and separating these sperm cells out.

Semen cannot be placed directly into the uterus (the cervix plays a significant role in ‘cleaning’ sperm and removing semen before it travels to the uterus). Sperm, however, can be injected into the uterus. And so, with this sudden access to simple, cheap sperm washing, came IUI – Intrauterine insemination – as well as IVF. IUI involves passing a catheter through the cervix, so that the washed sperm can be deposited directly into the uterus. In a short space of time, IUI very quickly replaced ICI as the de facto clinical treatment.

What is the difference between IUI and ICI?

To perform ICI (intracervical insemination), a couple would present in the clinic. The male produces a semen sample, which is taken by the doctor and poured into a cervical cap. The doctor would place that cervical cap into the female patient’s vagina, and she would then go wait in a room for a few hours with the cap in place, before returning to the doctor to have the cap removed.

It was a simple treatment, and therefore not overly expensive for the patient. But the cost of providing this treatment for clinics was still substantial.

To perform IUI (intrauterine insemination), the couple present in the clinic. The male produces a semen sample, which is taken to the lab to be washed. The doctor then injects the washed sperm directly into the uterus of the female patient. The benefit of IUI is that there is no risk of sperm ‘falling out’, and so you’re free to go immediately after treatment. Because IUI involves sperm washing (needs a lab), catheters in uteruses (needs a trained physician) and – sometimes – sedation, it’s a much more involved, much more invasive, and much more expensive treatment. ICI is less profitable for clinics, thus the shift to offering IUI instead.

But, is ICI less effective than IUI? Is there a significant increase in IUI’s efficacy that merits the increased cost of the treatment? Well…

How successful is ICI?

But, we’re looking for alternatives for IVF, and neither ICI or IUI are as effective. True. However, when it come to fertility treatments, cumulative success rates are the key, and IVFs substantial price tag makes multiple cycle impossible for most people, so we need a more affordable alternative which allows multiple cycles .As it turns out, the efficacy between ICI and IUI doesn’t vary greatly. In 2018, a Cochrane scientific peer review was published comparing studies of ICI and IUI, concluding that there is not enough evidence to suggest that ICI is any less effective than IUI as a fertility treatment.

A 2015 study involving 1843 women, each undergoing multiple cycles of either IUI or ICI, found pregnancy rates of 20.1% after 3 cycles in the ICI group, and 22.4% after 3 cycles in the IUI group. The same study found a pregnancy rate of 40.5% after 6 cycles in the IUI group, and 37.9% after 6 cycles in the ICI group. According to a number of studies, the differences in efficacy between both treatment types, over 3 and 6 cycles, are marginal.

So why don’t clinics offer ICI?

Because in many cases, it’s not profitable for them to do so. IVF and IUI are both highly profitable for clinics so alternative treatments, such as ICI are often discarded. ICI takes up a lot of resources for a relatively inexpensive treatment. IUI, with all the add-ons that go with it, is much more expensive, and therefore, much more profitable.

From the 80’s onwards, ICI slowly disappeared from the menu of treatment options at most fertility clinics. IUI is now the world’s most popular fertility treatment, with over 75,000 IUIs performed across the UK alone in 2017.

Today, you won’t find ICI on offer at all in clinics, except some rare exceptions in certain countries that adopt a more holistic, natural approach to fertility.

Is ICI more affordable than IUI and IVF?

In short, yes. According to one study, the cost of IUI is approximately 4 times the cost of ICI. London clinics will offer a single round of IUI for £800-£1500, however, these prices often do not include the cost of a consultation (£250+), the cost of any medication, the cost of follow up consultations (£200+) and any additional services around your IUI.

Over 3 cycles, IUI has shown to be 2.3% more effective than ICI. This 2.3% gain in effectiveness will cost more than 4x what you might have paid for ICI. The increase in efficacy does not correlate to the significant increase in treatment cost. This sounds obvious, but the economics of this break down when each IVF treatment round costs well over £3000 – very few people can afford multiple rounds of fertility treatments, so a more financially viable alternative is badly needed. Today, the average spend per couple on treatment in the UK is £12,000. The average spend on fertility treatment in the US is $61,000 per couple. That kind of expense is beyond the reach of most. It is simply not fair, and this is why we need to bring affordable, gateway treatments into the market, so people can take advantage of cumulative success rates without breaking the bank.

Hold up. Isn’t ICI just the syringe method?

No. You’ll sometimes hear people talking about ‘intracervical insemination by straw’, ‘syringe insemination’ or the ‘syringe method’. The syringe or straw method of insemination is not the same as intracervical insemination. ICI mechanically holds semen against the cervix for extended periods of time. The straw or syringe method injects semen into the vagina, essentially mimicking intercourse.

Can you get pregnant using a syringe?

The short answer is, yes. However, like with most things, it’s not that simple. If you’re using donor sperm – and you’ve only got one shot at insemination – is it the most effective way to conceive? Absolutely not.

Compared to the syringe method, ICI is scientifically proven to have higher efficacy rates per insemination. In one key study comparing syringe insemination with cervical cap insemination, the pregnancy rate of the syringe insemination group was 5.9% after one cycle, whereas the pregnancy rate of the cervical cap insemination group was 15.2%, nearly three times higher. Another study found that the concentration of semen in the cervical mucus after cervical cap insemination was 3.25x higher than after sexual intercourse.

What are ICI and IUI vials?

What you might sometimes hear is people talking about donor sperm in terms of ICI Vials and IUI Vials.

Vials are what donor sperm arrive in. ICI vials contain donor sperm that has not been washed and is suitable for insemination at the cervix (i.e. intracervical insemination). IUI vials contain donor sperm that has been washed (there is no semen fluid, just sperm cells), and is suitable for IUI (i.e. insertion into the uterus) and IVF.

Can ICI be used at home?

Some solutions exist to help you perform an ICI treatment at home. You can buy cervical caps at your local pharmacy. These can be inserted into the vagina after intercourse to hold semen as close to the cervix as possible. These self-inserted cervical caps are not an ideal solution (it’s tough to place a cap at the cervix using your own hands). The Béa Treatment Kit will allow you to perform ICI successfully at-home, and our applicator allows for easy insertion at the cervix.

Can IUI be used at home?

What you cannot do at home is IUI. Passing a catheter through the cervix is a medical procedure that must be performed by a trained doctor. It carries significant risk, can damage the uterus, not to mention unwashed semen should never be injected directly into the uterus.

Which is the best alternative to IVF?

That’s not for us to say. When it comes to your fertility decisions of whether to have treatments and which treatments to try is a personal one. So many factor can affect your decision: mental health, location, financial situation, relationship status, medical history and more. We’ve laid our both IUI and ICI as valid alternatives to IVF treatments and hope this will help you to make an informed decision. But when it comes to the battle for the title of ‘best fertility treatment’, there isn’t a best one, only the best one for you.