Fertility treatment is increasingly expensive and inaccessible for many. NHS treatment in England is dictated by a postcode lottery and cuts to funding (together with inconsistent rules about access) mean that only 32% of the country's IVF cycles and 6% of IUI cycles are funded by the NHS. The rules are even harder to navigate for same-sex couples and single women, who are left with no choice but to go down the private clinic route. This can cost up to £1,600 for one round of IUI and £5,000 for one round of IVF.
While IVF and IUI are the most popular forms of assisted conception, they are not the only ones out there. There is in fact a treatment that can be done at home and was popular for the majority of the 20th century but fell out of favour with the arrival of IVF. This vintage treatment, known as intra cervical insemination (ICI), is being brought back by Béa Fertility in an attempt to level the playing field when it comes to assisted conception.
So what is ICI? Essentially, it is a simpler form of artificial insemination where semen is held up against the cervix for an extended period of time This is usually done using a small silicone cup or 'cervical cap', which is a bit like a menstrual cup. The cervical cap holds semen in place. Tess Cosad, the cofounder of Béa Fertility, says: "It was the original form of artificial insemination and as early as 1910 and 1920, you would find clinics offering this in various shapes or forms."
It was really popular right up until the mid 1970s but fell out of favour with the development of IVF, which inadvertently led to IUI too. While IVF is a far more involved procedure and not a like-for-like exchange for ICI, the need to extract sperm cells out of semen samples for the treatment also enabled clinicians to inject sperm cells directly into the uterus, bypassing the cervix’s semen filter. This is what is known as IUI.
Tess theorises that clinics started offering IUI over ICI in part for commercial reasons. "IUI is probably about four to six times the cost of ICI because it’s a lot more invasive and a lot more resource intensive. You need a clinician, you need embryologists to wash semen in the lab, you need a woman on a bed in stirrups, possibly sedated, with a doctor placing a catheter through the cervix. So I think clinics felt that they could charge a lot more for it." On top of that, ICI is more time-consuming as it requires two appointments: the insertion, followed by a wait and then removal of the cervical cap. "So you've got one patient, taking up two slots in a day as opposed to one. And I think for commercial reasons IUI just made a lot more sense for clinics to offer."
As to whether ICI or IUI is a more effective treatment, for a long time there wasn’t enough data to compare the two. But from 2015 onwards, more effort was put into establishing a comparison. Tess says: "One of the main conclusions that's found is actually there isn't enough evidence to suggest that there's any difference in efficacy at all between the two. And if there is any difference in efficacy, it's very small." For example, a study in Europe of 1,800 women found that the cumulative success rate across six treatment cycles of ICI was 37.9%, compared to 40.5% for IUI.
Unlike IVF and IUI, ICI is the only treatment that really works outside of a clinical setting, making it appealing to those who want their conception to be less clinical and more personal. The reasons it works at home are many, says Tess: "It's natural, there are no drugs associated with stimulating a cycle, it is invasive to a point but it's effectively a tampon applicator, except instead of pushing out a tampon you're pushing out a cervical cap." It's so simple that it really is ideally suited for people to do at home.
That said, not everyone will be able to use a home setting thanks to the laws around donor sperm in the UK. Single people and same-sex couples who need donor sperm to conceive can either buy from a sperm bank or use known sperm donated by a friend or loved one. Sperm bought from a sperm bank cannot be sent to home addresses and must be processed through a private clinic. While this is not a legal requirement for known sperm, it is preferable as fertility clinics do a lot of the necessary groundwork to protect the users, from legal work around parental rights to screening the sperm for genetic disorders, STIs and HIV.
Béa Fertility's kit is set to launch next year and will be priced between £250 and £300 – around five times cheaper than one round of IUI. For that price you get two insemination devices (when you inseminate on consecutive days at ovulation, you can boost efficacy) as well as 20 ovulation tests, a few pregnancy tests and two semen containers.
At-home ICI treatment therefore is not immediately accessible to everyone who needs assisted conception. However Béa Fertility is working on ways to offer the right support to those using known donors. They are speaking to family lawyers about the best way they could offer a known donor agreement service with their kits, says Tess. "Obviously, that is not necessarily a document that would stand up in court. It shows intent but like all good prenups it could be absolutely shredded later. But what it does is force the conversation that I don't think many people going down that route have early on." Béa Fertility is also aiming to create a resource library with a list of providers for STI screenings. Again, this makes these kinds of considerations part of the conversation from the beginning. Tess concludes: "I think the key will be empowering women who are using a donor to actually ask for these things."