Intrauterine Insemination
WHAT IS THE PRINCIPLE OF PERFORMING AN IUI?
Intrauterine insemination (IUI) is a technique whereby sperm obtained from washed semen is placed into the uterine cavity using a sterile flexible catheter.
The aim of performing an IUI is to induce ovulation using medications and at the time of ovulation, washed semen containing motile and active sperms are placed in the fundus of the uterine cavity so that the sperm will have a shorter distance to travel into the fallopian tubes to fertilize an egg.
WHEN IS IT NOT POSSIBLE TO PERFORM AN IUI?
IUI cannot be done when:
- both the fallopian tubes are blocked or severely damaged. This is because there will not be a place for the eggs to meet the sperm in the fallopian tube.
- In severe male factor infertility (when the sperm count, motility and morphology is very poor). When the sperm quality is very poor, sperms will not be able to “swim” into the fallopian tubes to fertilize an egg.
- a woman cannot produce eggs. In women who have ovarian failure (menopause or premature menopause) and in women with advanced endometriosis where follicles do not grow, IUI is not advised because of poor success rates.
WHEN CAN IUI BE DONE?
IUI can be performed in any women who have difficulty in conceiving but do not have the problems discussed above. The common conditions for which IUI is performed are
- unexplained infertility
- problems of ovulation
- polycystic ovarian syndrome
- mild male factor infertility
- mild endometriosis
- inability to have coitus due to erectile dysfunction or vaginismus.
HOW IS IUI DONE
Before performing an IUI several tests must be done:
- Sperm Count
- tubal patency test (hysterosalpingram or laparoscopy).
You will be seen on the second day of your menses. Blood test will be done. The blood tests are
- serum FSH (follicular stimulating hormone
- serum LH (Luteininsing hormone)
- Serum prolactin
These blood test are done to ascertain your ovarian reserve.
Ovulation induction will then be started from the second day of the menses. Ovulation induction drugs includes
- oral medication (clomiphene citrate, tamoxifen, letrozole (Femara)
- injections HMG (human menopausal gonadotrophin), FSH follicular stimulating hormone
Due to the fact that pregnancy rates are better using injections, this is the preferred method of ovulation induction. The dose and duration of the medication is usually individualized and it depends on the several factors namely your age and your ovarian reserve.
Serial transvaginal ultrasounds are performed usually from day 8 of the menstrual cycle. When 2 follicles reach about 16 -18 mm in diameter, hCG (human chorionic gonadotrophin) injection will be given to induce ovulation. IUI is done 36 hours after that hCG injection.
On the day of the IUI, the husband/partner will need to produce a semen sample by masturbation. He should abstain from ejaculation for 3-5 days before the day of IUI. It is advisable for the semen sample to be produced in the IVF centre, but in man who have difficulty in doing so; the sample can be produced at home but must be brought to the hospital within 30 minutes.
The semen will then be washed in the laboratory. This is called sperm washing or sperm processing. The sperm is separated from the other components of the semen and concentrated in a small volume. Various media and techniques can be used for the washing and separation. Sperm processing takes about 30-60 minutes.
Once the sperm is ready for insemination, a speculum is placed in the vagina and cervix is gently cleaned. The washed specimen of highly motile sperm is placed in the uterine cavity using a sterile flexible catheter. You may feel a slight discomfort during the procedure. You will be advised to remain lying down for about 30 minutes and then you can return home.
You are advised to have sexual intercourse for 2 more days to further increase the number of sperm available for fertilization.
SUCCESS RATE
The success rate of IUI using
- clomiphene citrate is about 5%
- injections is about 15%.
Pregnancy rates are lower if
- you are above 38 yrs of age
- sperm quality is poor
- you have moderate or severe endometriosis
- your tubes are severely damaged
- couples with long duration of infertility (more than 3 years).
Pregnancy rates are usually higher if you do not ovulate on your own for example if you have polycystic ovarian syndrome.
Pregnancy rates are low after 3-failed attempts of IUI. You will be advised to undergo assisted reproductive techniques.
PROBLEMS WITH IUI
Several problems may arise during an IUI cycle.
- Ovaries may not produce follicles and so the cycle may have to be cancelled. This occurs especially during your first IUI cycle when the doctor is unsure as to the dose of injection that needs to be given. You will be started on a low dose injection so as not to have too many follicles. However sometimes the dose may be too low and no follicles develop in your ovaries. In such situation, the cycle may need to be cancelled and a new cycle has to be started with a higher dose of injection.
- Sometimes too many follicles may have grown in your ovaries. In this situation, there is a risk of multiple pregnancies. If this happens several things can be done
- The cycle can be cancelled and a new cycle is started later with a lower dose of injection.
- The IUI is to converted to an IVF cycle.
- Follicles are aspirated until there are only 2 follicles left before the IUI is performed.
- Slow growth of follicles. This occurs especially in patients with polycystic ovarian syndrome (PCOS). In PCOS patients, the starting dose is usually low and the dose is gradually increased so as to ensure that only a few follicles reach maturity. Usually in these patients the duration of the injection can be very long. On the average a non-PCOS patient may receive 6-8 days of injectable but in a patient with PCOS this may reach up to 21 days.
(https://www.youtube.com/watch?v=ZqwazWbA9mw)