Intrauterine Insemination (IUI)
IUI is one of the most commonly used assisted reproductive technique. It is being used for a variety of indications.It is a safe, cost-effective and non-invasive method. Semen of the husband or donor is clinically washed to improve its fertilization capability and injected into the womb of the wife. It can be done in a natural cycle but the results are much better if ovulation induction agents have bee used to make more eggs.
Indications
- Cervical factor
- Mild-moderate male sub-fertility
- Unexplained infertility
- Immunological factors
- An-ovulation
- Endometriosis
- Male anatomical defects
- Psychosexual disorders-erection ejaculation related problems
- Social indications for using the frozen semen sample of the husband when husband is away in the army or working abroad, touring job
- Indications for donor sample
- Azoospermia
- Genetic, hereditary problems
- Severe sperm defects
- Can not afford ICSI (in semen problems)
- Rh iso-immunization
- Contraindications
- Tubal block-at least one tube must be normal
- Severe tubal defects
- Severe semen abnormalities
- (post wash count of motile sperms less than 5 million )
- Pelvic mass or uterine cavity distortion
Evaluation prior to IUI
Proper patient selection and proper timing of IUI is the key to success
A detailed clinical history and physical examination of both partners is required. Semen analysis (if possible sperm viability Study), TVS to study female genital tract, HSG for evaluation of Tubes, lapro-hysteroscopy if any tubo-peritoneal abnormality is suspected, evaluation of major hormonal problems needs to be carried out.
Age is an important factor to determine the success of IUI . With advancing age and decreasing fecundity either the patient may be advised for IVF or fewer cycles of IUI are offered.
IUI Lab
Any center doing IUI must have,
-TVS facility
-Semen collection area
-Semen preparation lab with laminar hood, centrifuge, compound microscope, Co2 incubator, CO2 cylinders, semen freezing facility, and storage facility
-Insemination area
Collection of semen
Collection of semen is done by masturbation. In the event husband is not able to produce a sample, various types of vibrators are used. Certain medication may help in semen Collection process. In retrograde ejaculation, sperms may be retrieved from urine.
Steps for IUI
1)The patient is called on the second day of the period after all the required investigations have been done in the previous cycle.
2)A baseline follicular study ultrasound is done to see any cysts in ovaries or other problem.
3)Ovulation induction or egg formation is initiated either with tablets or injections.
4)Follicular study with TVS(Trans Vaginal ultrasounds) is done to tract the growth of egg.
5)When egg size reaches more than 16 mm an injection for egg rupture is given.
6)36-48 hrs later IUI is planned.
7)On the day of IUI husband gives semen sample which is processed in IUI lab.
8)The sample is injected into uterus using a fine IUI cannula. The procedure is painless and does not require any hospitalization and patient can go home after an hour.
9)Certain hormonal tablets are given for pregnancy support for next 15 days.
10) The patient is called after 15 days to check for pregnancy.
11) In case a donor sample is used the procedure remains the same only instead of husbands semen donor semen is used.
Success rate
Depending upon indication of IUI, the age of the patient and semen report success varies from 6-28%.
Problems related to the procedure of IUI?
Though IUI is a very simple and safe procedure certain problems may arise in some patients like
- Trauma to cervix
- Difficulty in going through cervix if it is stenosed
- Infection-though very rare if all aseptic precautions are taken
- Cramps or pain
- Retrograde low-due to loose cervix or wrong position of the cannula
- Anaphylaxis-albumin present in media or sperm protein may cause a reaction
- Fortunately, all complications of IUI are very rare and can be managed easily
How many cycles?
Normally not more than 3-6 cycles of IUI are done and if this does not result in pregnancy patient are advised for IVF / ICSI required.
Ovulation Induction
Ovulation induction is a process which helps in achieving growth of more than one egg to improve the chances of fertilization, to overcome defects of ovulation and luteal phase.
Ovulation induction is required both in IUI and IVF. The drugs and medications used are more or less the same with a difference in doses.
There are two categories of patients
-Those who don’t form eggs-called anovulatory
-Those who have normal eggs but number of eggs are required to get better results in IUI or IVF.
Various drugs used for ovulation induction,
Depending upon the aim of induction (for IUI or IVF) age, hormonal status, various protocols have been developed for induction of ovulation
- Clomifene citrate-oral
- Letrozole-oral
Injections
- Gonadotrophins- recombinant FSH, highly purified FSH
- LH(Luteinizing Hormone)
- HMG(Human Menopausal Gonadotrophin)- highly purified, or standard
- GnRH antagonist
- GnRH analogs
Various combinations have been used in different doses and every clinic follows an individualized protocol for each patient.
Monitoring ovulation induction.
It is very important to monitor the growth of eggs to decide the dose of stimulation medicine and also to time the procedure where IUI or IVF timely
Monitoring is done by,
- Serial ultrasounds
- Monitoring of blood levels of hormones
