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26/May/2015

Pictures showing different kind of sperm morphologies:

Normal Sperm

1

Tapered sperm head:

2

Round headed sperm:

3

Amorphous sperm head

4

Elongated sperm head & sperm with double head

5

 Sperm with thick tail

6

Sperm with short tail

7

Pin head sperm

8

Semen sample showing plenty of pus cells in the sample, suggestive of infection. This will require treatment with antibiotics.

9

Semen sample showing leucocytes with ingested sperm head

10

Semen sample showing RBCs/ blood in semen sample

11


26/May/2015

What is IVF or test tube baby?

  • IVF stands for in vitro fertilization. It refers to the process by which a woman’s eggs are collected and then fertilized outside her womb in the laboratory.
  • This is done in a Petri dish (“in vitro” is Latin for “in glass”) where the collected eggs are kept and the washed semen containing sperms is added to it so that one of the sperms fertilizes the egg.
  • The fertilized eggs (embryos) are cultivated and grown in the laboratory and after appropriate growth, they are transferred back to the uterine cavity.

ivf

What is ICSI?

  • ICSI is a form of gamete (sperm and egg) micromanipulation that involves the direct injection of a single sperm into the cytoplasm (inside portion) of an oocyte (egg).
  • ICSI is an acronym for “Intra Cytoplasmic Sperm Injection” – which is a long, fancy way of saying “inject sperm into the middle of the egg”.
  • ICSI is a very effective method to get fertilization of eggs in the IVF lab after they have been retrieved from the female partner.
  • IVF with ICSI involves the use of specialized micromanipulation tools and equipment and inverted microscopes that enable embryologists to select and then pick up individual sperms in a tiny specially designed hollow ICSI needle. The sperms are first inactivated by breaking their tails. (Hence ICSI is mostly used in males with severe motility disorder, severe asthenozoospermia)
  • Then the needle is carefully advanced through the outer shell of the egg and egg membrane and the sperm is then injected into the inner part (cytoplasm) of the egg. This will usually result in normal fertilization in approximately 70-85% of eggs injected with viable sperm.

Fig. Intracytoplasmic sperm injection (ICSI)

icsi

Who requires IVF?

Couples who require IVF include:

  • Women with tubal diseases like blocked tubes, hydrosalpinx, and previous tubectomy done.
  • Patent tubes but non functional like in previous pelvic inflammatory disease or tubal tuberculosis.
  • Infertility due to endometriosis.
  • Unexplained infertility
  • Infertility due to male factor likeoligospermia ( low count), asthenozoospermia (less motility), teratozoospermia (abnormal sperms) or a combination of abnormalities like oligoasthenoteratozoospermia.

 


26/May/2015

  • High concentration of highly motile, best quality sperms are placed very close to the egg. This increases the chances of conception manifold.
  • Very simple procedure. No need of anaesthesia.
  • Patient can go home or to work soon after the procedure.
  • Extremely useful for couples with sexual dysfunction like dyspareunia, vaginismus, erectile dysfunction, non consummation of marriage, mild male factor infertility, grade I & II Endometriosis, unexplained infertility etc.
  • Usually husband is not required at all visits.

 

Disadvantages

  • The pregnancy rates are lower in case of IUI, approximately 10-15%. During folliculometry we document the release of the egg from the ovary. In the IUI procedure, we inseminate the active motile sperms into the uterus of the women, however we have no control over the fusion of the egg and the sperm. This explains the low pregnancy rates in case of IUI.
  • Apart from the time spent on visiting the doctor, there are no disadvantages of the procedure. IUI is one of the most basic procedures done to enhance fertility. We try and reduce the number of your visits to the clinic, so as to that the work burden on you doesn’t build up.
  • In most cases, 5-6 visits is all that is required. This includes the day we start ovulation induction, 3-4 follow up visits for follicular growth and a visit on the day of IUI.

 

IUI with normal semen parameters

  • It does make sense to try IUI if you haven’t had success with intercourse with a normal sperm count.
  • IUI increases the chance of success with injectable Gonadotrophins no matter what the sperm count is.
  • With intercourse, only few sperms make it through the cervical mucus and up into the uterus and fallopian tubes. With IUI, significantly more number of sperm will be available for fertilization.

 

Video of Semen Sample with Normal Parameters, Pre & Post Wash

Pre Wash

 

Post Wash:

 

IUI with abnormal semen parameters

  • Research has shown that an IUI done just prior to ovulation and repeated again after ovulation increases the conception rate specially in cases of sample with abnormal semen parameters.Therefore, we at Ankoor Fertility clinic, do “double insemination” in such specific cases.

Video of Semen sample with abnormal parameters

Precautions after IUI 

  • No precaution is the “Best Precaution”.
  • However, complete mental relaxation is what we want.
  • Apart from 10 – 15 minutes of lying down immediately after IUI, no additional bed rest is required.
  • There are no restrictions on travelling as also on mode of travel. You can safely travel by autos, 2 wheelers, local trains, metro etc…etc… It will not change your success rate.
  • You can safely go to work from the following day.
  • No restrictions on the food that you eat. One can definitely have papaya, mangoes, veg, non-veg, etc..without changing the success rate.

Medication after IUI

  • IUI is a very simple procedure. To enhance your conception rate, very few medicines need to be taken.
  • The medications given are generally various progesterone preparations used to support the pregnancy in the luteal phase (the phase of implantation of embryo and continuation of pregnancy after ovulation).
  • The progesterone preparations may be given in the form of oral drugs or vaginal preparations for insertion in the vagina or a combination of both oral and vaginal preparations.
  • These medicines are usually started a day after the IUI procedure.
  • The vaginal preparations are found to be superior to oral ones as they work locally (in the vicinity) without undergoing the systemic metabolism (absorption into the blood) and also giving higher pregnancy rates.
  • At Ankoor Fertility Clinic we evaluate the endometrium on Day2 or Day3 and the endometrial blood flow on Day 10 of the cycle. If the blood flow is found adequate and the endometrial lining is good, the likelihood of conception is higher. In cases of deficient endometrial blood flow, medications like Ecosprin, Sildenafil and Arginine are added. Studies have shown these drugs improve the implantation and conception rate. Such a holistic approach gives good results for our patients.

Pain during IUI

  • IUI procedure is usually painless per se. Most women feel a little discomfort similar to internal examination. The actual pain is generally not felt.
  • It’s more of fear of the procedure that results in pain/discomfort rather than IUI itself
  • In 1-2% of patients, there could be abdominal cramps or back pain after IUI, the severity of which is not more than the pain during periods.
  • Many women also experience ovulation pain which may contribute to the discomfort during IUI because IUI is done at the time of ovualtion.
  • Adequate information regarding the procedure and counseling will reduce the discomfort of the procedure.

 

Discharge/Semen coming out after IUI

  • Before IUI we clean the vagina with sterile gauze piece to remove the debris and the natural discharge.
  • Then we use a sterile medium solution to wash out the vagina before IUI and make it more receptive to the sperms. This fluid might trickle down to give you a sensation that sperms are coming out.
  • Also the motile sperms are injected directly into the uterine cavity which is higher up than the vagina and they will swim up as soon as they are injected into the uterus towards the fallopian tubes and not in the vagina. The semen sample is already into the uterine cavity once the catheter is removed. Thus it is normal to have some fluid discharge after the procedure but this does not contain the motile sperms.

 

Bleeding after IUI

  • IUI is a simple, atraumatic procedure taking a few minutes.
  • Generally there is no bleeding after IUI. However, bleeding can happen if the catheter does not enter the cervix (the lower part of uterus) and hence the need to hold the cervix with an instrument called tenaculum arises.
  • This is called as mild spotting and it stops in 24 hrs. In some patients ovulation itself could be associated with some spotting.

 

Intercourse after IUI

  • It is absolutely safe to have intercourse soon after IUI.
  • Infact, we recommend intercourse soon after IUI so as to make sure that the fertile period is completely taken advantage of.

 

Husband not available at time of IUI 

  • One can freeze the semen sample before an IUI procedure if they are physically away at the time of procedure.
  • Once semen sample is given to the lab; a complete semen analysis is performed which includes, volume, liquefaction and viscosity, sperm count, motility, forward progression and morphology.
  • This semen is then subjected to freeze and can be revived on IUI day (Freezing can sometimes reduce the motility of the sperms).

 

Outcome of IUI with frozen semen

  • Freezing process tends to kill off weaker sperms, and may thus lead to survival of the best sperms.
  • It does not change the success rate.
  • It has been documented in the literature that pregnancy has occurred using semen frozen for 21 years.

 

Implantation after IUI

  • In normal conditions, the sperm meets the ovum in the fallopian tube around ovulation, the fertilized embryo then travels the entire length of tube and implants in the uterus after around 5-6 days.
  • The same thing happens after IUI. Hence bed rest following IUI is not required.
  • This is the time required for fertilized egg to travel from your fallopian tubes to the uterus. This is also the time when lining of uterus will be ready to accept your fertilized egg.
  • At our centre, we do Color Doppler assessment of the Endometrial blood flow. If the blood flow is good, the receptivity of the endometrium for fertilized embryo is good. If the blood flow is inadequate, we at our centre, provide necessary treatment to improve the blood flow of the endometrium either in the same cycle or the next to increase the pregnancy rates.

 

VIDEO SHOWING GOOD ENDOMETRIAL BLOOD FLOW ON USG COLOUR DOPPLER

 

Good Endometrial blood flow at the time of ovulation

 

Post ovulatory good endometrial blood flow

What happens after IUI? 

  • Post IUI the medication for luteal support (2nd half of the cycle)is given for 14 days.
  • After stopping the medications, youneed to wait for 5 days.
  • If you don’t get your periods after that then you have to come for a checkup to “Ankoor Fertility center, Mumbai” to confirm pregnancy.
  • If within 5 days after stopping the medicines you get your periods, you have to come and see us on the second or third day of periods.

 

Detecting Pregnancy after IUI

  • If pregnancy occurs, there is release of hormone β HCG from the developing embryo. Serum levels of this hormone are measured to detect pregnancy. This hormone is also secreted in urine.
  • Pregnancy can be detected earliest around 14 days after IUI.
  • A simple urine pregnancy test done at home will tell you about your pregnancy.
  • If in doubt, blood test for hormone βHCG levels can confirm the same.

 

Method of delivery after IUI

  • Mode of delivery i.e. normal delivery or cesarean section is not decided by the way you achieve pregnancy. In the absence of any risk factors, you can safely have a normal delivery.

 

Success rate in IUI                    

The success rate of IUI depends on a multitude of factors like women’s age, ovarian reserve, previous obstetric history and semen parameters and most importantly on stimulation protocol used.

  • IUI done in natural cycles has a success rate of 8-10%.
  • Stimulation done with oral medications (Clomiphene Citrate) increases the success rate to 14 – 15%.
  • Use of injectable Gonadotrophins increases the rate of success to 18 – 20%.
  • Using highly potent recombinant Gonadotrophinsfurther increases the success rate.
  • Addition of GnRh antagonist increases the pregnancy rates further by 26-30%

 

Overall, at Ankoor Fertility centre, the success rate following 3 IUI has been 18-25%.

How to further enhance the success rate in IUI ?

At Ankoor fertility centre, we do a various unique things, so as to help you become pregnant faster and in a healthier way.

Trial cycle – Before commencing, we often do a trial cycle in which we observe the growth of your follicles, their rupture, the timing of rupture, whether spontaneous rupture occurs or not and most importantly evaluation of the endometrium.

Endometrial evaluation – Gametes are like seeds and the endometrium (lining of uterus) is like the soil. Just as for proper implantation of seeds, good soil is necessary, so is the endometrium for the embryo. We routinely evaluate the thickness and pattern of endometrium so as to prepare optimum endometrium and enhance the results.

This is done by serial Ultrasound at our clinic.

If found necessary, certain medications are given to increase the thickness and also Color Doppler for blood flow to endometrium is done. If the blood flow if found deficient, a medical treatment is initiated along with constant evaluation of the same to increase the live birth rates and decrease the abortion rates.

Video 2: Post ovulatory good endometrial blood flow

Evaluation of male partner – We do semen analysis in our Lab, so as to pick up any subtle abnormalities which might be present inspite of normal count and motility.

Certain specialized tests like Sperm Function Test, DNA fragmentation rate and Mitochondrial assay are done in specialized circumstances so as to enhance the result.

Sperm function test gives an idea of the capacity of sperm to fertilise an egg.

DNA fragmentation rate gives an idea of genetically normal sperms. High fragmentation rate is associated with higher rates of abortion.

 

What are the predictive factors influencing pregnancy rates after intrauterine insemination?

The predictive factors after IUI are as follows:

  • Female partner’s age (less than 35 years of age have better results),
  • Body mass index (BMI) (BMI <26 have better results),
  • Duration of infertility (Longer the duration of infertility, poorer are the results),
  • Type of infertility (primary versus secondary),
  • Follicle stimulating hormone (FSH) level and estradiol (E2) on third day of the cycle (If the Estradiol levels are 1000 to 1200 for 3 mature follicles, then the response is better),
  • Number of preovulatory follicles (More the number of follicles, better the response),
  • Endometrial thickness (If endometrial thickness is 9 to 12 mm around the time of IUI, then the response is better),
  • Total motile sperm (TMS) count (more than 5 million, better response) and ratio of progressive motile sperm.

 

Reasons for failure in IUI

  • The success of IUI depends on multiple factors like age of women, ovarian reserve, semen parameters, cause of infertility, duration of infertility etc.
  • Even in a natural cycle with couple having no abnormality, the success rate in a cycle is only 8-10%.
  • Failure can be due to poor quality egg, abnormal semen parameters or just due to probability of success.
  • Even if 2-3 IUIs have failed, you should not get disappointed as we have seen success after 6 cycles of IUI too.

 

Working women/couple and the number of visits to the clinic 

  • IUI is an outpatient procedure, so leaves from office are not required during the monitoring phase.
  • Moreover, at Ankoor fertility Clinic, most procedures are done in the evening after your office hours. 
  • Only on the day of procedure, half a day leave may be required, since the time from giving semen sample to processing the semen sample and doing the IUI procedure takes about an hour and a half to two hours.
  • If done during the morning hours, the busy schedule of the husband can be easily handled by allowing him to leave for his job after giving the semen sample and the initial semen count been checked. The wife could stay back till the procedure is over and resume duty after that.
  • Also, during the monitoring phase, husband is not required at all visits. However, if time permits he can accompany you.

 

Number of IUIs to be done in a cycle ?

  • Generally at “Ankoor Fertility Center, Mumbai”, we perform one IUI after confirming the rupture of follicle (release of egg). Usually the follicle ruptures after 36 hrs.of administration of HCG injection. Sometimes two IUIs are done in a cycle in selected group of patients like previously repeatedly failed IUI’s, male factor infertility, unexplained infertility and when time is a constraint (e.g. The husband is working abroad and has come to India for limited time period) etc.
  • In our experience by doing two IUI for male factor infertility like low sperm count or motility would give a higher pregnancy rates than one IUI in a cycle.
  • These IUIs are done generally at 24 hours and 48 hours after the hCG injection.

 

Failure in IUI

  • Usually for a perfectly healthy couple trying for pregnancy without any intervention, success rate in any given cycle is only 8 – 10%.
  • By doing IUI, success rate can be increased upto12%.
  • In case of failure to conceive in one cycle of IUI, the same treatment and procedure is usually carried ahead by most of the Gynaecologists. But we at Ankoor Fertility Clinic, go beyond this. Not only is a detailed counseling assured, but also a change in the ovulation induction protocol, a better endometrial evaluation and an approach to increase the male sperm count, improvement in the endometrial blood flow and a better support of the luteal phase, i.e. after ovulation to enhance the success of the treatment in the next cycle.
  • If oral medications were used for ovulation induction, we use Injectable Gonadotrophins can increase the success rate next cycle.

 

What is included in the IUI treatment cost?

  • Preparation of the Semen sample.
  • Insemination of the processed semen in the uterus of his wife

 

What is not included in the IUI treatment cost?

  • Initial consultation
  • Treatment planning
  • Monitoring Ultrasound scan
  • Cost of fertility drugs or injections
  • Fee for freezing sperm (if required)
  • Fee for donor sperm (if required)
  • Pregnancy test

 

Cost for IUI?

 

Cost of IUI depends on the medications used as well as the whether the consultation and folliculometry was also done with us. It also increases if a donor sample is used for IUI. The cost at Ankoor Fertility Clinic is around Rs. 5000/-, but it varies between Rs. 2000/- to 10,000/- depending on the above mentioned factors.

 

Number of IUIs before moving to IVF / next line of treatment ?

  • This depends on factors like age of the couple, cause for infertility, semen count of the male partner, number of years of infertility, any other associated factors involved etc.
  • In a young couple, at least 6 cycles of IUI with ovulation induction are advised whereas in an elderly couple (age > 35 yrs) 3 cycles of IUI are advised. Also in cases with mild to moderate Endometriosis, it is better to restrict to 3 cycles and then move to higher treatment. Individualization of the cases is done and same parameters cannot be used for all the patients.
  • A study conducted at Centre for Reproductive Medicine, Department of Obstetrics and Gynaecology, Academic Medical Centre, Room H4-213, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands stated that as many as 9 IUI cycles can be performed but at our centre “Ankoor Fertility Centre, Mumbai” we restrict to 6 cycles as we found that patient returning for further trial and pregnancy rates dropped after initial 6 cycles.Bottom of Form

 

What is Donor IUI?

  • At Ankoor fertility clinic, we also do Donor IUI. Donor semen is required in cases of severe male infertility with very poor sperm count or very poor motility. It is also done in cases of no sperms in the semen (azoospermia).
  • We screen the donor for infectious diseases like HIV, HbsAg, HCV (jaundice), VDRL (sexually transmitted diseases) and also the blood group. The donor is also matched physically as per the husband.

 


26/May/2015

Some centers have folliculometry (USG monitoring) facilities but may not have Semen processing facilities or IUI facilities; while a few may not have folliculometry (USG monitoring) facilities too. Thereby, the wife has to go to a radiologist or some other center for doing the follicular study (serial USGs) for 5 to 7 days depending on the growth of her follicle. Once the follicular rupture has been confirmed, the husband needs to give sample and it has to be processed (washed). If this centre does not have facility for the same, then the couple has to go to another center for getting the semen washed.

The processed and washed sample has to be carried back to the clinic doing the IUI. Thus all this leads to confusion for the patients as well s precious time is wasted in travelling and communicating at various centers. As a result of which there is tremendous stress and exhaustion for the couple. Also there may be reduced sperm motility, thereby decreasing the chances of conceiving.

At our centre, we provide everything from consultation to follicular monitoring, semen collection, preparation and insemination under one roof. This help us to attain better pregnancy and live birth rates.

Studies have shown that techniques for channelizing the positive energy and reducing stress increases success of IUI. Once such technique is “Accupuncture”. At Ankoor clinic we also have facilities for Accupuncture by qualified specialist too under the same roof. This can further boost your success changes.

 


26/May/2015

Sometimes there may be problem in visualizing the cervix and doing IUI. In these cases, one should use a tenaculum (long vaginal instrument) and give traction to manipulate the Utero-Cervix angle and also to stabilize the cervix. Maklers or metal catheter (standard) also help in these cases.

VIDEO : Endometrial contractions seen in USG. These may be seen in cases of difficult IUI and may hamper the result.

Various positions of the uterus during Difficult IUI:

  • Empty Bladder and Acutely Anteverted Uterus

acutrely_anteverted_uterus

In these cases it is better to have a Full Bladder and or use Allis (instrument) Traction in the opposite direction as shown in the figure below.

 acutrely_anteverted_uterus2

  1. Full Bladder and Acutely Retroverted Uterus.

 acutrely_retroverted_uterus

In these cases, patient should empty her bladder and traction should be applied using Allis forceps or tenaculum in the opposite direction as shown in the figure below.

 acutrely_retroverted_uterus2

Ankoor clinic recommendations:

In cases of Difficult IUI, one must consider cervical dilatation with smallest dilator (helps to identify the direction and also to negotiate the stenosis). Also it is very important to make a note on the paper and consider for Cervical dilatation on the 1st or 2nd day of next menses.

 

Is Ultrasound-guided IUI better ?

Studies have shown that Ultrasound-guided IUI does not produce better results than blind insemination, because the pregnancy rate per cycle is similar. (Reference: Hum Reprod. 2009 May;24(5):1080-4. Epub 2009 Feb 5 )

 


26/May/2015

  • Before the procedure, the semen processing media is removed from 2-8°C and is kept on the heating block at 37°C for atleast 20-30 mins so that the temperature of the media and the semen sample is almost the same. After collection, the sample is kept in the laminar flow over the heating block for liquefaction in sterile air with 37*C.( This generally takes 20 minutes).
  • The count and motility is then checked under the microscope &a live image is stored where in the couple is informed about the sample (We have special video & snap system).
  • The raw semen sample is then taken in a sterile test tube &an equal volume of the sperm preparation medium is added. After thorough mixing, this tube is then placed in the spermifuge for a desired time and speed (depending on the sample).
  • After centrifugation, the supernatant is discarded but a small volume is left behind.
  • The pelette formed is then gently resuspended in this supernatant.
  • The sperm preparation medium is then layered slowly from the side wall of the tube without the pellet being disturbed. At this time, there are 2 clearly distinct layers formed, the top being of the medium and the lower layer being the resuspended pellet. The tube is then incubated in the heating block at 37°C for 45-60 minutes.
  • Post incubation, the top most layer now containing the active sperms is aspirated for insemination &the post wash count is checked.
  • Both, the pre-wash and post wash count are checked and the image/video of the same are shown to the couple along with a detailed report of the same.
  • The required consent form is signed and we then proceed for insemination.
  • The female partner is then made to lie down on the bed and with her legs parted.
  • An instrument called speculum is inserted in the vagina to see the cervix. The vagina is then cleaned with sterile gauze piece to remove the debris and discharge.
  • A thin tube called the IUI catheter is introduced in the uterus via the cervix (The lower part of the uterus) and the washed semen sample is slowly released in the uterus.
  • Then the female partner has to lie down on the bed for 15-20min.

 

IUI : Media 4

Medium should maintain sperm integrity, and promote acrosome reaction and capacitation.

Commonly used media are as follows:

  • Bicarbonate buffer media, equilibrated with 5% carbon dioxide, 5% Oxygen and 90%Nitrogen at 37ºC with 95% humidity for 8 days.
  • 10% heat inactivated serum or HAS or synthetic serum can be added as protein supplement.
  • Additions of methyxanthene derivatives like pentoxyphylline & caffeine can be added.

Spermifuge

It is a tabletop centrifuge with a temperature controlled chamber specially made for semen sample preparation. It is intended to be used in Andrology (preparation in IUI and IVF labs). It has a graphic LCD display and a dial encoder. The function of a temperature controlled chamber makes this equipment unique the lab. The entire emphasis is to maintain the specimen temperature at 37 *C (to keep the temperature as close to body temperature) and to eliminate any thermal shocks. This advantage prevents any kind of damage to the sperms, thus maintain the quality and motility of the sperms to produce very good result.

5

Laminar air flow

The laminar air flow is capable of maintaining a sterile work area even when operated even in an uncontrolled environment. This is achieved by the total removal of the airborne droplet nuclei & dust – borne bacteria uni- directional oriented streamlines of clean air at velocities designed to flush the contaminating particles. This also creates a sterile pressure against the intrusion of external contaminants, & sweeps out particulates produced by the work process not allowing them to deviate, let alone settle down. It is used in IUI lab for air flow that air flow passed throw hepa filter. The air flow passed through hepa filter is clear of dust, microorganisms and thus transferring only the sterile air in which we can perform processing.

6

Microscope

The microscope is attached with LCD,to show the prewash &postwash semen count to the couple.

7

Heating Block

  • This is used for warming the test tube, sample & medium to maintain the temperature as close as possible to body temperature.

 

What is Intrauterine Insemination Catheter?

Various types of catheter have been used for IUI. These are known as IUI catheters. They are easy to use. They were semi-rigid devices that fit the curvature of the uterus & minimize trauma to the cervical crypts, endometrium and uterine walls. They are made of non-toxic material. They carry a small volume from their intrauterine tips with minimal dead space (to minimize backflow). Care is taken so that the tip of the catheter does not touch the fundus of the uterus as it may cause contractions.

 

Instruments used for IUI :

 8

A well timed IUI is the critical key to success of the procedure.

After documenting ovulation, the husband has to give semen sample for IUI. This semen sample is then processed. The processed and washed semen is used for insemination.

The patient is told to lie comfortably in supine position with flexion at her hips. The mouth of uterus (Cervix ) is visualized with the help of a speculum (instrument). Irrigate the ectocervix and endocervix with buffer. Place the catheter fully assembled, negotiate the internal os gently and deliver it 1.5-2 cm from the internal os. The semen sample is then injected slowly into the uterine cavity with the help of IUI catheter over period of 1-2 mins. Remove the catheter slowly after 30 seconds.

After the insemination, the woman is told to remain in the dorsal position for around 10 -15 minutes.

There is no need of prolonged bed rest, head low, pain killers, antispasmodics or antibiotics.

Studies have shown that catheterizing distance of 2 cm from the fundus with infused semen volume of 0.3 ml can significantly improve pregnancy rate in patients undergoing IUI with the husband’s semen.

Ankoor clinic recommendations:

  • There is no restriction on any kind of diet.
  • There is no restriction on traveling, exercise, climbing stairs, swimming etc.
  • Intercourse after IUI in fact has shown better pregnancy rates.

 


26/May/2015

IUI cycle can be done in natural unstimulated cycle or in a stimulated cycle (using oral drugs/injections).

Time of IUI

In a natural cycle, with menses coming every 28 days, ovulation, i.e., release of the egg after follicle rupture, happens around 14 days before the next menses.IUI in a natural cycle is done after the rupture of the follicle is confirmed by ultrasonography. In women with longer cycles, the days may vary.

When drugs or injections are given for follicular maturation (ovulation induction cycles), IUI is usually done 36 hours- 48hrs after HCG injection. This injection is given to facilitate release of the egg from the ovary (ovulation and release of ovum).

The egg is usually alive for 24-48 hrs after ovulation. Sperms are alive for around 48-72 hrs after they are released into the female genital tract. Thus, if processed / washed semen sample is deposited around this time, the chances of conception are very high.

 

Anaesthesia in IUI

 

Will there be any pain while doing the procedure? Is anaesthesia required?

IUI is the simplest of all procedures. It causes no pain or discomfort.

It is best performed when you are awake. Interacting with the Doctor/ Fertility physician performing the procedure will not give you the time to realize as to when the procedure got over.

So the need for Anaesthesia in IUI never arises.

In patients with severe anxiety or severe female sexual dysfunction sometimes there may be need of Anaesthesia.

 

Do I require to fast on the night prior to IUI ?

IUI is a very basic procedure. No anaesthesia or pre-medication is required. So, fasting is not required. In fact a light snack before the procedure may help.

 

What happens in Natural cycle IUI?

  • In a natural cycle, on the second day of menses, a sonography is done to rule out any ovarian cysts (FLUID FILLED swelling in the ovary). A repeat sonography is done on 8th/9th day of the cycle.
  • Depending on the size of the follicles in the ovary, further scans are done on daily basis or on alternate days. When the follicle in the ovary (which contains the female egg) reaches optimum size (around 18-20mm), sonography is done everyday to identify the exact day of ovulation (release of egg) and the IUI is done either on the same day or the next day.

 

Ovulation induction cycle

  • In a stimulated cycle, we induce ovulation by using medicines such as clomiphene citrate or N-clomiphene or injections such as gonadotropins (hMG, FSH).
  • It is generally given from 2nd/3rdday of menses for 5 days.

Fig. USG image of both ovaries on Day 2 or 3 of menses

1

  • A repeat sonography is done on 8th/9th day of the cycle. Depending on the size of the follicle in the ovary further scans are done on daily basis or on alternate days.
  • The monitoring of the cycle is done as above. When the follicle reaches around 18-20mm in size, hCG injection is given (hCG trigger). The IUI is generally done 36 hrs after hCG injection and after confirmation of ovulation (release of the egg).

2
Below is the picture is of an ultrasound image of the follicle of 18 to 20 mm at which time hCG trigger (hCG injection) is given for rupture of follicle (ovulation).

Fig . Triple line endometrium of good thickness seen during rupture of follicle.

3

It has been found that stimulation protocols yield better results as compared to natural cycle. This could be related to the quality of oocyte available for fertilization and better endometrial development (inner lining of the uterus).

 

Ankoor clinic recommendations:

Monitoring of patient is very important, as proper monitoring is the key to success. Preconceptional Folic Acid supplementation is started. On Day 2 of her periods a transvaginal ultrasonography (TVS) is done to rule out retention cyst. Ovulation Induction medication is generally given between Day 2- Day 6 of menses – Oral Clomiphene Citrate 50mg/ 100mg or Injectable gonadotrophins. On Day 8 TVS is repeated to see the growth of the follicle and endometrial thickness .

This TVS may be repeated on alternate days to monitor growth of the follicle. Once the follicle reaches a size of 18 to 20mm, trigger(Injection HCG) is given for rupture of the follicle and release of egg (ovulation). IUI is generally performed 36 hrs after this trigger after confirming ovulation.

Post IUI Luteal Phase Support is given in the form of Oral or vaginal Progesterone for around 15 days. Patient needs to stop her medications after that and wait for 7days. If there is no menses then she follows up with a serum b hCG to confirm pregnancy.

 

IUI procedure : How should the husband prepare?

  • There should be at least 2 days/48hrsof abstinence after intercourse or ejaculation of the semen. Too long an abstinence (more than 7 days) will increase the chances of dead sperms in the sample.Too short an abstinence interval (less than 2 days) will reduce the sperm count in the sample collected. Short abstinence generally does not affect the semen quality of those who had a normal sperm count and motility, but sometimes can affect those who have low sperm count.
  • Once we know the patient has ovulated, necessary instructions are given to the husband. He is asked to collect the semen sample in a sterile, wide-mouth, labeled, tissue culture graded container provided at our centre.
  • The female partner is now asked not to go to the wash room as a partially full bladder for IUI procedure is always preferred.

 

COLLECTION OF THE SEMEN SAMPLE

Semen collection facility is available at our centre. Adequate privacy is ensured at “ANKOOR Fertility Clinic” and private rooms are provided for the same.

For those who are not comfortable collecting the sample here at our place, collection can be done at home but should reach the centre in the container provided by the centre (within 30-45mins).

Precaution like avoiding contamination of the semen container and keeping the temperature around the sample as close as possible to room temperature should be followed by the patient.

 

Instructions while collecting semen sample:

  • Wash your hands with soap and water.
  • Refrain from using lubricant, saliva or any product that may contain spermicidal agents.
  • Ejaculate directly into the provided sterile sample container. Try to capture the first part of the ejaculate and do not attempt to collect any spilled semen.
  • If by chance there is any spillage of the sample, please inform the concerned lab person.
  • Cap the container as soon as you have finished.
  • Make sure your name (both husband and wife) and the time and date of your sample is clearly mentioned on the container.
  • If at all the male partner faces difficulty in collecting the sample, the doctor/lab person should be informed prior.
  • Assistance in the form of medications or magazines, audio-visual aid etc can be provided.

 

WHY IS SPERM PROCESSING NECESSARY

  • Normally during intercourse the semen that gets deposited in the vagina contains seminal fluid (which helps to keep the sperms alive even in the acidic environment of the vagina) along with sperms. The cervix then adds as a barrier to this seminal fluid and allows only the motile sperms to enter in
  • to the uterus. The fluid that comes out after intercourse is the seminal fluid.
  • Only processed semen sample is used during IUI. Processing helps to separate the active motile sperms from the seminal fluid. This seminal fluid can be irritating to the uterine lining as it contains chemicals called Prostaglandins. Thus when the semen (unprocessed) is inserted directly into uterus, it could cause severe pain and cramping.
  • In the process, the most active, motile sperm are concentrated and separated from dead sperm, cellular debris, mucous and bacteria and thus only the active motile sperms are inseminated in the uterus.

 

SPERM PREPARATION TECHNIQUES

There are different techniques available for sperm preparation:

  • Swim –Up Wash
  • Density Gradient Wash
  • Simple Wash

At Ankoor fertility clinic, we do the SWIM UP method for semen processing.

Evidence suggests that there is no significant difference in the success rate for a particular method of semen processing.

(Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004507. )

Principle:
Get the progressive motile spermatozoa into the sperm washing medium.

Advantage:

  • High number of sperm with progressive motility available.
  • Effective separation from bacteria & cellular debris which are trapped in the settled pellet.
  • Sperm washing/Swim-up Technique is the only method to achieve any success when numbers & motility of sperm are very low.

26/May/2015

Intra-uterine insemination (IUI) also known as Artificial Insemination is a process in which the washed/processed  semen is placed directly into the uterine cavity with the help of a thin sterile plastic tube (catheter) in and around the time of ovulation (release of egg from the ovary).

Fig. Diagrammatic representation of Intra Uterine Insemination (IUI)

Intra Uterine Insemination-1

It is one of the simplest techniques of assisted reproductive technique (A.R.T.). It forms the first basic and the least invasive treatment technique for infertility management.

The purpose of IUI is to introduce the best and the most motile sperms high up in the uterine cavity i.e. as close to the ovum as possible so that the distance that the sperms have to cover is the minimal and to overcome factors like cervical mucus opposition for its entry into the uterine cavity. Also as generally it is done with follicular monitoring, the egg is matured and released or about to be released. Hence we are sure that both the egg and sperm are timed properly for optimum fertilization and increased chances of pregnancy.

What are the indications of IUI or who will be benefited by doing this procedure?

IUI is performed for both male and female cause of infertility as well as in unexplained infertility.

The main reasons where it is used are as follows :

Male Causes

  • Low sperm count and/ or less number of motile sperms
  • Anatomic defects of the penis (abnormal structure of penis) leading to failure of deposition of sperm correctly
  • Sexual or ejaculatory dysfunction (problems related to having sexual intercourse or release of sperms in the vagina)
  • Retrograde ejaculation (occurs when semen, which would normally be ejaculated out via the urethra outside , is redirected back into the urinary bladder)
  • Immunological (presence of antibodies to sperm)
  • Increased viscosity (thick semen- does not liquefy easily to release the sperms )

 

Female Causes

  • Cervical factors- Thick cervical mucus preventing the sperms to reach the uterine cavity. There are also sometimes antisperm antibodies (a protein that attacks and destroys the sperm) in cervix which are harmful to the sperms and prevent fertilization.
  • Ovulatory dysfunction – No release or delayed or abnormal release of eggs (Oocytes) from the ovaries. Hence ovulation induction using drugs helps in increasing the conception rate.
  • Minimal endometriosis – Grade 1-2 (presence and growth of the tissue lining the uterus in places other than the uterus e.g., in ovaries, fallopian tubes, intestine)
  • Psychological and psychogenic sexual dysfunction ( Sexual intercourse is not possible )

 

Unexplained infertility

I.U.I has also shown good results in cases of unexplained infertility (No apparent cause found for inability to conceive on routine recommended medical testing) as well.

In some cases where husband is away for many days due to job like military or navy, their semen sample can be frozen and used later. Once the follicle is of appropriate size and has ruptured, IUI can be performed at the correct time even in his absence. Thus even if the husband is not able to be present on the day of ovulation, husband’s previously frozen semen sample can be processed and insemination can be done.

Is there any condition for which IUI not suitable?

  • Very low sperm count (less than 5 million) and poor motility
  • Abnormal or blocked Fallopian tubes. .
  • Abnormal or thin endometrial growth (Thin ET on USG).
  • Advanced age of the wife, husband or both.

 

How long does one IUI cycle treatment take?

It takes the same time as a normal menstrual cycle i.e. on an average of four to five weeks from the beginning of menses cycle till the pregnancy test.

First sonography is done on day 2 or day 3 of menses to rule out cyst or any other abnormality. Later on she is put on ovulation induction drugs for 5 to 6 days and called for USG on day 7 or 8. Her USGs are repeated (folliculometry) and the follicles are monitored for growth. Once rupture occurs, IUI is done. This generally happens around 14 to 16 day of cycle. After IUI some medicines are given for support for another 14 days.

Is there any risk in performing IUI?

There is generally no risk in performing IUI for both the husband and the wife. It is one of the safest procedures. There may be a small chance of multiple pregnancies as sometimes more than one follicle may develop when ovulation inducing drugs are used.


26/May/2015

Uterine septum is a deviation from normal shape of the uterus which is present congenitally (from birth). The uterine cavity is normal or slightly enlarged with a central septum. It is like a curtain dividing the uterine cavity into two spaces. This curtain can be partial i.e. dividing only the upper part of the cavity into two or complete, in which case the curtain divides the entire uterine cavity into two.

Arcuate-uterus

(Laparoscopic view of Arcuate uterus / uterus with septum)

Uterine-Septum-2

3D Ultrasound image of T shaped uterus

 

Uterine-Septum-3
USG image of T shaped uterus

septum-4

T shaped uterus due to uterine septum

What is the cause of septum?
The uterus is formed in a female fetus by fusion of two tubes. Incomplete central absorption of the tubes can lead to a septate uterus.
Why the absorption should be incomplete is not known. Septate uterus can be hereditary but not always. It may be associated with congenital anomalies of kidney and ureters.

subseptate-uterus-5

Around 3 % of women in reproductive age group will have septate uterus in some or another form. Around 15 % of women with history of recurrent abortion might have an underlying septate uterus.

What are the symptoms of septate uterus?
In many a women septate uterus may never be diagnosed. They may even have history of normal pregnancy. Some of the women may have history of excessive bleeding during menses.

However it may lead to infertility and pregnancy loss. In a septate uterus, the septum or the curtain has less blood supply compared to the walls of uterus. If the embryo implants onto the septum, it may not grow due to poor blood supply and thus leading to failure of implantation. Infertility may be thus result of failure of implantation. In some cases the embryo may implant onto the septum, will grow to some extent, but then due to poor blood supply may lead to spontaneous (women may start bleeding soon after missed period) or missed (fetal heart activity may not be seen) abortion.

Abortion may also occur as the uterine cavity may not be big, enough due to the septum, for the embryo to grow. Even pregnancy losses between 3 to 6 months are common as congenital malformation of uterus is often associated with weak cervix (mouth of the uterus). This is however avoidable if USG is done to check the cervix. If any doubt of weak cervix is present on USG or the woman has past history of pregnancy loss after 3 months, a cervical stitch can be place to avoid any complications.

How is septate uterus diagnosed?
It is most commonly diagnosed on Hysterosalpingography (HSG) or ultrasonography (USG).

In HSG either two cavities are seen or indentation onto the uterine fundus is visualized. A septum may be commonly diagnosed on USG as it is a routine investigation done for women with infertility or recurrent pregnancy loss.

Hysteroscopy is not a routine investigation to diagnose uterine septum but is used to treat the septum. Sometimes a small septum may be diagnosed during hysteroscopy, which can be treated in the same sitting.

MRI can also accurately diagnose a uterine septum. However other modalities are as sensitive in diagnosis and therefore it is not a cost-effective method for routine diagnosis of septate uterus.

Transvaginal USG showing evidence of septate uterus

Transvaginal USG showing evidence of septate uterus-6

MRI showing septate uterus

MRI showing septate uterus-6

How is septate uterus treated?
As such if the woman has no symptoms there is no need to treat septate uterus. Infertility and recurrent pregnancy loss are indications for treatment of septate uterus.
Surgery is the only method for treatment for septate uterus. Medications cannot treat it.

Hysteroscopic visualization and resection is the gold standard of treatment.

Hysteroscopic septal resection or fundal metroplasty is the surgery which needs to be performed. In this a special knife mounted on resectoscope is used through which electric current is passed. This knife is used to cut the narrow walls of the uterine cavity and make the cavity broad. As the entire procedure is done under hysteroscopic guidance, it is very safe and equally effective.

 

A balloon may be kept in the uterine cavity to keep the cavity distended and to prevent scar formation for one week. Also some medications may be given for the lining to grow over the cut portion. Follow up may be scheduled after 7 days, when the balloon is removed. The growth of lining and response to surgery is monitored for the next month or more.

What are the complications of the surgery?
The complications are same as in other operative hysteroscopy surgeries. However complication rates are negligible in hands of expert


26/May/2015

Intrauterine Adhesions & Asherman’s Syndrome

Asherman’s syndrome or intrauterine adhesions, is an acquired uterine condition, characterized by formation of adhesions or scar tissue within the uterus. In simple language these are thick bands of scar tissue which make the front and back wall of uterus stick to each other. (To naked eye they look like dried glue bands). The scar tissue may lead to obliteration of the cavity. They may occupy only a part of uterus or the entire cavity. Depending on the extent of adhesions we can classify the syndrome as mild, moderate or severe. These adhesions are generally avascular.

 

Video of calcification

(Video lateral wall synechiae)

There is a variant of Asherman’s syndrome that is more difficult to manage called as “unstuck Asherman’s” or “endometrial sclerosis”. In this condition the uterine walls are not stuck together, instead the endometrium is peeled off and destroyed.

adhesions-1

How do I know that I may have Asherman’s syndrome?

Symptoms depend upon the severity of adhesions , with some women having no symptoms at all. Many a times in such women, Asherman’s syndrome is diagnosed during investigation for infertility or recurrent pregnancy loss. Most women, however present with either decreased blood flow during their menstrual periods or complete amenorrhoea (absence of menstrual flow). Some women experience excessive pain during menstrual periods as uterine muscle have to contract harder to get rid of menstrual fluid past the scar tissue. Sometimes the scar tissue may completely obstruct the menstrual fluid and cause severe pelvic pain.

 

What causes intrauterine scarring or synechiae?

Normally uterus is lined by endometrium which is shed cyclically in every menstrual cycle. Trauma to this endometrial lining triggers the process of wound healing which leads to formation of scar tissue or adhesions. For example if you get a cut in your skin the two edges will stick to each other and form a scar. Similar process can occur if there is deep cut or trauma to both front and back wall of uterus. When this trauma heals it forms a scar which will finally make both the walls stick to each other.

Pregnancy related dilatation and curettages (D & C’s) account for 90 % of Asherman’s cases. These include D & C performed because of missed or incomplete abortions, elective abortions or after delivery for heavy bleeding in cases of retained products. Asherman’s risk increases with the number of D&Cs performed; after a single procedure the risk is 16% however after 3 or more D&Cs the risk jumps to 32%. Adhesions may also occur following pelvic surgeries such as caesarean section, fibroid removal and septal surgeries. In developing countries like India, infection particularly Tuberculosis and other RTI/ STIs are also an important cause of intra uterine scarring.

normal-hsg-2 narrow-constricted-3

What is the incidence of Asherman’s syndrome?

Asherman’s is thought to be under-diagnosed because it is usually undetectable by routine diagnostic procedures such as ultrasound scan. The condition is estimated to affect 1.5% of women undergoing HSG, between 5 and 39% of women with recurrent miscarriage, and up to 40% of patients who have undergone D&C for retained products of conception following childbirth or incomplete abortion.

What investigations will help in the diagnosis?

Direct visualization of the uterus via Hysteroscopy is the most reliable method for diagnosis. Other methods are sonohysterography (SHG) and hysterosalpingogram (HSG).

Fig showing Hysterosalpingogram with filling defects suggestive of intrauterine adhesions.

 intrauterine-adhesions-4 intrauterine-adhesions-5

What is the treatment of Asherman’s syndrome?

Asherman’s must be treated by an experienced surgeon via hysteroscopy (sometimes assisted by Laparoscopy). Under direct visualization of hysteroscope the scar tissue is cut with scissors. However one should remember that adhesions have a tendency to reform especially in more severe cases. In order to prevent re-scarring after surgery, estrogen supplementation may be given to stimulate uterine healing and growth of endometrium. A balloon can be placed in the cavity to prevent apposition of the walls during the immediate post-operative healing phase for 1 week. The pre-operative instructions are same as in other hysteroscopic surgeries.

 




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WE CARE, WE CAN