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
- 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).
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.
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. )
Get the progressive motile spermatozoa into the sperm washing medium.
- 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.