Faqs on Intra Uterine Insemination

  1. What is Intra uterine insemination (IUI)?

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

In the diagram: Sperms to be pointed in uterus and fallopian tubes.

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.

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

Unexplained infertility is infertility that is idiopathic in the sense that its cause remains unknown even after an infertility work-up, usually including semen analysis in the man and assessment of ovulation and fallopian tubes in the woman. Approximately one in five couples will be diagnosed with unexplained infertility even after going through a complete fertility work-up. The ‘unexplained infertility’ diagnosis is given to around 25% of women with fertility difficulties.

IUI in unexplained infertility:

  1. IUIwithout stimulation when compared with timed intercourse, also without stimulation was found to have no evidence of a difference in cumulative live births between the two groups. The evidence suggested that if the chance of a live birth with timed intercourse was assumed to be 16%, that of IUI would be between 15% and 34%.
  2. IUI versus timed intercourse, both in a stimulated cycle –again the study reported that there was no evidence of a difference between the two treatment groups with the evidence suggesting that if the chance of achieving a live birth in timed intercourse was assumed to be 26%, the chance of a live birth with IUI would be between 23% and 50%.
  3. IUI in a natural cycle versus IUI in a stimulated cycle– there WAS an increase in live birth rates for women who were treated with IUI in a stimulated cycle compared with those who underwent IUI in natural cycle (without stimulation). The evidence suggested that if the chance of a live birth in IUI in a stimulated cycle was assumed to be 25%, the chance of a live birth in IUI in a natural cycle would be between 9% and 21%.
  4. IUI in a stimulated cycle versus timed intercourse in a natural cycle– there was no evidence of a difference in live birth rate between the two groups The evidence suggested that if the chance of a live birth in timed intercourse or expectant management in a natural cycle was assumed to be 24%, the chance of a live birth in IUI in a stimulated cycle would be between 12% and 32%.

I find this one particularly interesting as surely an IUI in a stimulated cycle would be better than just letting nature do run it’s course? What it does say though, is that in the context of this particular study, for women who are experiencing unexplained infertility, there is still just as much of a chance that a pregnancy may still occur by trying through the ‘old fashioned way’ than by having a full blown IUI!

  1. IUI in a natural cycle versus timed intercourse in a stimulated cycle– There was evidence of an increase in live births for IUI.  The evidence suggested that if the chance of a live birth in timed intercourse in a stimulated cycle was assumed to be 13%, the chance of a live birth in IUI in a natural cycle would be between 14% and 34%

In Summary

In some cases it is the IUI itself that seems to improve success rates but sometimes it doesn’t.  Other times medication might be key to success but then this is not continued. And then in another scenario a stimulated IUI had no statistically significant improvement over ‘expectant management’!  It did appear though that if you had decided that you needed to take action and see if an IUI was going to work for you, IUI with medication was the way to go.

At the moment it may appear that IUI for couples with unexplained infertility IUI isn’t necessarily the best evidence based approach to take, but does that necessarily mean that IVF is? IUI is cheaper and often physically easier for many women. For those reasons it still may be a very worth while first port of call when entering the world of fertility treatments.

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.

Special indications for IUI

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.

 

Patients undergoing any form of chemotherapy, can also freeze their semen samples before undergoing chemotherapy. This sample can be used at a later date for IUI.
Q 3 How to Proceed
What happens in Natural cycle IUI?

 

 

 Ovulation induction cycle

 

 

FIG USG image of both ovaries on Day 2 or 3 of menses

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2

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 Q4 What are the basic requirements and investigations in prior to IUI ?

Pre requisites for IUI

  • Normal uterine cavity
  • At least one patent and functional fallopian tube
  • Ovulating spontaneously or with ovulation induction drugs
  • Husband semen analysis showing a count above 10 million with Total motile sperm count above 5 million

Pre IUI investigations:

  • HIV, HbsAg, HCV & VDRL of both husband and wife
  • TSH, Prolactin of wife

 

Q5. How to prepare both husband and wife for IUI ?

  • Before starting IUI stimulation or procedure, the couple needs to be counselled about the details of the procedure in the previous cycle itself.
  • This may include details of the stimulation protocol, steps of IUI, requirement of husband for giving sample at the time of ovulation.
  • You may have to come to the clinic 3-4 times for follicular monitoring.
  • Husband will be required only on the day of IUI. But it is always better that the husband accompanies the wife as it is a couple problem. Also this increases bonding and reduces stress of the couple.

 

Q 6. When is the trigger given and when is IUI done?

The patient comes for folliculometry in the IUI cycle. These ultrasonographies are called as follicular scans. Once the dominant follicle is selected and it grows to around 18-20mm, mature follicle, a final injection is given for ovulation. This is also called as TRIGGER.

The follicle ruptures and the mature egg is released roughly 36 hours after this, also called as ovulation.

IUI is to be done around the time of ovulation.

 

Q 7. What is Single vs double IUI? Advantage and disadvantage of this?

A double IUI can be done especially in cases where the husband may not be available at a later date due to work related assingments.

 

Q 8 . How to proceed on the day of IUI ?

  • A scan (Ultrasonography) may be done to confirm the rupture of follicle (ovulation) and release of egg from the ovary.
  • The husband is then instructed for giving his semen in a sterile container provided by Ankoor fertility clinic.
  • The husband is provided with an air conditioned room with adequate privacy to collect the sample.
  • He has to write his name and his wife’s name on the container provided for semen collection before doing the semen collection.
  • If the husband faces any difficulty during semen collection, he should inform the doctor or technician immediately
If the husband has problem during collection of semen sample?

·  Please inform prior to the procedure of IUI

·  Psychological counselling – This facility is available at Ankoor Fertility clinic, with prior appointment

· Meditation – This helps in many of our patients as giving semen sample for IUI may be stressful for many men.

· Medications – Sometimes giving medications like sildenafil helps in erection and ejaculation and thus the husband can give the semen sample

· Audiovisual aid for stimulation – This method can be tried for arousal problems

· Collection at home – If one is not able to give sample in the clinc, semen collection from home can also be done in a sterile container provided by the clinic Complete privacy during sample collection is available at Ankoor fertility clinic.

 

 

  • Semen processing can be done by two methods:
  • Swim up
  • Density gradient
  • Swim up method – This technique is routinely offered for good sperm count and motility.
  • Density gradient method – This technique is routinely offered for low sperm count and motility.

 

  • Time required for the semen sample processing is around 45 -60 mins
  • The couple has to sign an IUI consent form
  • There is no fasting required.
  • No anaesthesia is required
  • Sometimes you may be given additional medications like blood thinners, progesterons, HCG / decapeptyle injections, depending on the cause of infertility and endometrial evaluation.

 

 

POST  IUI  (INTRA UTERINE INSEMINATION)  INSTRUCTIONS

·  You can pass urine & wash your private parts after 10 mins. Of IUI.

·   There is no need of bed rest, you can resume your daily activity including lifting heavy weights, going up & down  the staircase will not affect IUI results.

·  Travelling any where by any type of vehicle will not affect the results of IUI.

·  You can have all kinds of foods, including chicken, eggs unless you are kept on dietary restrictions by Doctor for weight loss.

·  You can also have sexual relations from the next day of IUI.

·  Please take your medicines as advised.

·   You can also do any form of exercises.

·  If you are stressed, please do meditation, deep breathing exercises, listening to music or pursue any hobby you like.

·  Some women have minimum spotting, backache & pain in abdomen after 24-48 hours of IUI. This may last for 3-4 days.

·  In case of severe pain in abdomen, fever, kindly contact the Doctor at the earliest.

·  You will be advised to take some oral and vaginal tablets for supporting the pregnancy, which has to be taken from tomorrow and continued till 14 days after IUI procedure.

·  After stopping these additional tablets, wait…If you don’t get menses/ periods in the next 7days, please visit us.

·  If you get menses, don’t get disheartened and do visit the clinic on 2nd or 3rd day of your menses.

 

 

Q 9. What about the Results / Success of IUI ?

  • Result of IUI depends on many factors like:
  • Type of ovulation induction – Better results are seen after stimulation with gonadotrophins
  • Number of follicles produced
  • Husband’s semen count and motility
  • Semen processing technique used
  • Endometrial thickness, echotexture and blood flow
  • Generally the success rate is around 8-10% when oral drugs are used for induction. This may increase upto 15 – 25% when injectable drugs are used.
  • With injections more eggs are stimulates (2-3), hence the chances of conception are more, but there is the possibility of multiple pregnancy.

 

Q 10. Why IUI fails?

  • The success rate of IUI is anywhere between 8 to 25% depending on various factors.
  • Hence it fails in a majority of cases
  • The reasons could be any problem with the endometrium, very low sperm count, unilateral blocked tube, low ovarian reserve, age of the couple, duration of marriage etc.
  • As we cannot see the fertilization of the egg with the sperm in IUI, we don’t know what happens at the molecular level and this explains the low success rate.

 

Q 11. How to cope up with IUI failures?

  • As mentioned above, there are many varied reasons for failure of IUI.
  • One needs to understand this before undergoing the procedure.
  • This being the basic level of management one should definitely try this before undergoing higher forms of treatment like in vitro fertilization (IVF).
  • IUI is a very safe and easy procedure
  • For failed IUI cycles, we may change the induction protocol like oral, oral + injectable or only injectable
  • We try to reassess the follicular count, AMH etc.
  • We also offer holistic approach like weight loss, acupuncture, meditation and stress management which has shown us positive results in many of our patients.

iui

IUI

 

if you have not conceived after 5-6 cycles of IUI, then you may require higher form of treatment like in vitro fertilization (IVF).



WE CARE, WE CAN





WE CARE, WE CAN