WHAT IS INTRAUTERINE INSEMINATION (IUI)?
Sometimes nature needs help to start a pregnancy- and the doctor can do this by giving the sperm a piggy back ride through a fine tube into the body. This procedure is called intrauterine insemination (IUI) or artificial insemination with husband’s sperm (AIH) and effectively, the doctor is giving nature a helping hand by increasing the chances of the egg and sperm meeting.
WHEN IS IUI USED FOR TREATING INFERTILITY?
IUI is useful when:
- The woman has a cervical mucus problem – for example, it may be scanty or may be hostile to the sperm. With an intrauterine insemination (IUI) the sperm by pass her cervix and enters the uterine cavity directly.
- The man has antibodies to his own sperm. The “good” sperm which have not been affected by the antibodies are separated in the laboratory and used for IUI.
- If the man cannot ejaculate into his partner’s vagina. This is usually because of psychological problems such as impotence (inability to get and maintain an erection) and vaginismus (an involuntary spasm of the vagina muscles so that vaginal penetration is not possible), or anatomic problems of the penis, such as uncorrected hypospadias, or if he is paraplegic.
- The man suffers from retrograde ejaculation in which the semen goes backward into the bladder instead of coming out of the penis.
For unexplained infertility, since the technique of IUI increases the chances of the eggs and sperm meeting.
- If the husband is away from the wife for long stretches of time (for example, husbands who work on ships or work abroad), his sperm can be frozen and stored in a sperm bank and used to inseminate his wife even in his absence.
- Low sperm count, low motility.
HOW IS IUI PERFORMED?
Intrauterine Insemination (IUI)
In this method, the sperms are removed from the seminal fluid by processing the semen in the laboratory and they are then injected directly into the uterine cavity. It is not advisable to inject the semen directly into the uterus, as the semen contains chemicals (prostaglandins) and pus cells which can cause severe cramping, and even tubal infection.
HOW IS THE IUI TIMED?
Timing the IUI is very important; it must be done during the “fertile period” when the egg is in the fallopian tube. Pinpointing the time of ovulation accurately using either vaginal ultrasound or ovulation test kits is crucial. A good clinic should provide this as a 7-day week service; since there is a 1 in 7 chance that ovulation will occur on a Sunday eggs don’t take holiday! It is important to superovulate the wife at the same time (with clomid or HMG injections), so that she can produce more than one egg. Superovulation increases her fertility potential as well, thus increasing the chances of conception by improving the chances of the eggs and sperm meeting.
The IUI is done either when ovulation is imminent or just after. The husband masturbates into a clean jar – preferably in the laboratory or clinic itself, and at least three days of sexual abstinence to get optimal sperm counts.
Some men may have considerable difficulty producing a semen sample at the appropriate time, because of the tremendous stress they are under, and the “pressure to perform”. For these men, using a previously stored frozen sample can be helpful. Viagra (sildenafil citrate) can also be used to help them to get an erection. The best sperm are separated from the rest of the seminal fluid, by special laboratory processing techniques. The actual insemination procedure is simple and takes only a few minutes to perform. It can be uncomfortable.
The wife lies on an examining table, and a speculum is placed in the vagina. The doctor puts the sperm through a thin plastic tube (catheters) through the cervix in to the uterus. There may be a bit of uterine cramping at this time, and some discomfort for about 12 to 24 hours. Some patients may experience a little vaginal discharge after the procedure, and they are worried that all the sperm are leaking out of the uterus. However, discharge is just the cervical mucus the sperm cannot “fall out” of the uterine cavity.
No special bed rest is required after the IUI. Some doctors may repeat insemination after 24 hours. We usually encourage our patients to have intercourse on the night of the IUI, and 2-3 days after this as well, to maximize the chances of the sperm and egg meeting.
HOW IS THE SPERM PROCESSED IN THE LABORATORY FOR IUI?
Sperm processing allows the doctor to concentrate the actively motile sperms into a small volume of culture fluid. Sperm do not remain alive in the culture medium for very long unless maintained at the right condition – hence a prompt insemination after sperm processing is important. This is why processing should preferably be done in the clinic itself, so that time is not wasted in transporting the sperm after the wash.
There are different methods of processing the sperm and all of these require special laboratory expertise. The simplest method is that washing the semen with a culture medium (by centrifuging it and collecting the pellet).
The swim-up method uses a layering technique, in which a special culture medium is placed above the semen in a test-tube. The good quality sperm will swim up into the culture medium and after 45 to 60 minutes, this medium (with the motile sperm) is removed and injected into the uterine cavity.
The more sophisticated method today uses a density gradient column. This method allows one to separate the good quality sperm from the immotile sperm, the pus cells and the seminal plasma, because these are lighter than the motile sperms. It is the standard technique in use today, especially for quality sperm samples.
WHAT RECENT ADVANCES HAVE OCCURRED IUI TREATMENT?
Of late, doctors have tried adding various chemicals to the washed sperm to try to improve their motility, so as to increase the chances of reaching their goal. The chemicals include caffeine and pentoxyfylline and they may be helpful in some patients.
During IUI, sperms are injected into the uterine cavity in the hope that they will swim up from here into fallopian tubes where they can fertilize the egg. But then, why not inject the sperm direct into the fallopian tubes where the eggs are present? This feat was technically difficult to accomplish in the past, because the tubes are so thin. Today with specially designed catheters (Jansen-Anderson catheters set); it is possible to do this in the doctors clinic. Thus the processed sperm can be injected directly into the tubes under ultrasound guidance, without anaesthesia or surgery! This is an intratubal insemination. Also know as a SIFT – (Sperm intrafallopian Transfer). However, pregnancy rates are no better with this method than with IUI, which is why it is rarely performed today.
Men may feel a loss of self-esteem because they feel that they need a doctor’s help to do what a “normal man” should have been able to do by himself. They also feel guilty about having to subject their wife to the pain and intrusion of insemination. Women may feel anger towards their husbands for having the fertility problem. The insemination may also make patients feel that someone has “intruded” into their sex life and this may affect their intimacy.
WHAT IS THE SUCCESS RATE OF IUI TREATMENT?
Success Rate of IUI
The success rate of IUI depends upon several factors. First of all the cause of the infertility problem is important. For example, men with normal sperm counts who are unable to have intercourse have a much higher chance of success than patients who are undergoing IUI for sperm counts. In addition, female factors play an important role. If the female is more than 35 years, the chance of a successful pregnancy is decreased. Generally, cumulative conception rate is about 50% (Remember, nature’s efficiency for producing a baby in one month is about 15 to 25%). However, if IUI is going to work for a couple, it usually does so within 4 treatment cycles. If a pregnancy has not resulted by this time, the chances of IUI working for you are very remote. You have reached the point of diminishing, returns, and should stop persisting with IUI and explore the option of IVF.
WHAT ARE THE RISKS OF IUI TREATMENT?
Risks of IUI
The major risk of IUI today is that of multiple pregnancies. Since the patient is being superovulated, more than one egg may get fertilized, resulting in twins or even triplets or quadruplets. Because the doctor cannot precisely control how many follicles will grow and rupture, the risk of a multiple pregnancy is actually even more after IUI rather than IVF. If you grow too many follicles, you may choose to cancel the cycle. Some clinics can also offer you the option of saving the cycle by concerting it to IVF. This can be a cost-effective option, since it allows you to make good use of the egg you have grown.
In poorly equipped clinics, there is also a risk of developing an infection after the IUI, if appropriate sterile precautions are not taken. This can tragically cause infertility.
While many gynaecologists today offer IUI treatment, many of them are not specialized enough to provide comprehensive service. This often means that patients need to run around from the gynaecologist to the ultrasound scan centre to the lab. Not only is this very time consuming and frustrating, it often means that care become fragmented because of poor coordination. Try to find a clinic which offers all the services under one roof.
The other major risk of IUI is that many gynaecologists repeat it again and again, because they do not have anything better to offer. Rather than referring the patient for IVF, they keep on subjecting the patient to repeat cycles of IUI (sometimes as many as 12 cycles). Patients ultimately get fed up and frustrated, and lose confidence in doctors and themselves, as a result of which they deprive themselves of IVF technology. Often, patients will change doctors, but the new gynaecologists will repeat the same IUI treatment, even though the patient has already done many IUI cycles in another clinic.