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).
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 treatment(Artificial Insemination) 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.
IUI (Artificial Insemination) 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:
IUI treatment (Artificial Insemination) 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 far 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 (Artificial Insemination) 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 treatment (Artificial Insemination) 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 (Artificial Insemination)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 (Artificial Insemination) procedure is done. This generally happens around 14 to 16 day of cycle. After IUI (Artificial Insemination) procedure some medicines are given for support for another 14 days.
- Is there any risk in performing IUI (Artificial Insemination) procedure?
There is generally no risk in performing IUI treatment 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.
- IUI – How to Proceed?
IUI treatment (Artificial Insemination) can be done in natural unstimulated cycle or in a stimulated cycle (using oral drugs/injections).
- Time of IUI (Artificial Insemination)
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 treatment (Artificial Insemination) 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 (Artificial Insemination) 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.
- Will there be any pain while doing the IUI (Artificial Insemination) procedure? Is anesthesia required?
IUI (Artificial Insemination) procedure 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 IUI (Artificial Insemination) procedure will not give you the time to realize as to when the IUI (Artificial Insemination) procedure got over. So the need for Anesthesia in IUI (Artificial Insemination) procedure never arises.
- Do I require fasting on the night prior to IUI procedure (Artificial Insemination)?
IUI (Artificial Insemination) is a very basic procedure. No anesthesia 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 (Artificial Insemination)?
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 every day to identify the exact day of ovulation (release of egg) and the IUI(Artificial Insemination) procedure 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/3rd day of menses for 5 days.
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 treatment(Artificial Insemination) is generally done 36 hrs after hCG injection and after confirmation of ovulation (release of the egg).
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 gonadotropins. On Day 8 TVS is repeated to see the growth of the follicle and endometrial thickness.
IUI treatment (Artificial Insemination) is generally performed 36 hrs.After this trigger after confirming ovulation.
- IUI treatment: How should the husband prepare?
There should be at least 2 days/48 hrs of 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.
- Collection of the semen sample:
Semen collection facility is available at our hospital. Adequate privacy is ensured at “Panacea Hospital” and private rooms are provided for the same.
The success rate of IUI (Artificial Insemination) 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 (Artificial Insemination) 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%
How to further enhance the success rate in IUI Procedure (Artificial Insemination)?
- 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.
- 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?
- 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 Procedure (Artificial Insemination)
- The success of IUI Procedure (Artificial Insemination) 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 (Artificial Insemination) have failed, you should not get disappointed as we have seen success after 6 cycles of IUI Procedure (Artificial Insemination) too.
- Number of IUIs to be done in a cycle?
Generally, we perform one IUI Procedure (Artificial Insemination) after confirming the rupture of follicle (release of egg). Usually the follicle ruptures after 36 hrs.of administration of HCG injection. Sometimes two IUIs (Artificial Insemination) are done in a cycle in selected group of patients like previously repeatedly failed IUI’s (Artificial Insemination), male factor infertility, unexplained infertility.
- What is Donor IUI Procedure (Artificial Insemination)?
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.