INTRAUTERINE INSEMINATION | IUI
Intrauterine insemination (IUI), is the process of injecting concentrated sperm directly into the uterus at the time of ovulation by means of a catheter directed through the cervix, has been practiced for many years. It is one of several infertility treatments that use a small catheter to insert “washed” sperm directly into the uterus. The goal of IUI is to increase the number of good sperm that reach the fallopian tubes and subsequently increase the chance of fertilization. The use of clomiphene citrate or injectable medications, called gonadotropins, combined with IUI, increases the chance of conception. We time the intrauterine insemination with an ultrasound scan. This is an important aspect of treatment because it enables us to predict ovulation before it occurs.
IUI is usually selected as a treatment for conditions including
- unexplained infertility
- ovulation Problems
- low sperm count decreased sperm motility
- donor sperm
- A hostile cervical condition such as cervical mucus that is too thick or cervical scar tissue from past procedures
- Ejaculation dysfunction and timing issues
- Failed treatment with clomiphene without inseminations
Preparation of IUI Cycle
Prior to beginning an IUI cycle, the couple will need to have a basic fertility workup, including lab work, semen analysis, and an HSG or laparoscopy to be sure the fallopian tubes are open. The female spouse will be asked to report on day 3 of the menstrual cycle for an ultrasound scan & if required a blood test for hormonal analysis, Medications will be prescribed based on the investigations & the female spouse will be asked to report back on the day 12 or 13 depending on the follicular size on the basal scan i.e. on day 3. Make sure you and your husband will be in town and available during the treatment process. If the husband cannot be available during the IUI process the semen sample can be frozen to be used for the insemination when required.
The Process of an IUI cycle
The semen sample can be collected at our hospital or can be collected at home in a sterile condition and brought to the hospital without exposing to extreme conditions within an hour of collection. Our lab will then prepare the sperm for insemination and perform a sperm count and motility evaluation. Using a small catheter, the sperm concentrate is then placed into the uterus through the cervix. In the majority of cases, IUI is a completely painless process. Some inseminations are accompanied by cramping, but this is usually very mild and transient. It is necessary to remain to lie down for approximately 10 minutes after which time you can resume your usual activities. Couples are encouraged to have intercourse later in the day or evening of insemination to further increase chances for conception.
Luteal phase support after IUI
The female spouse is put on progesterone pills from day 16 to day 25 of the menstrual cycle post an IUI procedure as luteal phase support. If the female spouse does not get her periods even after a week past the expected date of menstrual cycle they are asked to report to the clinic for a blood test for ßhCG which if positive are tested for hormones like estradiol & progesterone as well, if found defective are supplemented to support the ongoing pregnancy.
The Probability of pregnancy with IUI
With natural conception in couples without fertility issues, the probability of achieving a pregnancy in any given cycle is approximately 15-20 %. In couples undergoing infertility treatment, the chances of pregnancy vary depending on the individual fertility problems and the type of medication used. IUI increases pregnancy rates by controlling the timing of exposure of the eggs to sperm and by increasing the numbers of sperm that reach proximity to the egg. Fertility medications increase the probability of pregnancy by increasing the number of follicles on the ovary. In general, the pregnancy rate with Clomid is approximately 8-10 % per month, with injectable gonadotropins approximately 15-20 %, therefore, gonadotropins with IUI can raise the pregnancy rate to the level experienced by couples without fertility problems. We, therefore, typically recommend that a couple undergo at least three cycles of treatment before we can evaluate the effectiveness of the therapy.
How many IUI treatment cycles will be needed?
Some couples conceive with only one or two treatment cycles. If no conception occurs after three cycles, an appointment is made to discuss other treatment options. We understand that there is a certain physical and emotional toll that fertility treatment takes on patients, and we prefer not to continue with a plan that has been unsuccessful after three attempts. We would want to review your response to what has been done and make recommendations as to what would be the next step. Some treatments have a higher probability of success but require more time, effort and cost, so these factors must be taken into consideration in helping you decide on a new plan.
What is the risk from an IUI?
The main risk for IUI is the risk of multiple gestations, especially those which are high-order multiple (triplets or more). The probability of multiples depends on the type of medications you are taking. For example, the risk of multiples with Clomid is approximately 1-2 %, however, with injectable gonadotropins, the risk increased to approximately 6-8 %. Your physician will discuss these risks with you prior to beginning a treatment cycle. However, it is important to note that physicians do not have absolute control over how many eggs are released at the time of ovulation and how many of those eggs are fertilized.
Physicians at DRIFF try to strike the right balance between good pregnancy chance and a low risk for multiple gestations, but even in best of hands, high-order multiples will happen.
Multiples, especially high-order multiples carry an elevated risk, especially premature delivery. Our goal is to achieve pregnancy with as low a risk as possible to mother and newborn child.
For many couples, IUI is the gateway to infertility treatment. IUI can be the first treatment option if:
- The female partner is young—under age 35
- Ovarian reserve is normal for maternal age
- Fallopian tubes have been documented to be patent bilaterally
IVF is more reasonable if:
- The female partner is over age 35
- Ovarian reserve is low (indicated by high FSH and/or low AMH)
- Cause of the infertility is a severe male factor
- History is consistent with Tubal disease
For example, in severe male-factor infertility, IUI may not allow for fertilization because the sperm concentration is too low. Through IVF sperm can be microsurgically injected into the eggs, in a procedure called intracytoplasmic sperm injection (ICSI). Even when there is no sperm in the ejaculate, in about 80-85% of cases, a urologist can extract sperm from the testicles, which can then be used in ICSI (but not in IUI). Our team of physicians works closely with urologists to facilitate this procedure which requires detailed coordination during the IVF process. For couples with severe male-factor infertility, IVF combined with ICSI is often better (and sometimes the only) option.
Is IUI more cost-effective?
Many patients choose IUI over IVF, thinking that IUI is more cost-effective than IVF. Although IUI cycles, indeed, are less costly on a per-cycle basis, IUI cycles may be less cost-effective overall, because of IUI’s much lower pregnancy rates. Indeed, a number of recent studies concluded that, at least in many patients, going straight to IVF, skipping the interim step of up to three or four IUI cycles that may be used to attempt pregnancy beforehand, represents a more cost-effective approach. It certainly represents a more time-efficient approach!
Is IUI less invasive than IVF?
There are a lot of fears circulating when it comes to IVF, and many, if not most of them, are unwarranted. One important aspect that concerned patients often overlook is that at least once they reach ovarian stimulation with gonadotropins, IUI and IVF cycles are very similar: Both require daily self-injections; both require monitoring with ultrasound and blood testing; both take between 2-4 weeks. It is true that higher doses of medication are used for IVF than IUI and the ovaries are stimulated to be larger from more dominant follicles with IVF compared to IUI, but the main difference is that the IVF cycle requires egg retrieval under intravenous sedation.
Egg retrieval is a minor surgical procedure. While performed while the patient is asleep (not with a general anesthetic; just an I.V. sedation, administered by an anesthesiologist), egg retrieval involves no incisions. Egg retrieval involves the aspiration of follicles through the vagina with a long needle using ultrasound guidance.
THE NUMBER OF IUIs PER CYCLE:
There may be a higher pregnancy rate with more than one IUI per cycle. We suggest starting out with two to three inseminations to increase the chances of a successful conception. If you are being treated with drug therapy, we will instruct you about IUI timing.
FOR THE HUSBAND:
We realize that producing a sperm specimen may be difficult due to the environment. We do have collection suites that are quiet and have photographic materials to assist. If you prefer to collect at home (or somewhere else) that is possible. Collection kits are available at our clinic and must be used to collect the sample. The sample is preferred to be collected exclusively by masturbation (not interrupted intercourse). If you collect at home the specimen must be here to the lab within 60 minutes and must be kept at body temperature (placed between legs or held in hands, etc.). If the only possible way to collect is through interrupted intercourse, the lab can provide you with a special condom for this purpose. However, it is more difficult for the lab to work with a sample from a condom. If you are planning to collect at the clinic, the personnel at the desk should know that you have an appointment for sperm collection and you should simply need to say your name and not need to announce why you are here. After sample collection, you will be asked to provide several pieces of information to ensure that your sample is correctly identified and processed by the laboratory:
First, fill out the provided sticky label with your name and collection information. Attach the label to the sample container holding the specimen and place it UPRIGHT in the plastic box that is provided in the kit. From this point onwards, the sample must be maintained between room and body temperature.
Second, bring the sample to our facility. Our lab staff will ask you for a photo ID and for your signature on an identity verification document. You can do this in person or your partner can deliver the sample to you. If your partner delivers the sample to the lab, her photo ID and signature will be required.
Donor sperm can be used for intrauterine insemination (IUI) or for in vitro fertilization (IVF) procedures. This sperm is sometimes obtained from a known donor, but usually, it is obtained from an anonymous donor through a sperm bank. Donor insemination is the process of placing previously frozen sperm that has been thawed, washed, and prepared into a woman’s uterus around the time of ovulation. The donor sperm can be used in a “natural cycle” with IUI during which the woman will usually release one egg if she is ovulating on her own, or, more commonly, it can be used in conjunction with fertility medications that stimulate the ovaries to develop eggs and that trigger ovulation. In vitro fertilization(IVF) requires sperm to be placed around harvested eggs or injected into the harvested eggs to facilitate fertilization.
Patient situations that may require donor sperm:
- Single women
- Lesbian couples
- Couples where the male partner has no recoverable sperm
- If the couple cannot afford costly treatments like IVF-ET/ICSI treatment
- Repeated failed attempts of IUI or IVF with compromised semen parameters.
If you wish to use a known donor
Women who wish to use the sperm of a friend or acquaintance are required to obtain legal counsel to avoid future conflicts with such an arrangement. They are also strongly encouraged to meet with a counselor to address questions that may arise in the future. Furthermore, they must abide by state laws that stipulate the testing of the male partner for specific sexually transmitted diseases and the quarantining of the semen for a specified time period prior to its use. In addition, patients may want to have their donor screened for genetic disease carrier status such as cystic fibrosis.
Indications for semen freezing
- Male partner who will be out of town around the time of planned insemination or IVF cycle
- Male partner with performance anxiety who wishes to have frozen “back up” sperm for IUI or IVF
We can prepare and store frozen sperm for later use in situations such as the above.
Women who are unable to produce or use their own eggs require donated eggs. The following are some of the reasons why:
- Premature menopause
- Genetic abnormality
- Carriers of a genetic disorder
- Poor ovarian response to hormonal stimulation
- The Absence of the ovaries
- Ovarian failure due to chemotherapy and/or radiation treatment.
Infertility may result, not only from the inability to conceive but also from the inability to support the developing baby during the pregnancy. Motherhood is still possible thanks to the generosity of women who are willing to carry a fetus that is not theirs. Gestational surrogacy is a treatment option in which embryos created by IVF are transferred into the uterus of a woman genetically unrelated to the embryos. Surrogacy may be used for women without a functional uterus; for women with underlying medical problems which could cause great risk to mother or baby during pregnancy, or for women with the history of multiple failed IVF cycles without a known cause.
We at DRIFF work with local surrogacy agencies to assist couples with the opportunity to become parents. The process is very similar to those used in donor egg cycles with embryo transfer into the recipient’s uterus. The woman producing the eggs undergoes an IVF cycle. At the same time, the gestational carrier prepares her uterus for conception with estrogen and progesterone. The eggs are fertilized and on the day of transfer, the embryos with the highest pregnancy potential are placed in the uterine cavity of the gestational carrier. The number of embryos transferred depends on the age of the woman producing the eggs and the quality of the cultured embryos.
Starting the Process
The surrogacy agency conducts the initial recruitment and screening of potential surrogates, provides legal referrals and offers administrative assistance during the process. The physician then meets the surrogate and performs an extensive medical screening exam to confirm a candidate’s adequacy for surrogacy. The process of being a gestational surrogate or gestational carrier involves finding a woman who has had healthy pregnancies; feels she is done having her own children and would like to participate in the joy of helping another woman have a child for whom there is no option otherwise.
We do not underestimate the issues with finding a carrier and realize that the women who need this help, are in some ways forgotten in the infertile population. The women who need to use a gestational carrier often struggle with not only the emotional issues of being unable to carry their own child but also the additional financial burden and challenge of finding a woman who is willing to do this for them.
Finding a carrier
After passing both medical and psychological screening exams, a gestational carrier is available to be matched. Once the agency has matched a couple or individual with a gestational carrier and all contracts have been signed, medical treatment begins. Our hospital is associated with a lawyers firm who can assist the couples with the legal advises in the course of treatment & to take the baby back to their respective countries in case of overseas couples availing surrogacy options at our facility.
Co-ordination of a Gestational Surrogate
Throughout this overview, the couple contributing the eggs and sperm are referred to as “The Female” and “Male Partner” or collectively as “The Couple” or as the “Intended Parents” and the woman receiving the fertilized eggs and carrying the pregnancy is referred to as “The Gestational Surrogate”. A gestational surrogate’s cycle requires a great deal of coordination, from selecting the surrogate and matching her with a couple, to synchronizing and performing the related medical procedures. Candidates for the Gestational Carrier Program are usually couples in which the Female Partner has no uterus due to surgery (hysterectomy), has an abnormally shaped (malformed) uterus, has had an endometrial ablation, or has a medical condition that prevents her from carrying a pregnancy or previous multiple IVF failures with either immunological problems or unknown reasons or in cases of repeated pregnancy losses . These women usually are good candidates for ovarian stimulation with fertility drugs. Egg donation is also recommended to these couples when the woman is not a good candidate for ovarian stimulation because of age or decreased egg quality.
1. Synchronizing the Female Partner’s and Carrier’s Cycles
Like The Female Partner, The Carrier will be placed on birth control pills in order to synchronize their two cycles. Instead of medication to stimulate egg development, the carrier requires a medication called Lupron (GnRH agonist) to suppress ovulation, and hormone injections (estradiol and progesterone) to prepare her uterine lining for implantation of the transferred embryos.
2. Ovulation Induction and Monitoring of the Female Partner
ART (Assisted Reproductive Technology) success rate depends upon the numbers of eggs or embryos available for transfer. Additionally, the egg retrieval must be carefully timed so as to retrieve mature eggs. To accomplish these two goals, ovulation induction medications and careful monitoring are employed.
The start of the ovarian stimulation is timed using oral contraceptive pills (OCP). The Female Partner takes OCP for two to four weeks prior to the beginning of the stimulation. The Female Partner begins injections of gonadotropins, according to a schedule that is provided by the clinic from day 3 of the menstrual cycle. We arbitrarily call this first day of gonadotropin administration Stimulation Day 1.
Once the follicles (containing the eggs) are deemed ready or mature, the Female Partner takes an injection of human chronic gonadotropin (hCG). This hormone replaces the woman’s normal LH surge and is necessary for the final maturation of the eggs so that the sperm can fertilize them.
3. Building the Carrier’s Lining with Hormonal Injections
In a natural cycle, the uterine lining is built up in response to the hormone estradiol that is produced by the developing follicles within the ovaries. In the carrier, we replace the follicle-derived estradiol with the medication.
Approximately 2 to 5 days before the anticipated embryo transfer, daily injections of progesterone begin in order to optimize the gestational carrier’s endometrium for implantation.
4. Egg Retrieval
At DRIFF, the egg retrieval is accomplished non-surgically using a vaginal ultrasound probe to guide a needle into the ovaries. The procedure does not require general anesthesia and is performed with intravenous sedation. An anesthesiologist administers the sedation to maximize the comfort and safety.
5. Sperm Processing
To comply with the rules & regulations male partner collects sperm for freezing before the IVF cycle is initiated. The sample is collected after his infectious disease screening has been completed. After the egg retrieval, the frozen sperm sample is thawed and prepared for IVF.
6. In Vitro Fertilization
In-vitro fertilization literally means “fertilization in glass”. Follicular fluid removed from the ovaries is examined in IVF lab for the presence of eggs. These eggs are isolated and placed in culture media where they are allowed to further mature. A few hours later, the processed sperm are placed around each egg or ICSI is performed for the fertilization, the fertilized eggs are further cultured and then transferred to the surrogate’s womb in anticipation of a successful pregnancy.
7. Embryo Transfer to the Carrier’s Uterus
At DRIFF, all embryo transfers are performed under trans-abdominal ultrasound guidance. We have found that ultrasound-guided transfers are easier to perform and have resulted in higher pregnancy rates. The ultrasound allows for the accurate placement of the embryos approximately 1.5 centimeters from the top of the uterus. The embryos are transferred via a thin plastic tube called a catheter. The catheter is carefully guided into the upper part of the uterus where the embryos are placed. The transfer is a painless procedure and the surrogate (carrier) remains resting for 30 minutes.