Intrauterine insemination (IUI) with either husband or donor sperm is a procedure done in the clinic. IUI is basically artificial insemination procedure in which washed sperm directly into the uterine cavity.
In IUI cycle we try to create the best possible chances of conception and implantation. By giving stimulation medicines we ensure good number of follicles are recruited for development and that best possible follicular growth occurs. Estrogen released by growing follicles plays a direct role in thickening of the endometrial lining which is essential for implantation. If good number of follicles are recruited, the endometrium will also achieve the desired thickness (> 7mm). The semen sample is washed to remove any bad sperms and the best sperms are separatedand inserted into the uterus at the best possible time (on the day of ovulation).
In a natural cycle, ovulation occurs between days 14-16 of menstrual cycle. The timing of an IUI can be adjusted to desired time by giving a “trigger” that induces ovulation within 24-36 hours.
The follicular growth can be tracked by Follicular monitoring through repeated Ultrasound Scans between D9 to D13. Once the follicles grow to the desired size (> 14 mm) “Trigger” is induced by administering HCG injection. Ovulation occurs within 36 hours of Trigger, and the IUI is scheduled likewise.
Another way to determine the time is by looking for LH surge which happens 48 hours before ovulation. This can be detected by doing a urine test using an ovulation predictor kit. If LH surge is detected, the Trigger can be induced.
The IUI procedure and sperm washing and ultrasonography cost Rs.4000, but the cost of medications can make a considerable difference. Someone doing a natural IUI cycle may spend only Rs.4000, while someone on injectable medications with monitoring may spend upto Rs.15000 to 20000.
The Treatment protocol of the wife remains the same. On the day of IUI the donor sperm needs to be thawed. It then undergoes sperm washing and the prepared donor sample is transferred into the uterus.
The Donor semen cycle would cost an additional Rs. 1000/- besides the cost of the IUI procedure, medicines and monitoring.
We are often asked what to expect in an IUI cycle?
How often do we have to come to the clinic?
An IUI cycle can be broadly broken down into the following stages:
Typically an IUI cycle last 15 days that is from the Day 2 to Day 15.
D2-D6: Stimulation medicines are started from D2. Based on the protocol and cost that the patient can afford, the protocol may be based only on medicines or a combination of medicines + stimulation injections or based only on Stimulation drugs. Based on the protocol the medicines have to be continued form D2 till the date advised by the fertility specialist.
D9-D12:Follicular scans are started form D9 and done on alternate days or on intervals decided by the doctor till D12 OR D13.
D12:Once the follicles achieve the desired size, Trigger is induced by giving HCG injection. In 90% of cases Trigger happens on D12. Ovulation occurs within 36 hours of Trigger.
D13-14:Another scan is done to check if the ovulation has occurred. If yes IUI is done on the same day. Else the IUI is scheduled on day 14.
Note: Depending on the stimulation protocol (what kind of medicines are prescribed) frequency of scans and the duration of taking the medicines would vary.
Instructions for Wife before IUI:
The semen sample is allowed to undergo liquefaction for 15-30 minutes. After this semen parameters are studied and recorded via microscopic examination. The next step is sperm washing.
What does “sperm washing” mean?
It is a laboratory technique for separating sperm from semen, and separating motile sperm from non-motile sperm, for use in assisted reproduction (IUI or IVF). It is sometimes also called sperm preparation or spinning.
There are various wash techniques used to try and separate the ‘good’ from the ‘bad’ sperms as well as improve the quality of the ‘not so good’ sperms. We follow the “double wash” or the density gradient separation technique which is gives the best results. This works especially well with semen samples with poor semen parameter’s like presence of poor sperm quality and/or low sperm count. Another advantage of this technique is that the toxicity effect of the gradient media is rules out by 2nd Wash.
What happens in Double wash technique of sperm washing?
Why is Sperm Washing done?
Sperm are washed free of seminal fluid before IUI is carried out. Sperm washing is done to prevent contact with parts of the seminal fluid that do not normally reach the uterine cavity during sexual intercourse. Sperm washing also is used to remove infectious agents and to reduce the volume of the specimen so it can be placed directly into the uterine cavity.
The semen sample obtained after washing is called prepared semen sample.
A predetermined aliquot, (approximately .5 ml) of prepared semen sample is taken for IUI procedure.
An IUI – intrauterine insemination – is performed by inserting a very thin flexible catheter through the cervix (mouth of the uterus) and injecting washed sperm directly into the uterus. The whole process does not take very long – it usually only requires the insertion of a speculum and then the catheter, a process that may take a couple of minutes. Sometimes when the cervix is hard to reach a tentaculum is used to hold the cervix, which makes the procedure easier.
Depending on the requirement a repeat IUI may be done after 24 hours.
Only under special circumstances will you be allowed to collect a specimen at home.
ASPIRIN (ECOSPRIN 75MG)
Low dose aspirin treatment is started either from the D1/D2 of periods or immediately after IUI. This enhances blood flow in multiple different organ systems. Studies have shown dramatic improvement in follicle development, pregnancy rates and implantation rates.
Progesterone hormone is produced after the follicle ruptures and releases the egg. This hormone supports the lining of the uterus and prepares it to receive the fertilized egg, i.e. the embryo. This phase after rupture of the follicle till the next periods occur is called the Luteal phase. Some women have a natural defect in their luteal phase which is aggravated when drugs like Clomiphene Citrate (Siphene) are given or when extensive down regulation is done as during IVF (with drugs like Lupride). Thus after IUI, progesterone supplementation is done to provide extra care and support to the lining of the uterus as well as reduce the irritability of the uterus to increase chances of pregnancy.
ANTI-OXIDANTS (GENEW OR LYCORED)
Stress, Smoking, Excess Alcohol and Environmental pollution lead to generation of ROS or Reactive Oxygen Species that cause damage to sperms and oocytes. Anti-Oxidants reverse this to some extent and have been shown to increase pregnancy rates.
Estradiol is responsible for increasing the lining of the uterine cavity. As the level of the hormone increases you will find the ET or Endometrial thickness increasing on the folliculometry scan. Sometimes due to drugs, some hormonal problems or idiopathic reasons, the lining does not develop well. In these times, Progynova supplementation & sildinafil insertion at the right time helps correct the problem.
Usually the sample is collected through ejaculation by masturbation into a sterile semen collection container in a private room at the clinic. From the time the sample is received, it takes about 1 hour 30 minutes to make the sample ready for insemination. The amount of time may vary depending on the sperm quality, as special techniques may be required.
Ideally, an IUI should be performed within 6 hours before or after ovulation. Timing is based on an HCG injection (given to release the egg) and the IUIs are usually done between 24 and 36 hours later. Typical timing would be to have a single IUI at about 36 hours post-hCG. If two IUIs are scheduled, they are usually spaced at least 12 hours apart between 24 and 48 hours after the HCG. Success rates are higher with two IUIs as compared to a single IUI. The egg is only viable for a maximum of 24 hours after it is released.
Most women consider IUI to be fairly painless – along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is the pain of the egg being released (ovulation) rather than from the IUI. The catheter usually does not cause pain as it is very thin and flexible and the cervix is already slightly open for ovulation.
Current research indicates that washed sperm can live 24-72 hours; however, it does lose potency after 12-24 hours. Another issue with IUI is that the sperm can keep on swimming beyond the fallopian tube, so the ideal window is really within 6-12 hours of the egg being released; with a larger margin before ovulation than after since the egg’s viability is shorter. Sperm can live up to 5 days in fertile mucus, 2-3 days being common, so combining IUI with intercourse may provide better coverage.
We advise patients to lie down on the table for 30-45 minutes after the procedure.
Most people don’t need to, but if you had cramping or don’t feel well afterward it makes sense to take rest for a day or two. We advise against any heavy work or travelling by buses, rickshaws or scooters as the bumpy ride may reduce chances of conception.
This depends on your individual situation, but it usually should not be less than 3 days and not more than 7 days in order to ensure the best motility and morphology. We advise that you have an intercourse around the 7th or 8th day of your cycle and then abstain.
Usually you can have intercourse any time after an IUI. We suggest waiting 48 hours to resume relations if you had any bleeding during the IUI or if a tentaculum is used.
Once the sperm is injected into the uterus, it does not fall out. There can, however, be increased wetness after the procedure because of the catheter loosening mucus in the cervix and allowing it to flow out.
According to different studies, 3-4 follicles gives one the best chance of getting pregnant, while more follicles beyond that simply increases the risk of multiples.
IUI can help patients taking only tablets containing clomiphene citrate where cervical mucus is a problem, and IUI increases the chance of success in patients on injections no matter what the sperm count. It does make sense to try IUI if you have tried but haven’t had success with intercourse. It is important to note that with intercourse, only the best and strongest sperm make it through the cervical mucus and up into the uterus and fallopian tubes. With IUI, more number and better quality of sperms are available for fertilization.
A count above one million (after sperm preparation) appears necessary for success, with a significant reduction in pregnancy rates when the inseminated is count is lower than 5-10 million (in other words, in most cases one should consider 5 million a lower limit for success, 10 million for cost-effective). Higher success rates are with washed counts over 20-30 million, while increasing counts over 50 million did not appear to offer advantage.
It depends on what you can afford and what medication you are taking. One might do 1-2 IUIs on Tablets before moving on to Injections, then do 3-4 cycles on Injections. If one doesn’t have success after four good ovulatory cycles on Injections with well-timed IUI, it would be time to consider IVF. Age is also a factor, the higher the age, the more aggressive is the treatment required.
An IUI shouldn’t be done at home without medical supervision because the sperms needs to be washed to prevent infection – i.e., separated from the semen. A vaginal insemination can be done at home, but is no more successful than intercourse. Getting semen or air into the uterus could be quite dangerous – perhaps life-threatening.
It doesn’t usually happen, but it isn’t uncommon. Some women also have light bleeding with ovulation.
Implantation takes place 6-12 days after ovulation – so 6-12 days after a well-timed IUI.
Transvaginal Ultrasonography is done from Day 10 or 11 of the menstrual cycle to note the growth in follicular size and look for signs of ovulation like reduction in size of follicle, fluid in POD etc.
Follicles are usually considered mature once they have achieved a size of about 18 mm. Also, follicles continue to grow until they release, usually at a rate of about 1-2 mm per day. A woman may ovulate more than one follicle in a cycle, but the releases will occur within 24 hours. When HCG is not used, only follicles close in size are likely to release. The use of HCG induces ovulation in about 95 percent of women, and will get most mature follicles to rupture.
The main risks are some discomfort such as cramping, minor injury to the cervix that leads to bleeding or spotting. There are also risks of hyper stimulation associated with the use of ovulation induction medications such as clomiphene citrate (low risk) and gonadotropin therapy (higher risk). Proper technique and adequate monitoring reduce risks.
Most women don’t need medication for pain associated with IUI. If there is cramping, it is best to avoid medications such as ibuprofen and naproxen (NSAIDS), but paracetamol is considered safe (but maybe not that helpful for cramps).
No. A tubal ligation is effective birth control because it prevents the sperm and egg from meeting. The process that leads to pregnancy is having an egg released from a follicle in the ovary and then beginning the journey to the uterus through the fallopian tube. Sperm will travel from the vagina, through the cervix, through the uterus, into the tube where fertilization occurs. IUI bypasses the need for the sperm to travel through the cervix, but that’s it. It doesn’t get the egg to the other side of the obstruction, so fertilization won’t take place. The only way to get pregnant after tubal ligation or blocked tubes is by having reversal surgery or an assisted reproduction technology that includes egg retrieval, such as in vitro fertilization (IVF).