Author Name: Dr. Aakriti Lamba || Mentor Name: Dr. Amol Wankhede on April 13, 2020
Intrauterine Insemination (IUI), also called Artificial Insemination is a fertility treatment where sperms are placed into the woman’s uterus during the time of ovulation (egg release).
It is simply a modification of the natural way of conception.
During natural conception, ovum is released from the ovary at the time of ovulation, picked up by the fallopian tube and transported towards uterine end. The sperm has to travel from vagina through the cervix into the uterus and upto the fallopian tube and then fertilize the egg.
The goal behind IUI is to make sure the presence of sperms in greater number at the site of fertilization at right time.
It is a simple and less expensive procedure.
1. Cervical factor infertility:
Cervix is the lower end of the uterus, providing connection between vagina and uterus. Certain factors in cervix may prevent sperms from reaching up to the uterus like excessive scarring, thick mucus, antisperm antibodies.
With IUI, cervical factors of infertility can be bypassed and thereby increasing the chances of achieving pregnancy.
Anovulation i.e. failure to release egg and is a common cause of infertility. During IUI, oral or injectable medications can be used to develop follicles and release eggs on time. This improves the chances of pregnancy in cases such as PCOD.
3. Male factor infertility:
Sperms get destroyed and damaged while they travel up to the fallopian tubes. Males with low sperm count, decreased motility or abnormalities in size and shape of sperms can face difficulty in becoming father naturally. In IUI semen sample is processed and portion semen containing good sperms is prepared. When this sample directly injected into uterus, obviously chances of pregnancy increases in such cases. Also if husband cannot produce semen sample or does not have sperms in semen, these patients can go for IUI with donors sperm.
4. Sexual Dysfunction
Sexual dysfunctions like ejaculatory defects, retrograde ejaculation, impotence or dyspareunia may be a cause of infertility in some couples. There may be other factors that are not due to underlying diseases such as alcohol consumption, tobacco use, drug use, work stress or relationship factors. Many such couples can be benefitted by IUI.
5. Unexplained Infertility
Approximately 5-10% of couples fall in this category, where even after a complete infertility work-up, the cause remains unknown. In such cases 1, 2 or even 3 cycles of IUI can be advised before moving on to advanced procedures like IVF / ICSI.
Though IUI is can be useful for many patients, there are certain conditions in which IUI is of no additional benefit and we need to think about other treatment options for such cases. Such conditions are listed below.
● women who have had both tubes removed or have blocked fallopian tubes
● women with advanced fallopian tube disease
● women with history of multiple pelvic infections
● severe cases of endometriosis
● women with low ovarian reserve, advanced maternal age.
● men who are not able to produce sperm (can proceed with donor semen insemination)
● history of previous failed IUIs.
So as we saw, not all patients can be benefited by IUI, we need to investigate couple if they are right candidate for IUI. To conceive through IUI, ovaries should produce good oocytes and should be able to release them timely. Fallopian tubes must be functional to pick up and transport the eggs towards the uterine end. Sperms should have adequate motility and normal morphology. Besides these factors body hormones such as thyroid stimulating hormone (TSH), prolactin, anti-mullerian hormone (AMH) and other hormones required by doctors depending upon patient’s condition should be within normal range to get better success rate. Important tests are discussed below.
1. Tubal Patency Tests:
Various tests are available to test if fallopian tubes are open or closed. Hysterosalpingography is a radiographic evaluation of fallopian tubes and to certain extent assessment of uterine cavity. In HSG, a dye is pushed into the uterus which eventually moves up into the tubes and X-rays of the pelvis are taken at specific intervals. If the tubes are open, the dye gradually fills it and spills into the pelvic cavity, which can be seen on x-ray of pelvic region.
Hysteroscopy is also a similar test. Other commonly used tests are sonosalpingography and Laparoscopy dye test for tubal patency.
Laparoscopic chromopertubation is the gold standard procedure. Benefits as diagnostic as well as therapeutic because minor blocks can be removed during the same procedure.
Females with tubal blocks which can be removed, do not get benefited with IUI and procedures like IVF are recommended for such patients.
2. Ovarian Reserve and Function:
Regular menstrual cycles occurring at intervals of 21-35 days fairly indicate normal ovulation.
Ultrasonography can confirms number of follicles which represents ovarian reserve. Serial ultrasonography can tell us about follicular development and ovulation. It helps doctors to make decisions about follicular/egg count and whether medications are required for ovulation and to modify the dose of drugs according to response.
Also hormonal studies such as Serum AMH, FSH, LH gives idea about the ovarian reserve.
Women with low ovarian reserve are difficult to respond to treatment and have poor success rates with IUI.
Women with high reserve have abnormal hormonal conditions and so cannot develop follicle and ovulate timely on their own, as it happens in PCOD cases.
3. Semen Analysis:
Husband Semen Analysis is a must before taking up a couple for a procedure of IUI.
WHO states that normal sperm count be more than 15 million/ml with a minimum 32% of actively motile sperms. It recommends morphologically normal sperms be >4%.
Better the semen quality, better is the IUI success rate in that couple. If sperm count decreases less than 10 million/ml, chances of success decreases and it becomes very difficult as sperm count decreases beyond 5 million/ml. In these patients advanced procedures like ICSI or TESA are suggested.
Donor semen samples can be used after appropriate consent in conditions like azoospermia i,e. with no sperms in semen sample or in couples with known case of genetic abnormalities in the male partner.
The procedure is very simple, quick and painless. Needs no anaesthesia.
Ultrasonography is done at the beginning of the menstrual cycle to know about the number and size of eggs in each ovary and to rule out possibility of ovarian cysts and pregnancy.
As per the requirement, female is put on medications so that follicle grows adequately. Medications such as clomiphene citrate / FSH may be used for this purpose.
For patients with non ovulatory causes of infertility, IUI can be performed in a natural cycle also.
By the means of repeated USGs the follicles size are measured and after reaching the appropriate size, Injection HCG is administered which helps in final maturation of the egg and helps ovary to release the egg. This egg is then picked up by the fallopian tube and is transported towards uterine end.
IUI is performed typically 24-36 hours after the injection.
On the day of IUI, husband semen sample is collected in the lab in a sterile container by means of masturbation and is “washed” or processed to get a sample with higher concentration of good sperms.
Patient is made to lie down on the examination table and a speculum is inserted into the vagina. Vaginal area will be cleaned. Using a long and thin plastic catheter, the processed semen sample is then passed through the cervix and deposited in the uterus. This procedure is quick and painless. Sometimes cramp in lower abdomen may be felt by patient. Doctor can ask patient to remain lie down for few minutes.
Sometimes a second insemination may be required the next day.
Folic acid and progesterone preparations are usually prescribed after the procedure.
A pregnancy test is advised to do after 2 weeks or at a missed period.
No major risks are involved in the procedure. Minor risks associated are discomfort, cramps during or after the procedure, spotting, and minor infection.
With medications taken for ovulation induction, risk of multiple pregnancy rises if multiple follicles rupture. In these cases IUI can be cancelled in that cycle and can be re stared in next cycle.
Success rate in IUI depends on the causes of infertility and also the age of women. On an average females with age less than 35 have 10-20% chances of conception with IUI.
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