INTRA UTERINE INSEMINATION (IUI) TREATMENT

Is IUI an option for you ?

What is IUI ?

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).

How is the timing of IUI determined ?

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.

When is IUI recommended ?

• Sexual disorders like impotence, premature ejaculation erectile disorder, vaginismus, neurological disorders etc.
• In case of cervical factors like stenosis, infections, highly acidic cervical mucous or in case of anti sperm antibody present in cervical mucous IUI helps a lot as in case of IUI we bypasses the cervix & put the washed motile sperms directly into the uterus.
• In case of ovulatory dIsorders where we can correct it by stimulations.
• Grade 1 endometriosis provided the tubes are patent.
• AGE is a factor as fertility decreases by age which can be improved by stimulating injections.
• Male subfertility where the sperm count & motility is low IUI is indicated as we can put the washed motile sperms directly into the uterus near to the oocyte.

How much does IUI cost?

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.

What is the process of IUI with donor sperm ?

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.

What is the cost of IUI with sperm donor ?

The Donor semen cycle would cost an additional Rs. 1000/- besides the cost of the IUI procedure, medicines and monitoring.

Who do I contact for any doubts or appointments?

In case of any doubts contact your doctor Gouri at Care IVF

What happens in an IUI cycle ?

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 Husband before semen collection:

• Do not have intercourse for 2-3 days before the day of collection.
• The total number of days since last ejaculation should be no longer than 4-5 days. Sperm cells are made and replaced rapidly after each ejaculation. Prolonged abstinence (greater than 4 days) may increase the number of dead or poorly motile sperm cells.
• It is extremely important to collect the semen specimen using sterile techniques. Bacteria that are normally found on the skin can contaminate the specimen if the container or semen come in contact with the skin. Samples with visible contamination of bacteria, yeast or other potentially infectious agents will not be processed!
• Shower and wash well the morning of your appointment. Rinse all traces of soap from the body since soap contamination will kill sperm cells.

Instructions for Wife before IUI:

• Some antibiotics are given in the initial part of treatment to take care of infections. It is important that both partners take the medications. Make sure you understand correctly, what medications are required to be taken.
• For your convenience, injections are available at the Centre at wholesale rates. There is however NO COMPULSION that you have to buy medicines from the centre.
• Sub cutaneous injections should be given under the skin, either on the forearm or the thigh. Spirit should not be used to clean the area.
• It is important that you and your partner 'stay together' on either Day 7 or day 8 of the periods so that the semen sample on the day of IUI be between 3 to 7 days old.
• Once the eggs are mature (average of 18 - 20 mm size), an HCG injection would be given to you to release the mature eggs. If at any point of time after the injection you feel any pain in the lower part of your tummy, call the doctor immediately. The IUI may need to be re scheduled.
• IUI does not require any admission in the Nursing Home. However, do come with 2-3 hours in hand.
• Inform the Centre once your periods start so that a booking for Follicular Study (Ultrasonography) can be made on Day 2 and then again on Day 10. If it happens to be a Sunday, come on Saturday, not Monday.
• After IUI, a medication needs to be inserted vaginally twice a day. In the morning, lie down for one hour after the insertion. At night, insert at the time of going to bed. Some of the medication may come out in a liquid form, do not get alarmed.

Every couple undergoing IUI will have to follow the following steps on the Day of IUI Appointment:

STEP 1: Husband’s Semen Sample collection

• Inform the receptionist of your arrival.
• Follicular scan is done to check ovulation has occurred. If ovulation has occurred, Semen collection will be done.
• Your appointment for Husband’s semen collection will be 60-90 minutes before the insemination.
• The lab will provide instructions, the collection container, and a private area for collection.
• The sample should be collected by masturbation, without using a lubricant.
• Collect the entire ejaculate into the sterile container. The greatest numbers of sperm cells are found in the first part of the ejaculate, and extreme care should be taken not to lose this portion.
• You will be asked whether any part of the specimen was lost or spilled during collection.

STEP 2: Sperm Washing

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.

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?

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.

STEP 3: IUI Procedure

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.

OFF SITE COLLECTION

Only under special circumstances will you be allowed to collect a specimen at home.

• It is most important that the specimen be protected during transport to the clinic. It is best if the sample can be kept at body temperature (place under the arm or in a coat pocket). Hot or cold temperatures must be avoided or the sperm cells will die.
• The specimen must arrive in the Lab no later than 30 minutes after collection. You will be asked what time the specimen was collected.
• The container into which the specimen is collected must be sterile. Only containers approved and distributed by the Andrology Laboratory can be used for specimen collection. Specimens returned to the Lab in any other specimen container will be rejected, and no IUI done.
• Specimens must be labeled with patient’s name, hospital number, date and time collected. Place the container in the "BIOHAZARD" bag. Follow the directions printed on the bag. You then should place the Biohazard Bag and specimen container in another bag for transport to the hospital.

Information of certain Drugs used in IUI cycles

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.

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.

Where is the sperm collected? How long before the IUI?

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.

When is the best timing for an IUI?

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.

What does an IUI feel like?

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.

How long does washed sperm live?

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.

Do I have to lie down after an IUI?

We advise patients to lie down on the table for 30-45 minutes after the procedure.

I am a working woman. Do I need to take leave after IUI?

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.

How long before an IUI should the male abstain from intercourse/ejaculating and store up sperm?

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.

How soon after an IUI can I have intercourse?

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.

Can the sperm fall out?

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.

How many follicles give my best chance of getting pregnant?

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.

Does IUI make sense when there isn't a sperm count problem?

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.

How high a sperm count is needed for IUI?

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.

How many IUIs should I try before moving on to IVF?

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.

Can IUI be done at home?

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.

Is bleeding common after an IUI?

It doesn't usually happen, but it isn't uncommon. Some women also have light bleeding with ovulation.

How long after IUI should implantation occur?

Implantation takes place 6-12 days after ovulation - so 6-12 days after a well-timed IUI.

What kind of monitoring is usually done for an IUI cycle?

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.

At what size are follicles considered mature?

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.

What are the risks involved in IUI?

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.

Can I take pain medications before or after the procedure?

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).

Can IUI work after tubal ligation (having "tubes tied") or if both tubes are damaged or blocked?

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).