from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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What is intrauterine insemination ( IUI) ?
When is IUI used for treating infertility ?
How is artificial insemination performed ?
How is IUI performed ?
How is the IUI timed ?
How are the sperm processed in the laboratory for IUI ?
What recent advances have occurred in IUI treatment ?
What is the success rate of IUI treatment?
What are the risks of IUI treatment ?
How much does IUI treatment cost ?

What is intrauterine insemination ( IUI) ?

Sometimes nature needs help to start a pregnancy - and the doctor can do this by giving the sperm a piggy back ride through a fine tube into the body. This procedure is called intrauterine insemination ( IUI) or artificial insemination with husband’s sperm (AIH) - and effectively, the doctor is giving nature a helping hand by increasing the chances of the egg and sperm meeting.

When is IUI used for treating infertility ?

IUI is useful when:

1. The woman has a cervical mucus problem - for example, it maybe scanty or maybe hostile to the sperm. With an intrauterine insemination (IUI) the sperm bypass her cervix and enter the uterine cavity directly.
2. The man has antibodies to his own sperm. The " good" sperm which have not been affected by the antibodies are separated in the laboratory and used for IUI.
3. If the man cannot ejaculate into his partner's vagina. This is usually because of psychologic problems such as impotence (inability to get and maintain an erection) and vaginismus ( an involuntary spasm of the vaginal muscles so that vaginal penetration is not possible); or anatomic problems of the penis, such as uncorrected hypospadias; or if he is paraplegic.
4. The man suffers from retrograde ejaculation in which the semen goes backward into the bladder instead of coming out of the penis.
5. For unexplained infertility, since the technique of IUI increases the chances of the eggs and sperm meeting.
    
6. If the husband is away from the wife for long stretches of time (for example, husbands who work on ships or work abroad), his sperm can be frozen and stored in a sperm bank and used to inseminate his wife even in his absence.

How is artificial insemination performed ?

Methods for performing AIH
There are various methods of doing AIH (artificial insemination by husband). The crudest and simplest technique involves simply injecting the entire semen sample into the vagina by a syringe. You can also perform artificial insemination in your own bedroom. This is called self-insemination.  However, this is a waste of time if used for treating an infertility problem - after all, why go to a doctor to do something which you can do for yourself at home? Remember, a syringe is no better than a penis ! It is only useful if the reason for doing AIH is the inability of the husband to ejaculate in the vagina. However, a number of doctors still use it as they do not offer anything better.
 

A refinement of this technique is that of using a spilt ejaculate. The first squirt of semen which gushes forth during ejaculation is richest in sperm. This is because the sperm "surf" on the wave of the seminal fluid which carries them forward to the outside world. The man masturbates into a 2-part container, so that this first part goes into one container, while the rest goes into another. This is not as difficult as it sounds, and gets easier with practice! The first bottle is saved and the contents used for artificial insemination. This method is suitable for a small proportion of cases (for example, for the uncommon problem of a large volume of semen, which "dilutes " the sperm; or where laboratory facilities for sperm processing are not available).

How is IUI performed ?

Intrauterine insemination (IUI)
In this method, the sperms are removed from the seminal fluid by processing the semen in the laboratory and they are then injected directly into the uterine cavity. It is not advisable to inject the semen direct into the uterus, as the semen contains chemicals (prostaglandins) and pus cells which can cause severe cramping; and even tubal infection.

How is the IUI timed ?

Timing
Timing the IUI is very important - it must be done during the "fertile period" when the egg is in the fallopian tube. Pinpointing the time of ovulation accurately using either vaginal ultrasound or ovulation test kits is crucial. A good clinic should provide this as a 7-day week service, since there is a 1 in 7 chance that ovulation will occur on a Sunday - eggs don't take a holiday! It is important to superovulate the wife at the same time ( with clomid or HMG injections)  , so that she produces more than one egg. Superovulation increases her fertility potential as well, thus increasing the chances of conception by improving the chances of the eggs and sperm meeting.

The IUI is done either when ovulation is imminent or just after. The husband masturbates into a clean jar - preferably in the laboratory or clinic itself, and after at least three days of sexual abstinence to get optimal sperm counts. Some men may have considerable difficulty producing a semen sample at the appropriate time, because of the tremendous stress they are under, and the " pressure to perform". For these men, using a previously stored frozen sample can be helpful. Viagra ( sildenafil citrate) can also be used to help them to get an erection, as can using a vibrator.

The best sperm are separated from the rest of the seminal fluid, by special laboratory processing techniques. This separation takes about 1 to 2 hours. The actual insemination procedure is simple and takes only a few minutes to perform. It is not painful, though it can be uncomfortable. The wife lies on an examining table, and a speculum is placed in the vagina. The doctor puts the sperm through a thin plastic tube (catheter) through the cervix into the uterus. There may be a bit of uterine cramping at this time; and some discomfort for about 12 to 24 hours. Some patients may experience a little vaginal discharge after the procedure, and they are worried that all the sperm are leaking out of the uterus. However, this discharge is just the cervical mucus – the sperms cannot "fall out" of the uterine cavity.

No special bed rest is required after the IUI. Some doctors may repeat the insemination after 24 hours. We usually encourage our patients to have intercourse on the night of the IUI, and for 2-3 days after this as well, to maximize the chances of the sperm and egg meeting.

How are the sperm processed in the laboratory for IUI ?

Sperm processing:
Sperm processing allows the doctor to concentrate the actively motile sperms into a small volume of culture fluid. Sperm do not remain alive in the culture medium for very long unless maintained at the right conditions - hence a prompt insemination after sperm processing is important. This is why processing should preferably be done in the clinic itself, so that time is not wasted in transporting the sperm after the wash.

Laboratory Techniques:
There are different methods of processing the sperm, and all of these require special laboratory expertise.

1. The simplest method is that of washing the semen with a culture medium (by centrifuging it and collecting the pellet) but this is a poor technique and is not recommended.
2. The swim-up method uses a layering technique, in which a special culture medium is placed above the semen in a test-tube. The good quality sperm will swim up into the culture medium; and after 45 to 60 minutes, this medium ( with the motile sperms) is removed and injected into the uterine cavity.
3. The more sophisticated methods today use a density gradient column. This method allows one to separate the good quality sperm from the immotile sperm, the pus cells and the seminal plasma, because these are lighter than the motile sperms. It provides the best recovery of motile sperms and is the standard technique in use today, especially for poor quality sperm samples.

What recent advances have occurred in IUI treatment ?

Recent advances
Of late, doctors have tried adding various chemicals to the washed sperm to try to improve their motility, so as to increase the chances of their reaching their goal. These chemicals include caffeine and pentoxyfylline and they may be helpful in some patients.

During IUI, sperms are injected into the uterine cavity in the hope that they will then swim up from here into the fallopian tubes where they can fertilize the egg. But then, why not inject the sperms direct into the fallopian tubes where the eggs is present? This feat was technically difficult to accomplish in the past, because the tubes are so thin. Today, with specially designed catheters ( Jansen-Anderson catheter sets), it is possible to do this in the doctor's clinic. Thus, the processed sperm can be injected directly into the tubes under ultrasound guidance, without anesthesia or surgery! This is an intratubal insemination - also known as a SIFT - (sperm intrafallopian transfer). However, pregnancy rates are no better with this method than with IUI,  which is why it is rarely performed today.

Psychological Issues
Men may feel a loss of self-esteem because they feel that they need a doctor's help to do what a "normal man" should have been able to do by himself. They also feel guilty about having to subject their wife to the pain and intrusion of insemination. Women may feel anger towards their husbands for having the fertility problem. The insemination may also make patients feel that someone has "intruded" into their sex life and this may affect their intimacy.

What is the success rate of IUI treatment?

Success Rates of IUI
The success rate of IUI depends upon several factors. First of all the cause of the infertility problem is important. For example, men with normal sperm counts who are unable to have intercourse have a much higher chance of success than patients who are undergoing IUI for poor sperm counts. In addition, female factors play an important role. If the female is more than 35, the chance of a successful pregnancy is significantly decreased. Generally, the chance of conceiving in one cycle is about 10-15%; and the cumulative conception rate is about 50% over 4 treatment cycles. (Remember, Nature's efficiency for producing a baby in one month is about 15 to 25 %). However, if IUI is going to work for a couple, it usually does so within 4 treatment cycles. If a pregnancy has not resulted by this time, the chances of IUI working for you are very remote. You have reached the point of diminishing returns, and should stop persisting with IUI and explore the option of IVF .

What are the risks of IUI treatment ?

Risks of IUI
The major risk of IUI today is that of multiple pregnancy. Since the patient is being superovulated, more than one egg may get fertilized, resulting in twins or even triplets or quadruplets. Because the doctor cannot precisely control how many follicles will grow or rupture, the risk of a multiple pregnancy is actually even more after IUI rather than IVF . In fact, most of the infamous cases of high-order multiple births ( such as sextuplets and octuplets) have occurred after IUI. If you grow too many follicles, you may choose to cancel the cycle. Some clinics can also offer you the option of saving the cycle by converting it to IVF. This can be a cost-effective option, since it allows you to make good use of the eggs you have grown.

In poorly equipped clinics, there is also a risk of developing an infection after the IUI, if appropriate sterile precautions are not taken. This can tragically actually cause infertility !

While many gynecologists today offer IUI treatment, many of them are not specialized enough to provide a comprehensive service. This often means that patients need to run around from the gynecologist to the ultrasound scan center to the lab . Not only is this very time consuming and frustrating, it often means that the care becomes fragmented because of poor coordination. Try to find a clinic which offers all the services under one roof.

The other major risk of IUI is that many gynecologists repeat it again and again, because they do not have anything better to offer. Rather than referring the patient for IVF, they keep on subjecting the patient to repeated cycles of IUI ( sometimes as many as 12 cycles !). Patients ultimately get fed up and frustrated, and lose confidence in doctors and themselves, as a result of which they deprive themselves of IVF technology.  Often, patients will change doctors, but the new gynecologist will repeat the same IUI treatment, even though the patient has already done many IUI cycles in another clinic.

The other common  problem is that many gynecologists persist in doing IUI when the man has a low sperm count ( oligospermia). Their rationale is that we will concentrate the good sperm and inject them in the uterus. This is doomed to fail. Unfortunately, IUI is not a good treatment for oligospermia , because the problem is not just a low sperm count, but functionally incompetent sperm ! ICSI is a much better option for these couples !

How much does IUI treatment cost ?

The Cost Factor
The cost of performing IUI varies from clinic to clinic, but is about Rs 3000 to Rs 8000 for the entire treatment cycle. Of course, if gonadotropin injections are used for superovulation, the treatment then becomes much more expensive - and can be as much as Rs 20000 for one month's treatment.

IUI is a simple, inexpensive, effective form of therapy, and can usually be tried first, before going on to more expensive and invasive options. However, it can be very stressful and close cooperation between the husband and wife (and the doctor) is essential!

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