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.
IUI is useful when:
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.
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.
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.
The man suffers from retrograde ejaculation in which
the semen goes backward into the bladder instead of
coming out of the penis.
For unexplained infertility, since the technique of
IUI increases the chances of the eggs and sperm meeting.
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.
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. 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).
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.
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!
Often the wife's fertility potential is also simultaneously
increased by drugs so that she produces more than one
egg per cycle (superovulation) to increase the chances
of conception.
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.
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.
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.
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.
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.
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).
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.
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 60% over 5-6 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 6 treatment cycles.
If a pregnancy has not resulted in this time, the chances
of IUI working for them are very remote, and they should
stop persisting with IUI and explore other possibilities.
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 !
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 10000 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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