Intrauterine insemination (IUI) is the most widely used, economical and successful assisted reproductive technique. It involves directly inserting washed sperm into a woman’s womb.
Who requires IUI?
IUI can be useful in helping couples to conceive where:
There is a problem with the man’s sperm, like decreased count and motility or he cannot produce sperm during sexual intercourse. It is also useful in cases of unexplained infertility and women with minimal to mild endometriosis, cervical factor infertility and rarely in anovulatory infertility.
When should IUI be done
To maximize the chances of success, a cycle of intrauterine insemination (IUI) should be performed when a woman is at her most fertile period. This is usually around ovulation; ovulation is when one or more eggs are released from your ovaries into the fallopian tube for fertilisation.
How IUI is performed
One cycle of IUI can be described in this way.
Ovulation induction: First part of the treatment is to give medicine to the female partner to induce egg production. Since this medication has to be started in the initial days of menstrual period, couple is advised to meet the doctor within the first 3-5 days of her period. Her ovarian response is then monitored with help of trans-vaginal scan (Follicular monitoring). When the follicle (fluid filled sac which contains the egg) reached adequate size another medicine is given to time the egg release (ovulation). IUI can then be performed.
Semen collection: Your partner will be asked to provide a sperm sample at the fertility clinic. To obtain the sperm sample, your partner will be asked to masturbate into a specimen cup. He may be asked not to have sexual intercourse, or masturbate for two days before the sample is taken because this could affect the sperm sample’s quality.
Semen preparation: After a sample has been provided, it will be ‘washed’, which involves it being filtered using special equipment that removes any dead sperm and impurities to produce a concentrated sample of healthy sperm. The semen preparation may take around 1 hr.
IUI Procedure: A special instrument called a speculum will be inserted into your vagina. The speculum will keep the walls of your vagina open.A thin, flexible tube (catheter) will be placed inside your vagina and guided into your womb. This process is mostly painless, although some women can experience some mild cramping, similar to period pains. The processed sperm sample is then passed through the catheter and into your womb.
The IUI process usually lasts for no more than 5 minutes, and after IUI you are advised to lie down for 15-20 mts. You should be able to go home shortly after the process is completed.
In some circumstances, the man may not be able to produce any healthy sperm. If this is the case, frozen sperm, obtained from a donor, can be used.
Some frequently asked questions:
What is the success rate of IUI.?
The success rate of IUI if properly done, in one menstrual cycle is around 20%. So usually we advise 4-6 cycles of IUI to get a reasonable pregnancy rate.
What are the precautions after IUI?
After IUI usually there is no strict regulation in your routine activities. You can have your routine exercise, eating pattern, sexual life. Avoid unnecessary anxiety as that may be deleterious to the final result..
What is the procedure cost?
The procedure cost varies from patient to patient. It depends on the type of drug used for egg development and the type of semen preparation used.
Risks of artificial insemination
There is an increased risk of experiencing multiple births if you receive intrauterine insemination (IUI) in combination with fertility medication.
Ovarian hyperstimulation syndrome
Ovarian hyper stimulation syndrome (OHSS) is an uncommon but potentially serious complication that can occur when fertility medications are used during a cycle of IUI treatment.
What next after IUI Failure?
Intrauterine insemination (IUI) has a success rate of around 15-20 % per cycle of treatment. As with most other types of fertility treatments, the younger you are, the greater the chance of a successful pregnancy.If you are unable to get pregnant within six cycles of treatment, then you should consider trying other form of fertility treatments such as in-vitro fertilization (IVF) or intra cytoplasmic sperm injection (ICSI).
If by chance you husband is not available at the time of IUI; an option of freezing the semen sample is available. So that he can give the sample well in advance and at the time of IUI this stored sample is thawed and used for IUI.
Treatments like chemotherapy, radiotherapy and some surgeries can cause male infertility .If you are due to have one of the above treatments, and are still interested in having a child, you have the option of freezing a sample of your sperm so that it can be used at a later date.
‘IVF involves several complex steps.
There are different protocols for IVF. Here we narrate the commonly practiced version. Each woman and each cycle is different; however,this is an example of an IVF cycle schedule:
1.Developing the eggs (Controlled ovarian hyperstimulation)
At the start of your treatment your doctor gives you drugs to block the hormones your pituitary gland usually produces during your monthly cycle.This allows them better control over when your eggs are produced. Your ovaries are then stimulated to produce more eggs than usual. You will take daily injections follicle stimulating hormone (FSH) for about 10 to 14 days. These hormone injections will stimulate your ovaries toproduce several follicles, each of which may contain an egg. One of our nurses will teach you how to give the injections to yourself.You may have your ultrasounds and blood tests done at marc in the morning hours daily.
2 Checking on development
During this phase vaginal ultrasound scans are carried out to monitor your developing eggs. The clinic will also do blood tests to chart the rising levels of estrogen produced by the eggs. Once the ultrasounds and blood tests show that you have a reasonable size and number of follicles, we will give you an injection of hCG (human Chorionic Gonadotropin) to trigger the final maturation of the
eggs. We will retrieve the eggs in the clinic 34 to 38 hours after your hCG injection. Timing is crucial, as you must have this injection 34-38 hours before your eggs are collected.
3 Collecting eggs
Eggs are collected by ultrasound guidance and takes around 30 minutes and you are either given
a drug to make you drowsy or a general anaesthetic. Using vaginal ultrasound to produce pictures on a screen, your doctor inserts a thin needle through your vagina into each ovary. They then guide the needle into each follicle in turn; the fluid is aspirated from each follicle and looked at under a microscope for eggs.
4 Collecting sperm
Around the time female partner’s eggs are collected, male partner produce a fresh sample of sperm. This will be washed and prepared, so that the healthiest and most active can be selected.
5 Fertilizing the eggs
Your eggs are mixed with your partner’s sperm and left in a laboratory dish for 16-20 hours before they are checked to see if any have fertilized. Any that haven’t, or any that have fertilized abnormally, are discarded. The remaining embryos are then left for another 24-48 hours before being checked again. We expect about 70% to 80% of the eggs to be fertilized. It is important to know that not every follicle will contain an egg, not every egg will be fertilized, and not every egg that is fertilized will go on to form a good-quality embryo
6 Preparing for pregnancy
After your eggs have been collected, you are given progesterone via pessaries, injection or gel to help prepare the lining of your womb.
7 Transferring the embryos
Two to five days after fertilization, two to three healthy embryos are usually chosen and put back into your womb through your cervix via a catheter (a fine, thin tube). This takes only a few minutes, and most women don’t find it uncomfortable.The decision about how many embryos are transferred is important because it affects not just your chance of conceiving but also your chance of having a multiple birth. Remaining embryos may be frozen for future IVF attempts, if they are suitable.
8. Luteal Phase and Pregnancy Test
Many women return to work after a few days if their jobs aren’t too strenuous. Sixteen days after retrieval you will have a blood test to find out if you are pregnant. If your test is positive we will schedule an ultrasound for you. Once the ultrasound confirms that you have a healthy pregnancy, your doctor will discuss plans for pregnancy care with you.
Intra cytoplasmic Sperm Injection (ICSI) is a specialized technique for fertilizing male and female gametes. It most often used for men who have poor sperm quality or low sperm counts. During an ICSI procedure a single sperm is injected into each mature egg. ICSI has revolutionized the treatment of male infertility. To date tens of thousands of children have been born around the world as the result of ICSI.
Optimizing your chances
Weight: It is important to be at a healthy weight for your height. Women with a body mass index under 19 or over 32 have a lower chance of getting pregnant
and an increased risk of miscarriage.
Stress: Women who are over stressed and anxious has a lower chance of becoming pregnant and a higher rate of miscarriage.
Supplements: We recommend that you take a multivitamin containing folic acid (0.4 to 1.0 mg daily). This B vitamin reduces the risk of some serious defects of the brain and spinal cord in the fetus. You should start taking it a few weeks before your treatment begins.
What are the risks?
Ovarian HyperstimulationSyndrome(OHSS) (1%)
The ovaries become enlarged and extra fluid accumulates in the abdomen. Treatment includes rest, close monitoring, intravenous fluids, and, in cases, draining the abdominal fluid.
Twins occur in 10% to 35% of IVF/ICSI cycles, while triplets occur in 1% to 5%. Multiple pregnancies carry a higher risk of preterm delivery and other associated problems. Your doctor will review your age and the optimal number of embryos to transfer with your before you start your IVF cycle
Many factors influence success rates. One of the most important factors is your age. Your doctor will discuss your individual circumstances with you before you start your treatment cycle.
Many women describe the experience of coping with infertility and IVF treatment as an “emotional rollercoaster”. You may feel periods of intense sadness, anger or isolation during this time. Because we understand how emotionally difficult this journey can be, we include of counseling support for the couple. We also strongly encourage partners to participate in the treatment process. One of the most important sources of support for couples struggling with fertility challenges is each other.
What is cryopreservation?
Cryopreservation is a procedure for freezing and storing embryos (fertilized eggs). During IVF, more embryos may be created than will be transferred immediately. You will have the option of freezing any extra good quality embryos. In the cryopreservation process, water in the embryos is replaced with a chemical solution (cryoprotectant) that acts like antifreeze. This solution prevents ice crystals from forming which would destroy the embryo. Embryos are placed in liquid nitrogen and stored at -196º C. They may be stored this way for prolonged periods of time. When embryos are thawed, the cryoprotectant is removed and replaced with water. About 50% to 65% of good quality embryos will survive the freeze/thaw process.
ICSI Versus IVF
Following pre-IVF treatment with ovulation-inducing drugs, the resulting eggs are removed from the woman's ovaries and prepared for laboratory fertilization. In a conventional IVF procedure, the male partner's sperm cells are then placed in a dish with the eggs, and left for a certain period of time in the hope that they will be able to penetrate and fertilize them. In ICSI, however, this is not left to chance. Instead, a single sperm is inserted into each of the selected eggs, giving each sperm cell a fighting chance of turning its egg into an embryo.
In ICSI, after the mature eggs are harvested, an egg is selected by the embryologist who captures the egg in a special pipette. (At this point, the male partner has already provided a semen sample.) Now the embryologist, using microscopes to view the whole procedure, picks up an individual sperm cell in a very thin, hollow needle, and uses the needle to push the sperm cell through the outer layers of the egg (the "zona") and into the inner area (the "cytoplasm"). The eggs and sperm are then left for 24 hours, by which time it is likely that fertilization will have taken place.
Similarly to the IVF procedure, a certain number of fertilized eggs (now embryos) are transferred back to the woman's uterus, in the hope that at least one will implant and grow into a healthy baby. The number of embryos permitted will depend on several factors, not least the female partner's age, health, and whether or not previous IVF or ICSI treatments have been successful.
Various studies have placed ICSI fertilization success rates at between 75 and 85%. This doesn't mean, however, that all these women become pregnant, although some studies have found that the ICSI pregnancy rate is higher than that of IVF. The pregnancy rate with ICSI is still under 40 %. One reason for this might be that ICSI is often used to counteract male infertility - therefore the women who receive the treatment may be younger and have healthier reproductive systems than the women generally receiving IVF.
Candidates For ICSI
Currently, ICSI is most often offered to couples in which the male partner has a low concentration of sperm cells in his semen, and/or sperm cells with poor motility (the ability to swim to meet an egg, and to penetrate it), or poor morphology (sperm cells which are abnormally shaped).
ICSI may also be offered to couples for whom IVF has failed in the past, or who have had low egg harvests as part of the IVF process.
Intracytoplasmic morphologically-selected sperm injection (IMSI) is an infertility treatment developed in 2004 by Benjamin Baartov of Bar Ilan University, Israel - and is believed by some experts to be the most effective treatment to date for male factor infertility. The technique involves selecting the best quality sperms from a sample provided by the male partner, and injecting them directly into the eggs retrieved from the female partner, thereby increasing the probability that these sperm cells will fertilize the eggs.
In IVF, eggs are harvested from the female partner and left in a dish with sperm cells from the male partner. These sperm cells need to be strong enough (have good enough morphological quality) to swim to the eggs, penetrate their outer layers and fertilize them.
IMSI and ICSI do not rely on the sperm cells' ability to do this - both techniques give the sperm cells a helping hand to reach the inner layer of the egg (the cytoplasm). Where IMSI differs from ICSI, however, is that during IMSI, the embryologist carrying out the procedure uses an extremely high-powered microscope to select the sperm cells with the best morphological quality to be injected into the eggs.
How Is It Done?
IMSI begins with standard IVF procedure. The female partner is given ovulation-inducing drugs, and the resulting mature eggs are then harvested from her ovaries and prepared for fertilization in the laboratory. The embryologist will then use the high-powered microscope to examine the male partner's semen sample. He then uses a long, thin, hollow needle to pick up the desired sperm cell. He holds the egg cell in a special pipette, and then uses the needle to push the sperm cell through the outer shell of the egg and into its inner area, where fertilization can take place. The eggs and sperm are then left for 24 hours, during with fertilization is likely to occur. If this is indeed what happens, the now fertilized eggs (embryos) are transferred back to the woman's uterus where hopefully at least one will implant, resulting in a pregnancy.
The harvesting of sperm by the use of surgical techniques is done for several reasons. Some of these include:
- If a man is unable to ejaculate successfully
- If there is an obstruction present in the tubes that carry the sperm outwards
- A case of a failed Vasectomy reversal
There are two techniques that exist for Surgical Sperm Retrieval – PESA and TeSA. These techniques
are routinely performed and allow the patient to return to work the following day.
Percutaneous Epididymal Sperm Aspiration (PESA)
If a blockage in the epididymis or congenital absence of the vas deferens (the drainage tube for sperm from the
testis to the penis), is the cause for Azoospermia (no sperm in the semen), then this procedure is indicated for obtaining sperm.
A very fine needle is inserted into the Epididymis (the sperm collecting tube outside the testis) and sperms are aspirated.
This procedure is performed under local anaesthesia, requires no incision, and the patient can get back to work the same day.
Testicular Sperm Aspiration (TeSA)
In some men, the production of sperms in the testis is very low and no sperms are seen in the semen.
TeSA is a way of obtaining the few sperms that are available in the testis. Using local anaesthesia, a needle is
inserted into the testis to obtain some tissue. This tissue is carefully dissected in the laboratory and the few
sperms obtained may be used for ICSI or frozen for later use.