Artificial Insemination is a technique where fertility is facilitated by inserting several sperms directly into the female genital tract. Depending upon the quality and the sperm count, insemination is can be performed by two methods:
Artificial Insemination For Husband(AIH): The male collects the semen by masturbation and then this is artificially placed in the vagina, on the mouth of the womb (cervix), with the aid of a syringe.
Intrauterine Insemination(IUI): The semen is collected by masturbation, which is processed in the laboratory. The seminal plasma is discarded and the best quality sperms are harvested and kept in special culture media. The ratio of half to one ml of sperms are then artificially deposited into the uterine cavity with the aid of a thin catheter IUI.
Men who are unable to ejaculate in the vagina. This is the classical indication. Causes for ejaculation failure include:
- Multiple sclerosis
- Spinal cord injury
- Retograde ejaculation
Where sperms are released backward into the bladder instead of urethra. Retrograde ejaculation may be due to diabetes, trauma or operation in neck of the bladder or a side effect due to some drugs.
Men with mildly low sperm count, poor quality sperm or antisperm antibodies.
Men who wish to freeze their sperm for possible future use before vasectomy, chemotherapy or radiotherapy for cancer.
- Women with mild endometriosis
- Women with cervical mucus hostility or poor cervical mucus
- Couples with unexplained infertility
Indications For IUI Using Donors Sperm
Sometimes males do not respond to the the actual cycle of IUI. Even other ART methods might fail. In such cases fertilization can be achieved by performing IUI with donor sperms. This treatment can also be beneficial under conditions of:
- Males with azoospermia and who cannot afford advanced treatments such as ICSI.
- Males with genetic disorders, which can be prevented from being transmitted to the child by using donor sperms.
What are the minimum requirements for undergoing an IUI?
Ideally a patient should :
- be less than 40-41 years of age
- have atleast one potent (open) fallopian tube
- have a minimum sperm count of at least 10 million or a count following washing of semen of at least 3-5 million motile per ml.
The potency of the fallopian tubes can be ascertained by either a Laparoscopy or an Hysterosalpingography.
At Babies And Us, we treat patients with extremely low sperm counts. In such cases we advocate 3 to 6 IUI cycle attempts with simultaneous treatment for increasing counts by a male specialist. The success of IUI in patients with very low sperm counts is low. Consequently, those who fail to become pregnant, are advised to opt for ICSI or Donor Insemination.
Procedure of IUI
Ovulation stimulation and monitoring. The IUI can be done in a natural cycle or stimulated cycle.
The growth of a single egg in the growing follicle is monitored through vaginal sonography. Once the single follicle has reached an average diameter of 1.8 to 2 cm, an HCG injection is given to bring about ovulation(release of egg from the follicle) and IUI is done after 36 to 40 hours.
Multiple egg formation is achieved through drugs such as Clomiphene Citrate, Gonadotrophins(FSH or HMG) alone or in combination with clomiphene or GnRh analogues. A key requirement for most ART treatments is the stimulation of multiple follicles for the production of more than one mature egg, as this is generally associated with improved chances of conception. The growth of the eggs is monitored through vaginal sonography that shows follicle size and number.
Occasionally a blood level of serum Estadiol hormone (E2 Level) may be done. Once two leading follicles have reached a size of 1.8- 2 cm, HCG injection is given to bring about ovulation and IUI is done after 36-48 hours.
Normally the unit does four IUI cycles using Clomiphene. If this fails to achieve pregnancy, they use a combination of Clomiphene with Gonadotrophins (FSH), and try out 3-4 cycles. If this fails to achieve pregnancy, we try out 3 cycles with pure Gonadotrophin drugs, with or without GnRH analogue. In case this also fails, we go for either IVF or ICSI treatment.
Timing of IUI
The patient is called for IUI 36 -40 hours after HCG injection (at the time of ovulation). The incidence of ovulation is confirmed through a sonography, prior to the insemination or at times two inseminations are performed- one after 24 hours and the other, 48 hours after HCG. Only a single insemination is done within 36-40 hours and we do not perform an ultrasound to confirm ovulation. Our protocol is less cumbersome and yields the same success.
The husband is given a sterile container, specially imported from Britain. He is asked to produce sample by masturbation in a semen collection room. Alternatively, he can also produce the sample at home, provided he can come to the clinic within a period of 30-45 minutes. In case of difficulty, various options may be tried out, as elaborated in the section on IVF. It is important not to use any lubricant, including soap for semen production.
The semen is processed in the laboratory, using specially imported culture media. The semen can be processed and washed either by the standard swim-up method or the density gradient method using pure sperm. To maintain the potency of the sperms the laboratory uses specially imported media - plasticware and disposables, thus avoiding toxicity to the sperms. We do not recycle anything in the lab, thus avoiding infection and maintaining high pregnancy rates. Using imported carbon dioxide incubators the best quality sperms are harvested. These are floated in half to one ml of media, which is then used for insemination.
IUI is a short procedure, lasting about 2 hours, from the time semen is produced till the time the patient is released from the hospital.
It involves placing the sperms directly into the uterus thereby bypassing the cervix. The rationale for doing this is reduce the effects of vaginal acidity and cervical mucous hostility and to take advantage of the available, large number of good and highly motile sperms.
The patient is placed on the table, the vaginal speculum is inserted and the cervix (the mouth of the uterus) is exposed.
The cervix is cleaned with saline. No antiseptics are used, as they can kill the sperms. (It is important to note that the jelly used for vaginal sonography is also toxic to the sperm. Hence it should not be used on the day of the insemination, if a vaginal sonography has been planned.)
The sperm suspension is then taken in a syringe.
A special IUI Cannula, imported from Holland, is attached to the syringe. The Cannula is passed into the womb, and the sperm suspension is gently deposited in the uterine cavity. The use of washed semen has been known to have significant increase in pregnancy rates and side effects like uterine cramps and infection also do not occur.
The procedure is painless in most women, and takes about 5 minutes to perform. The woman is made to sleep on the table for 15 minutes after which she is sent home.
Do I need to take any drugs, following an IUI?
Yes. The patient is given a mild antibiotic such as Cephalosporin or Doxycyclin, for four days. This is combined with a vitamin. She is also given Luteal support either in the form oforal progesterone such as Duphaston or vaginal pessaries (tablets) like Microgest or Puregest for 14 days. After 14 days, she is asked to do a pregnancy blood test called B HCG. If pregnancy is confirmed, the Luteal support is continued for an additional duration of 2 months.
What are the success rates of IUI?
The success rates vary from 10-20 % per cycle depending on the cause of infertility. The best results are seen among patients with cervical factor and IUI using donor sperms. IUI success is usually low among patients with severely low semen counts- less than 10 million per mil. g
On the whole, if 10 patients undergo IUI every month, one or two will become pregnant every month. In about 6 months time out of the ten patients who started treatment, 4 to 6 patients will become pregnant. The rest would have to be treated with advanced procedures such as IVF or ICSI to achieve pregnancy.