Intrauterine Insemination
Intrauterine insemination, or IUI, is one of a number of treatment techniques that your GYFT physician may recommend depending
on your medical history. IUI involves depositing laboratory-prepared sperm into the uterus in order to increase the number
of sperm at the site of fertilization in the fallopian tubes. IUI may also be used in conjunction with one or more fertility
medications (see
Ovulation Induction) in order to enhance follicular development.
Albeit more sophisticated and definitely less romantic than timed intercourse at home, it is very commonly and effectively
used to create pregnancies in couples with unknown or minor infertility. This requires that the woman must be able to ovulate,
have normal tubes, have a normal uterine cavity, and the male must have reasonable sperm function. Wait, we can hear you already:
"So what kind of help is IUI, then? If I had all that going for me, I’d be pregnant on my own!" Touché. Still, there
are a couple of very common obstacles that can be overcome by doing IUI.
One of these is poor or failed post-coital
testing (see
Diagnosing Infertility, Cervical Factors).
In these couples, there is no clear-cut infertility problem except that the female partner’s
cervical mucus and the male partner’s sperm don’t seem to be compatible for one reason or another resulting in
the failure of motile sperm to pass through the cervix and into the uterus on their own. This is where IUI proves useful.
Sperm are loaded into a long, thin catheter and simply passed through the inhospitable cervical mucus and into the uterus
where the sperm are injected. Now there’s nothing but daylight (figure of speech - actually, it’s pretty dark
in there) between the sperm and the unsuspecting egg(s).
Another area of minor infertility which IUI can help remedy is in cases of low sperm count. Though the sperm must have
decent motility and function, the fact that a man has a low number of them can put him at a disadvantage when using intercourse
as the method of conception. Even if the cervical mucus is not a factor, a huge number of sperm (most, in fact) will never
complete the journey to the fallopian tubes because they run out of energy, take a wrong turn and refuse to ask for directions
(sperm do come from men, you know), and so on. So someone who has a low number of motile sperm is less likely to be
adequately represented when that egg makes its way down the tube. IUI allows the sperm to be prepared and concentrated in
the laboratory (see
Reproductive Assays Laboratory to read how the sperm preparation is performed) and then deposited in the uterus. As a result, you have many
more motile sperm in the uterus than there would be normally, all with a full tank of gas.
More sperm, with more energy
reserves, with less distance to travel – makes sense, doesn’t it? Incidently, the non-pregnant uterus (picture
it like a closed fist) can only hold a volume of 0.5 mL of fluid before the fluid re-fluxes back out. The average semen sample
is between 2.0 and 4.0 mL. The idea, then, is to put as much motile sperm in that 0.5 mL as possible. That end is not achieved
if you just take 0.5 mL of unwashed sperm since you’d be leaving much of the specimen behind. By preparing the specimen
in the lab, the majority of motile sperm are able to be concentrated into a 0.5 mL volume by separating them from the remaining
volumes of semen, cellular debris, immotile sperm, etc.
How The Technique Works
The use of fertility drugs in conjunction with IUI is quite common, even in couples without a diagnosed ovulatory disorder.
As discussed in Ovulation Induction, ovulation can be stimulated with a course of hormone treatment, either with clomiphene citrate or injectible
gonadotropins. Cycle monitoring can be performed by GYFT clinical staff using ultrasounds and serum estrogen levels. Monitoring
is particularly important due to the fact that several eggs can be produced in response to these medications and the chance
of pregnancy is increased due to the placement of the sperm in the uterus. Thus, if too many follicles develop, there can
be a risk of multiple pregnancy – which is something we try to avoid. Ideally, the aim is to generate between 3 to 5
eggs in an IUI cycle, which statistically gives the best chance at a single pregnancy. When 2 or 3 follicles have reached
their proper size, ovulation is induced (using HCG injection) or detected (using an ovulation predictor kit) and your infertility
specialist will schedule the time of the IUI (usually within the 24 to 36 hours following) and the time for the sperm specimen
to be brought to the lab. If the male partner will be providing the sperm, the specimen should be received in the lab approximately
2 hours before the scheduled IUI time so that the lab can adequately prepare the sperm for insemination. If a sperm donor
is to be used (these specimens are usually frozen), the lab is notified of the IUI time so the specimen can be ready when
the patient arrives. The IUI procedure itself is performed by one of our skilled fertility nurses by loading the washed sperm
specimen into a long, fine catheter and inserting it through the cervix and injecting the sperm high into the uterus of the
female partner. The procedure is quite painless and takes all of a minute or two. The nurse will have the patient lay down
for about 20 minutes to give the sperm a nice head start without having to fight the forces of gravity when standing, and
then she’s free to go. If desired, a follow-up appointment can be made for a day or two later in order to confirm ovulation
by ultrasound. A pregnancy test can be done two weeks later.
Sperm Donors
In cases of male infertility where the male partner’s sperm is severely abnormal, either because of a very low
count, total absence of sperm, or extremely poor movement (and ART is not an option), donor sperm is readily available from commercial sperm banks across the country. Frozen donor
specimens can be ordered and shipped to your fertility clinic overnight, and once thawed are every bit as effective in achieving
a pregnancy as a freshly collected specimen. Donors are anonymous and meticulously screened for fertility potential and absence
of inherited and sexually transmitted diseases. Sperm donors have traditionally been chosen by clients solely on their physical
characteristics, blood type, education, occupation, interests, etc., but still remain entirely anonymous. There are some commercial
banks that stretch the definition of "anonymous," however, and will let clients come just shy of meeting them through the
issuance of photos, taped interviews, and even video taped discussions. Check out some of the cryobank links at left to find
out more.
cryobank.html
Risks of IUI Treatment
Complications resulting from IUI are infrequent, but can include infection,
brief uterine cramping, or transmission of venereal disease if being inseminated with sperm from a person who has not been
appropriately screened (GYFT requires all couples to undergo STD screening prior to treatment, so this complication has been
effectively eliminated).
Ovarian Hyperstimulation Syndrome
Stimulating the ovaries with fertility medications comes with
its own set of complications. As mentioned above, multiple pregnancy is a risk when several follicles develop beyond a certain
size. If your infertility doctor finds the risk too great, he might discontinue treatment or recommend converting the cycle
to IVF. We try to avoid excessive multiples (three or more) at all cost as multiple pregnancies are associated with higher
rates of miscarriage and pre-term delivery. Ovarian Hyperstimulation Syndrome is a fairly uncommon condition which results
in pain in the abdomen caused by enlarged ovaries and a collection of fluid in the abdomen due to excessive stimulation from
fertility drugs. This condition does not usually require hospitalization and will resolve on its own once the medication is
stopped. If the pain becomes too uncomfortable for the patient, the abdominal fluid can be aspirated during a quick in-office
procedure.
Chance of Success
The success rates of superovulation and IUI are around 20% provided that the
male partner’s sperm count is within certain limits and the female’s tubes are healthy.
If we see success
with IUI, it usually occurs within one to five attempts. If not, there tends to be some underlying factor causing
the infertility and depending on the age of the female partner, the doctor may recommend a more aggressive treatment such
as IVF. IUI is currently a very popular and quite successful treatment for infertility. Although it is not as successful as
IVF on a per cycle basis, it is a less traumatic and less expensive method of treatment.
