What Is IUI ?
Intrauterine insemination (IUI) with either husband or donor sperm is a procedure done in the clinic. IUI is basically artificial insemination procedure in which washed sperm directly into the uterine cavity.
In IUI cycle we try to create the best possible chances of conception and implantation. By giving stimulation medicines we ensure good number of follicles are recruited for development and that best possible follicular growth occurs. Estrogen released by growing follicles plays a direct role in thickening of the endometrial lining which is essential for implantation. If good number of follicles are recruited, the endometrium will also achieve the desired thickness (> 7mm). The semen sample is washed to remove any bad sperms and the best sperms are separatedand inserted into the uterus at the best possible time (on the day of ovulation).
How Is The Timing Of IUI Determined ?
In a natural cycle, ovulation occurs between days 14-16 of menstrual cycle. The timing of an IUI can be adjusted to desired time by giving a “trigger” that induces ovulation within 24-36 hours.
The follicular growth can be tracked by Follicular monitoring through repeated Ultrasound Scans between D9 to D13. Once the follicles grow to the desired size (> 14 mm) “Trigger” is induced by administering HCG injection. Ovulation occurs within 36 hours of Trigger, and the IUI is scheduled likewise.
Another way to determine the time is by looking for LH surge which happens 48 hours before ovulation. This can be detected by doing a urine test using an ovulation predictor kit. If LH surge is detected, the Trigger can be induced.
When Is IUI Recommended ?
- Sexual disorders like impotence, premature ejaculation erectile disorder, vaginismus, neurological disorders etc.
- In case of cervical factors like stenosis, infections, highly acidic cervical mucous or in case of anti sperm antibody present in cervical mucous IUI helps a lot as in case of IUI we bypasses the cervix & put the washed motile sperms directly into the uterus.
- In case of ovulatory dIsorders where we can correct it by stimulations.
- Grade 1 endometriosis provided the tubes are patent.
- AGE is a factor as fertility decreases by age which can be improved by stimulating injections.
- Male subfertility where the sperm count & motility is low IUI is indicated as we can put the washed motile sperms directly into the uterus near to the oocyte.
What Happens In An IUI Cycle ?
An IUI cycle can be broadly broken down into the following stages:
1. Ovarian Stimulation
2. Ovulation cycle Monitoring
Typically an IUI cycle last 15 days that is from the Day 2 to Day 15.
D2-D6: Stimulation medicines are started from D2. Based on the protocol and cost that the patient can afford, the protocol may be based only on medicines or a combination of medicines + stimulation injections or based only on Stimulation drugs. Based on the protocol the medicines have to be continued form D2 till the date advised by the fertility specialist.
D9-D12: Follicular scans are started form D9 and done on alternate days or on intervals decided by the doctor till D12 OR D13.
D12: Once the follicles achieve the desired size, Trigger is induced by giving HCG injection. In 90% of cases Trigger happens on D12. Ovulation occurs within 36 hours of Trigger.
D13-14: Another scan is done to check if the ovulation has occurred. If yes IUI is done on the same day. Else the IUI is scheduled on day 14.
What happens on the day of IUI ?
STEP 1: Husband’s Semen Sample Collection
- Inform the receptionist of your arrival.
- Follicular scan is done to check ovulation has occurred. If ovulation has occurred, Semen collection will be done.
- Your appointment for Husband’s semen collection will be 60-90 minutes before the insemination.
- The lab will provide instructions, the collection container, and a private area for collection.
- The sample should be collected by masturbation, without using a lubricant.
- Collect the entire ejaculate into the sterile container. The greatest numbers of sperm cells are found in the first part of the ejaculate, and extreme care should be taken not to lose this portion.
- You will be asked whether any part of the specimen was lost or spilled during collection.
STEP 2: Sperm Washing
The semen sample is allowed to undergo liquefaction for 15-30 minutes. After this semen parameters are studied and recorded via microscopic examination. The next step is sperm washing.
What does “sperm washing” mean?
It is a laboratory technique for separating sperm from semen, and separating motile sperm from non-motile sperm, for use in assisted reproduction (IUI or IVF). It is sometimes also called sperm preparation or spinning.
There are various wash techniques used to try and separate the ‘good’ from the ‘bad’ sperms as well as improve the quality of the ‘not so good’ sperms. We follow the “double wash” or the density gradient separation technique which is gives the best results. This works especially well with semen samples with poor semen parameter’s like presence of poor sperm quality and/or low sperm count. Another advantage of this technique is that the toxicity effect of the gradient media is rules out by 2nd Wash.
What happens in Double wash technique of sperm washing?
Why is Sperm Washing done?
Sperm are washed free of seminal fluid before IUI is carried out. Sperm washing is done to prevent contact with parts of the seminal fluid that do not normally reach the uterine cavity during sexual intercourse. Sperm washing also is used to remove infectious agents and to reduce the volume of the specimen so it can be placed directly into the uterine cavity
The semen sample obtained after washing is called prepared semen sample.
STEP 3: IUI Procedure
A predetermined aliquot, (approximately .5 ml) of prepared semen sample is taken for IUI procedure.
An IUI – intrauterine insemination – is performed by inserting a very thin flexible catheter through the cervix (mouth of the uterus) and injecting washed sperm directly into the uterus. The whole process does not take very long – it usually only requires the insertion of a speculum and then the catheter, a process that may take a couple of minutes. Sometimes when the cervix is hard to reach a tentaculum is used to hold the cervix, which makes the procedure easier.
Depending on the requirement a repeat IUI may be done after 24 hours.
Where Is The Sperm Collected? How Long Before The IUI?
Usually the sample is collected through ejaculation by masturbation into a sterile semen collection container in a private room at the clinic. From the time the sample is received, it takes about 1 hour 30 minutes to make the sample ready for insemination. The amount of time may vary depending on the sperm quality, as special techniques may be required.
When Is The Best Timing For An IUI?
Ideally, an IUI should be performed within 6 hours before or after ovulation. Timing is based on an HCG injection (given to release the egg) and the IUIs are usually done between 24 and 36 hours later. Typical timing would be to have a single IUI at about 36 hours post-hCG. If two IUIs are scheduled, they are usually spaced at least 12 hours apart between 24 and 48 hours after the HCG. Success rates are higher with two IUIs as compared to a single IUI. The egg is only viable for a maximum of 24 hours after it is released.
What Does An IUI Feel Like?
Most women consider IUI to be fairly painless – along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is the pain of the egg being released (ovulation) rather than from the IUI. The catheter usually does not cause pain as it is very thin and flexible and the cervix is already slightly open for ovulation.
How Long Does Washed Sperm Live?
Current research indicates that washed sperm can live 24-72 hours; however, it does lose potency after 12-24 hours. Another issue with IUI is that the sperm can keep on swimming beyond the fallopian tube, so the ideal window is really within 6-12 hours of the egg being released; with a larger margin before ovulation than after since the egg’s viability is shorter. Sperm can live up to 5 days in fertile mucus, 2-3 days being common, so combining IUI with intercourse may provide better coverage.
Do I Have To Lie Down After An IUI?
We advise patients to lie down on the table for 30-45
minutes after the procedure.