IUI stands for “Intra Uterine Insemination”, a fairly new form of assisted fertilization. IUI involves the placing of freshly prepared sperm (from your partner or from a donor depending on the case) high in the uterine cavity at a selected time in your menstrual cycle. Conception is then allowed to occur naturally. These procedures are carried out on an outpatient basis and you need not be admitted to hospital.

Ideally, couples that have unexplained sub fertility and in woman where there is no evidence of damaged fallopian tubes. It may also help those who have minimal endometriosis or some male factor.

Intrauterine insemination is done very often in following conditions –

• Donor sperm IUI is recommended for poor or absent semen in the male partner, genetic diseases, or Blood group compatibilities.
• Frozen donor sperm samples are procured from certified ART banks, thawed and used for the IUI procedure.
• Unexplained infertility, Endometriosis or male factor related infertility.
  IUI can overcome some of these problems because preparing sperm for the procedure helps separate highly motile, normal sperm from those of lower quality.
• Cervical factor infertility

RAT IONALE OF IUI

There are three components of IUI which help in improving the results.

Semen preparation

• Selects most motile sperm fraction removing the debris and dead sperm.
• Removes prostaglandins present in high concentration in the seminal plasma and thus reduces the risk of uterine cramping.
• Removes infectious agents and leucocytes.
• Removes antigenic proteins in the seminal plasma and thus improve prospects of fertility.
• Helps in the capacitation of spermatozoa.
• Sperm washing media provide nutritional support for the spermatozoa and keep their activity for longer time.

Intrauterine

• All mucous barrier which may be hostile to the sperm.
• Increasing the density of sperm in the upper genital tract.

Overcomes Insemination

• By-passing the cervic anatomical cervical problems like stenotic cervix, deviated or kinked cervix.
• Accurate timing with ovulation.
• Overcomes coital difficulties.

Controlled Ovarian Stimulation

• Multiple ovulation exposes spermatozoa to multiple oocytes for potential fertilization.
• Controlled ovulation induction corrects subtle ovulation defects.

How do we do SEMEN COLLECTION?

Following precautions should be taken for sperm collection:

• To abstain from intercourse for approximately 48-72 hrs is desirable.
• To abstain from alcohol.
• Should never be collected at home.
• To collect the specimen in the container provided by the ART laboratory.
• The container needs to be disposable, wide mouth & Gamma Sterilized.
• Sample should be collected by masturbation, with proper hygienic and sterile techniques. Coitus interruptus should be avoided. Use of all types of condoms, lubricants, jellies etc. should be avoided.
• Specimen should be labeled carefully with patient’s name, registration number, date and time of collection.
• Exposure to extreme heat and cold should be avoided.
• To keep the lid securely tight to avoid any spillage during transport.
• In case of collection problems, reassurance, sildenafil and tranquilizers can help. A back up cryo frozen sample also reassures the couple.
• Long abstinence (more than 3-4 days), alcohol / drug intake and illness should be recorded.
• Small volume ejaculates, sample with anti sperm antibodies and viscous samples should be collected in the container to which 3-4 ml of pre warmed semen wash medium has been added.

The patient is made to lie down in Lithotomy position in a comfortable room on a standard gynae examination table with a U cut after evacuating the bladder. The patient is asked to read the identifying data on the test tube containing the sample. Specimen is aspirated in the IUI Cannula and 1 ml syringe without disturbing the pellet.

• Cervix is exposed with a bivalved Cusco’s speculum.
• Cervix is gently wiped and negotiated very gently
• No antiseptic solution should be used.
• Approximately 0.5 to 0.6ml of sperm preparation is injected very slowly (over 3-5 minutes) to avoid any regurgitation.
• The tip of the catheter should be 0.5cm below the fundus.
• Patient is advised to rest for 30 minutes. After this patient can go home.
• There should be minimal pain or discomfort with the procedure.
• It needs time, patience and gentleness to negotiate many difficult cervixes.
• You may also need to individualize Cannula according to the patient.
• There is no need to prescribe analgesics or antibiotics routinely.
• Any trauma, bleeding or regurgitation is likely to lead to a failure.

The semen sample is collected by ejaculation into a sterile wide mouth container collection jar meant for use in ART procedures only.An appropriate semen collection room should be used for this.

Semen should be collected,analyzed and prepared within 60 min of ejaculation.

We perform the IUI as soon as possible after washing is completed for optimal results.

Ideally an IUI should be performed approximately 36 hours after the ovulation trigger or after confirming the ovulation on ultrasound.

If two IUIs are scheduled, they are usually spaced at least 12 hours apart between 24 and 48 hours after the hCG.

Some units plan the timing of IUI on a natural LH surge. In that case, a single IUI at 36 hours is the norm.

We have to remember that the egg is viable only for a maximum of 24 hours after it is released.

Natural cycle IUI, in which no fertility drugs are used, tend to have lower success rates amounting to about 6-8 % in some cases. Overall a success rate of 12% to 18 % is expected with an IUI procedure.

TROUBLESHOOTING in IUI

• How many cycles should be done?
  Maximum results are achieved in the first 3 months. Some results come in the next 3 months. After 6 months an occasional patient may conceive.
• When to start an ultrasound?
  Day 9 of the cycle.
• What to do with thick semen?
  Ideally, we need to collect the semen sample in 5ml of Wash Media & start processing immediately, but in extreme circumstances, you can consider breaking up the strands bypassing the semen through progressively thinner needles or even increasing the centrifugation speed, while processing.
• How to improve motility?
  Pentoxyphylline or caffeine added into the sample may help.
• What to do with poor endometrium?
  Generally little can be done to help. In case it is because of Clomiphene effect, a change to gonadotrophin cycle may help.
• How many IUI’s to be performed per cycle?
  The issue of one v/s two IUI’s is still being debated. With two IUI’s there is a slight increase in success rates.

What are the POST INSEMINATION FOLLOW Ups for IUI

• Luteal support in the form of progesterone pessaries or HCG may be given depending upon the stimulation protocol.
• There is no need for prolonged rest for more than 30 min, restriction of activity, dietary modification.
• Intercourse is also not prohibited.
• Pregnancy test is advised after 15 days of last IUI.
• A tentative plan for next cycle should be made on the last day depending upon the result of ovulation study and IUI.

Maximum women perceive IUI to be fairly painless procedure baring slight pain as felt during an IUI procedure.

Sperm washing must be done before IUI is performed. The process can take 20 min- 40 minutes with different sperm wash techniques. Insemination should occur shortly after the sperm has been prepared.

Any Side Effects Of IUI

• Cramping: Uterine cramping is the most common side effect observed which may be there in up to 5 % of cases. Inadequate removal of seminal plasma, infection in semen culture medium or genital tract or difficult insemination may be the cause. Any NSAID along with an antispasmodic medicine may be given for symptomatic relief.
• Infection: Semen preparation under unhygienic conditions, infection in the semen or genital tract may predispose to acute infection in the female partner. IUI should be avoided in the presence of infection. Intracervical or intravaginal insemination may be done in such cases.
• Multiple Pregnancies; may occur as a result of over zealous ovarian stimulation.

Psychological Complications: IUI may result in psychological complications such as sexual dysfunction, fear of congenital malformations, mix-up of samples etc. Careful counseling and precautions can avoid these problems.