Intrauterine
Insemination (IUI)
from the book How to Have
a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD
and Dr. Anjali Malpani, MD.
table of contents ·
previous page · next page
Sometimes
nature needs help to start a pregnancy - and the doctor can do this
by giving the sperm a piggy back ride through a fine tube into the
body. This procedure is called intrauterine insemination ( IUI) or
artificial insemination with husband’s sperm (AIH) - and effectively,
the doctor is giving nature a helping hand by increasing the chances
of the egg and sperm meeting.
IUI is
useful when:
- The
woman has a cervical mucus problem - for example, it maybe scanty
or maybe hostile to the sperm. With an intrauterine insemination
(IUI) the sperm bypass her cervix and enter the uterine cavity directly.
- The
man has antibodies to his own sperm. The " good" sperm which have
not been affected by the antibodies are separated in the laboratory
and used for IUI.
- If
the man cannot ejaculate into his partner's vagina. This is usually
because of psychologic problems such as impotence (inability to
get and maintain an erection) and vaginismus ( an involuntary spasm
of the vaginal muscles so that vaginal penetration is not possible);
or anatomic problems of the penis, such as uncorrected hypospadias;
or if he is paraplegic.
- The
man suffers from retrograde ejaculation in which the semen goes
backward into the bladder instead of coming out of the penis.
- For
unexplained infertility, since the technique of IUI increases the
chances of the eggs and sperm meeting.
- As
an inexpensive alternative to GIFT, IUI is a reasonable first choice
( especially for younger couples) since it is so much cheaper and
less intrusive.
- If
the husband is away from the wife for long stretches of time (for
example, husbands who work on ships or work abroad), his sperm can
be frozen and stored in a sperm bank and used to inseminate his
wife even in his absence.
- For
male factor infertility, though this is a controversial area - especially
for the common problem of oligospermia (a low sperm count ). What
is the rationale behind using IUI for treating this problem? Remember
that infertility is a problem of the couple's - not just the oligospermic
male's. Whether a given couple will conceive or not depends on the
sum of their fertility potentials. Therefore, the fertility potential
of the wife is improved by superovulating her, so that instead of
producing 1 egg per cycle, she produces 2-4 eggs per cycle. In addition,
the husband's sperms are processed in the laboratory, and the best
sperm are used for IUI. This increases the chances of the best sperms
being able to reach and fertilize the egg.
Methods
for performing AIH
There
are various methods of doing AIH (artificial insemination by husband).
The crudest and simplest technique involves simply injecting the entire
semen sample into the vagina by a syringe. However, this is a waste
of time if used for treating an infertility problem - after all, why
go to a doctor to do something which you can do for yourself at home?
Remember, a syringe is no better than a penis. It is only useful if
the reason for doing AIH is the inability of the husband to ejaculate
in the vagina. However, a number of doctors still use it as they do
not offer anything better.
A refinement
of this technique is that of using a spilt ejaculate. The first squirt
of semen which gushes forth during ejaculation is richest in sperm.
This is because the sperm "surf" on the wave of the seminal fluid
which carries them forward to the outside world. The man masturbates
into a 2-part container, so that this first part goes into one container,
while the rest goes into another. This is not as difficult as it sounds,
and gets easier with practice! The first bottle is saved and the contents
used for artificial insemination. This method is suitable for a small
proportion of cases (for example, for the uncommon problem of a large
volume of semen, which "dilutes " the sperm; or where laboratory facilities
for sperm processing are not available).
Intrauterine
insemination (IUI)
In this
method, the sperms are removed from the seminal fluid by processing
the semen in the laboratory and they are then injected directly into
the uterine cavity. It is not advisable to inject the semen direct
into the uterus, as the semen contains chemicals (prostaglandins)
and pus cells which can cause severe cramping; and even tubal infection.
Timing
Timing
the IUI is very important - it must be done during the "fertile period"
when the egg is in the fallopian tube. Pinpointing the time of ovulation
accurately using either vaginal ultrasound or ovulation test kits
is crucial. A good clinic should provide this as a 7-day week service,
since there is a 1 in 7 chance that ovulation will occur on a Sunday
- eggs don't take a holiday! Often the wife's fertility potential
is also simultaneously increased by drugs so that she produces more
than one egg per cycle (superovulation) to increase the chances of
conception.
The IUI
is done either when ovulation is imminent or just after. The husband
masturbates into a clean jar - preferably in the laboratory or clinic
itself, and after at least three days of sexual abstinence to get
optimal sperm counts. Some men may have considerable difficulty producing
a semen sample at the appropriate time, because of the tremendous
stress they are under, and the " pressure to perform". For these men,
using a previously stored frozen sample can be helpful. Viagra ( sildenafil
citrate) can also be used to help them to get an erection, as can
using a vibrator. The best sperm are separated from the rest of the
seminal fluid, by special laboratory processing techniques. This separation
takes about 1 to 2 hours. The actual insemination procedure is simple
and takes only a few minutes to perform. It is not painful, though
it can be uncomfortable. The wife lies on an examining table, and
a speculum is placed in the vagina. The doctor puts the sperm through
a thin plastic tube (catheter) through the cervix into the uterus.
There may be a bit of uterine cramping at this time; and some discomfort
for about 12 to 24 hours. Some patients may experience a little vaginal
discharge after the procedure, and they are worried that all the sperm
are leaking out of the uterus. However, this discharge is just the
cervical mucus – the sperms cannot "fall out" of the uterine cavity.
No special bed rest is required after the IUI. Some doctors may repeat
the insemination after 24 hours. We usually encourage our patients
to have intercourse on the night of the IUI, and for 2-3 days after
this as well, to maximize the chances of the sperm and egg meeting.
Sperm
processing:
Sperm
processing allows the doctor to concentrate the actively motile sperms
into a small volume of culture fluid. Sperm do not remain alive in
the culture medium for very long unless maintained at the right conditions
- hence a prompt insemination after sperm processing is important.
This is why processing should preferably be done in the clinic itself,
so that time is not wasted in transporting the sperm after the wash.
Laboratory
Techniques:
There
are different methods of processing the sperm, and all of these require
special laboratory expertise.
- The
simplest method is that of washing the semen with a culture medium
(by centrifuging it and collecting the pellet) but this is a poor
technique and is not recommended.
- The
swim-up method uses a layering technique, in which a special culture
medium is placed above the semen in a test-tube. The good quality
sperm will swim up into the culture medium; and after 45 to 60 minutes,
this medium ( with the motile sperms) is removed and injected into
the uterine cavity.
- The
more sophisticated methods today use a density gradient column.
This method allows one to separate the good quality sperm from the
immotile sperm, the pus cells and the seminal plasma, because these
are lighter than the motile sperms. It provides the best recovery
of motile sperms and is the standard technique in use today, especially
for poor quality sperm samples.
Recent
advances
Of late,
doctors have tried adding various chemicals to the washed sperm to
try to improve their motility, so as to increase the chances of their
reaching their goal. These chemicals include caffeine and pentoxyfylline
and they may be helpful in some patients.
During
IUI, sperms are injected into the uterine cavity in the hope that
they will then swim up from here into the fallopian tubes where they
can fertilize the egg. But then, why not inject the sperms direct
into the fallopian tubes where the eggs is present? This feat was
technically difficult to accomplish in the past, because the tubes
are so thin. Today, with specially designed catheters ( Jansen-Anderson
catheter sets), it is possible to do this in the doctor's clinic.
Thus, the processed sperm can be injected directly into the tubes
under ultrasound guidance, without anesthesia or surgery! This is
an intratubal insemination - also known as a SIFT - (sperm intrafallopian
transfer).
Psychological
Issues
Men may
feel a loss of self-esteem because they feel that they need a doctor's
help to do what a "normal man" should have been able to do by himself.
They also feel guilty about having to subject their wife to the pain
and intrusion of insemination. Women may feel anger towards their
husbands for having the fertility problem. The insemination may also
make patients feel that someone has "intruded" into their sex life
and this may affect their intimacy.
Success
Rates of IUI
The success
rate of IUI depends upon several factors. First of all the cause of
the infertility problem is important. For example, men with normal
sperm counts who are unable to have intercourse have a much higher
chance of success than patients who are undergoing IUI for poor sperm
counts. In addition, female factors play an important role. If the
female is more than 35, the chance of a successful pregnancy is significantly
decreased. Generally, the chance of conceiving in one cycle is about
10-15%; and the cumulative conception rate is about 60% over 5-6 treatment
cycles. (Remember, Nature's efficiency for producing a baby in one
month is about 15 to 25 %). However, if IUI is going to work for a
couple, it usually does so within 6 treatment cycles. If a pregnancy
has not resulted in this time, the chances of IUI working for them
are very remote, and they should stop persisting with IUI and explore
other possibilities.
Risks
of IUI
The major
risk of IUI today is that of multiple pregnancy. Since the patient
is being superovulated, more than one egg may get fertilized, resulting
in twins or even triplets or quadruplets. Because the doctor cannot
precisely control how many follicles will grow or rupture, the risk
of a multiple pregnancy is actually even more after IUI rather than
IVF . In fact, most of the infamous cases of high-order multiple births
( such as sextuplets and octuplets) have occurred after IUI. If you
grow too many follicles, you may choose to cancel the cycle. Some
clinics can also offer you the option of saving the cycle by converting
it to IVF. This can be a cost-effective option, since it allows you
to make good use of the eggs you have grown.
In poorly
equipped clinics, there is also a risk of developing an infection
after the IUI, if appropriate sterile precautions are not taken. This
can tragically actually cause infertility !
While
many gynecologists today offer IUI treatment, many of them are not
specialized enough to provide a comprehensive service. This often
means that patients need to run around from the gynecologist to the
ultrasound scan center to the lab . Not only is this very time consuming
and frustrating, it often means that the care becomes fragmented because
of poor coordination. Try to find a clinic which offers all the services
under one roof.
The
Cost Factor
The cost
of performing IUI varies from clinic to clinic, but is about Rs 3000
to Rs 8000 for the entire treatment cycle. Of course, if gonadotropin
injections are used for superovulation, the treatment then becomes
much more expensive - and can be as much as Rs 10000 for one month's
treatment.
IUI is
a simple, inexpensive, effective form of therapy, and can usually
be tried first, before going on to more expensive and invasive options.
However, it can be very stressful and close cooperation between the
husband and wife (and the doctor) is essential!
previous
page · next
page
|
