Intrauterine Insemination (IUI)

Infertility is defined as the inability to conceive after having regular unprotected sexual intercourse for more than a year.

There can be both male and female causes of infertility. Normally, during intercourse, post ejaculation the sperm travels from the vagina through the cervix into the uterus and then reaches the fallopian tubes where the egg is usually present, waiting to get fertilised. The journey can be hindered either due to issues in the sperm (male factors) or a hostile environment (female factors). As a result, fertilisation may not occur despite repeated attempts, leading to infertility.

Intrauterine insemination is a method of Assisted Reproductive Technology (ART) used to treat infertility. It involves injecting sperm from the male partner/donor into the uterus, thereby increasing the chances of fertilisation of the egg. The technique reduces the time and distance for the sperm to fertilise the egg. It is a technique of in-vivo fertilisation (where fertilisation takes place within the uterus of the patient).

A single cycle of IUI has only a 20% chance of success but the overall success rate increases when considering multiple cycles.

Indications for intrauterine insemination are many. They may be divided into male and female factors:

Male factors:

• Low sperm count
• Low sperm quality and motility
• Any genetic defect in the male which is unfavourable for the child

Female factors:

• Unfavourable cervix: the cervical mucous is too thick, also known as unreceptive cervical mucous, cervical stenosis or any structural abnormalities in the cervix
• Unfavourable uterus: as in the case of endometriosis (when the severity of the disease is mild)
• If treatment alone with infertility medication is not successful
• Semen allergy

Other scenarios where IUI is an option:

• A female patient wishes to use donor sperm
• When same-sex couples (females) wish to conceive they can use a donour sperm
• In cases of unexplained infertility
• If sexual intercourse is too painful for conceiving

Intrauterine insemination is not advised in the following cases:

• Severe endometriosis
• Blocked fallopian tubes
• History of pelvic infections

Intrauterine insemination is performed by an infertility expert who is primarily an OBG doctor. The doctor takes a detailed history of the couple and asks relevant questions to try to narrow down the reason for infertility. A physical examination of both partners is done to rule out any anatomical defects.

Investigations include:

• Semen analysis in the case of the male partner
• Blood work of both partners which involves hormonal studies of both the partners
• Ultrasound/ CT/ MRI of the pelvis to visualise the uterus and ovaries. Future ultrasounds are done to see the progression of the developing egg in the ovaries and to monitor the correct time for ovulation (release of the egg into the fallopian tube)

Counselling is a very important part of the overall process. Infertility is a sensitive discussion to have and the expectations of becoming parents are high. Counselling helps in dealing with the stress associated with the procedure and is especially necessary if the ART procedure is not successful.

Once all the relevant reports clear the couple for IUI, the female partner can be started on fertility medications. The medications can be taken either orally or through injections. They are started from the first day of the menstrual period and continued till mid-cycle. These drugs promote the growth of the eggs in the ovary as well as make the uterus suitable for receiving the fertilised egg. Certain ovulation kits help determine when the eggs are ready for ovulation by checking the hormone levels in the urine.

Serial ultrasounds monitor the growth of the eggs and the uterine lining. Towards the peak of ovulation, the doctor may give an injection that releases the eggs into the fallopian tube (multiple eggs may be released from both ovaries). IUI is done usually within 1 to 2 days after ovulation.

The procedure is quite simple, quick and painless. On the day of the procedure, the patient arrives at the infertility clinic with all the relevant reports. Written consent is taken from the patient (and the partner, if required) by the doctor after explaining the technique and the associated risks of the procedure.

The procedure contains the following steps:

1. Semen collection: if a sperm donor is being used, then the donor sperm is thawed and prepared for insertion. If not, the male partner is required to visit the clinic and give his semen sample. The sample is given in a sterile cup via masturbation. In case the partner does not wish to give the sample in the clinic (due to physical, cultural or religious reasons) he can collect the sample at home. However, it is to be noted that the sample has to be taken within one hour to the clinic while keeping it at body temperature. A scenario could arise when the male partner is unavailable on the day of the IUI. In this case, the sample can be given to the clinic a day before where it is frozen and then later thawed at the time of the procedure.
2. Semen washing: once the semen is collected, it is then put through a special procedure known as semen washing. The “washing” removes all impurities and offensive sperm elements that may interfere with fertilisation and separates the highly active, normal sperm from the lower-quality sperm. By doing this, the likelihood of pregnancy increases because a highly concentrated sample of healthy sperm is being utilised.
3. IUI: the female patient will be shifted to a sterile procedure room and asked to lay down in the lithotomy position (a position where the patient is lying on their back and the legs of the patient are spread wide, akin to when giving birth). A monitor is attached to keep track of the vitals - heart rate, blood pressure and oxygen saturation - of the patient. A special catheter (a thin hollow tube with one end connected to a vial containing the pre-treated semen) is inserted into the cervix. The “washed” sperm is then injected into the uterus via the catheter. The patient may feel some mild cramping pain which is normal. The entire procedure takes 10 to 15 minutes.

The chance of pregnancy per IUI is about 20%. Hence many such visits may be required for the patient to get pregnant. Ideally, a minimum of 3 such cycles (up to 6 cycles) of treatment may be required to achieve pregnancy.

The procedure is relatively safe although it may have the following complications

• Infection: there is a slight chance of developing an infection as a risk of the procedure.
• Spotting: while placing the catheter in the cervix there may be a little bleeding. However, this does not affect the process of conception.
• Multiple pregnancies: IUI by itself does not cause multiple pregnancies. However, when combined with fertility drugs (which are responsible for multiple releases of eggs) there is an increased risk of multiple pregnancies. Multiple pregnancies have their own risks such as preterm labour and low-weight babies.
• Ovarian Hyperstimulation Syndrome (OHSS): in this condition, more than 20 follicles may be released. When such an event occurs, the doctor advises against the procedure and advises the couple to abstain from intercourse. An immense release of follicles can cause the ovaries to become painful. In extreme cases, the condition may be life-threatening.

Once the procedure is complete, the patient is asked to lie on their back for 10 to 15 minutes. The vitals of the patient are checked. A discharge summary is then prepared by the doctor which contains the details of the procedure performed, along with specific instructions for subsequent follow-ups.

A progesterone suppository may be prescribed to keep the uterine lining favourable for pregnancy.

The doctor is to be notified if any of the following symptoms arise:

• Excessive bleeding/ spotting per vagina
• Excessive lower abdominal pain
• Any pus-like discharge per vagina
• Fever

The first visit to the doctor is usually 14 days after the procedure, once the patient has carried out a home pregnancy test. If the procedure is a success, the test is positive. Testing too soon may produce a result that is:

• False-positive: it is seen when the ovulation-inducing medication is still circulating in the body, which may indicate a pregnancy when the patient isn’t really pregnant.
• False-negative: this occurs when the pregnancy hormones haven't yet reached a measurable level. In this case, the test shows a negative result when the patient is actually pregnant.

The doctor will prescribe an ultrasound scan and specific blood tests which are more sensitive and specific to detecting a pregnancy. If the patient is not pregnant, the process can be repeated multiple times before opting for other methods of ART. Counselling is important in these situations and is focused on keeping an optimistic approach and also discussing other methods of having a child in case IUI ultimately fails.

Intrauterine Insemination is a favourable method of ART in couples, same-sex couples or single women who wish to conceive. The procedure is fairly safe and simple with a relatively lower cost as compared to other methods of ART. Counselling is important and should be properly sought. The success of a single IUI is low (20%). However multiple such cycles significantly improve the chances of pregnancy.

(Read more: In Vitro Fertilization)