Intra uterine insemination

What is intrauterine insemination (IUI)?

Sometimes nature needs help to start a pregnancy - and the doctor can do this by placing the sperm directly into the uterus through a fine flexible plastic tube. This procedure is called intrauterine insemination (IUI)or artificial insemination with the sperm of the mail partner and its application can increase the chances of egg fertilization after meeting the sperm.

When is IUI used for treating infertility?

IUI is useful when:
  1. The woman has a cervical mucus problem - for example, it may be scanty or may be hostile to the sperm. With an intrauterine insemination (IUI) the sperm bypass the woman’s cervix and enter the uterine cavity.
  2. 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.
  3. If the man cannot ejaculate into his partner's vagina. This is usually because of psychological problems such as impotence (inability to get and maintain an erection) and vaginismus (an involuntary spasm of the vaginal muscles that make vaginal penetration impossible); or anatomic problems of the penis, such as uncorrected hypospadias; or if he is paraplegic. 
  4. The man suffers from retrograde ejaculation in which the semen goes backward into the bladder instead of coming out of the penis.
  5. For unexplained infertility, since the technique of IUI increases the chances of the eggs and sperm meeting.
  6. If the husband is away from the wife for longer periods 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.
The procedure is not recommended in men with low sperm concentration and motility, since cell functionality and viability is low.

How is artificial insemination performed?

There are various methods of doing AI (artificial insemination). The crudest and simplest technique involves simply injecting the entire semen sample into the vagina by a syringe. It can be also performed by the partners in their own bedroom. This is called self-insemination. However, this is in fact a waste of time if used for treating an infertility problem. The only indication would be situations when a male partner would be unable to ejaculate directly into the vagina. Although there are doctors still using this procedure, they do not offer a real advantage or help for the couple.

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 goesinto the second one. The first bottle is saved and its content is used for artificial insemination. This method is applicable 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).

How is IUI performed?

In this method,sperm cells are removed from the seminal fluid by processing the semen in the laboratory and then they are 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 or even tubal infection.

How is the IUI timed?

The IUI is done either when ovulation is imminent or just right after it’s occurrence. Themale partner masturbates into a clean collector - 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. Stimulant medication can also be used to help them to get an erection, as can using a vibrator.

The highest quality 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 painless, though it can be uncomfortable. The wife lies on an examining table, and a speculum is inserted into the vagina. The doctor places 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 also 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 more abundant cervical mucus specific to the ovulation period and 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 sexual 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.

How are the sperm processed in the laboratory for IUI?

Semen processing allows the doctor to obtain more concentrated sperm with improved motility and activity in a relatively small volume of fluid. Sperm do not remain alive in the culture medium for very long time unless maintained in the right conditions - hence a prompt insemination after sperm processing is important. This is why masturbation and sperm collecting should be done preferably in the clinic, so that time is not wasted in transporting the sperm after the wash.

Laboratory techniques:

There are differentways of processing the sperm, and all of these require special laboratory expertise.
  1. 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.
  2. The swim-up method uses a layering technique, in which a special culture medium is placed above the semen in a test-tube. The high 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.
  3. 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 white blood 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 in the IUI treatment

During the past years, doctors have tried adding various chemicals to the processed sperm to try to improve their motility, so as to increase the chances of their reaching their goal. These chemicals include caffeine andpentoxifylline 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 egg is present? Technically this method was difficult to accomplish in the past, because the fallopian tubes are very thin. Today, with specially designed catheters (Jansen-Anderson catheter sets), this can be done in the clinic. Thus, the washed 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). However, pregnancy rates are not superior with this method than with IUI, that is why currently it is rarely performed.

Psychologicalissues

Infertile men may be frustrated and may loss self-confidence because they need a doctor's help to do what a "normal man" should have been able to do by himself. This occurs especially when the compare themselves with other potent men who can solve problems on their own. They also feel guilty about having to subject their wife to the pain and discomfort of insemination. Women may feel anger towards their partners for having the fertility issues. The insemination may also make patients feel that someone has "intruded" into their sex life and this may affect their intimacy.

What is the success rate of IUI treatment?

The success rate of IUI depends on 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, femaleinfertility factors play an important role. If the female is more than 35, the chance of a successful pregnancy is significantly decreased. Generally, the success rate in one cycle varies between 10 and 15%; and the cumulative conception rate is about 50% after 4 treatment cycles. It is worth mentioning that the chance of natural conception in one month is about 15 to 25 %. However, if IUI is going to work for a couple, it usually becomes successful within 4 treatment cycles. If a pregnancy has not resulted by this time, the chances of IUI working for you are very unreal. In these situations assisted reproduction methods (IVF) should be considered.

What are the risks of IUI treatment?

The major risk of IUI today is the possibility of multiple pregnancy.Since the patient is treated with ovarian simulating treatment, 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 with IVF. If too many follicles grow, the stimulating cycle can be cancelled. Also the treatment cycle can be saved by converting it to IVF method. This can be a cost-effective option, since it allows harvesting a large number of good eggs.
Clinics that provide this type of treatment (artificial insemination) usually can monitor their patients, performing hormonal tests and repeated ultrasound scans. However, there are fertility centers where such services are not available ad this can be very time consuming and frustrating for the patient.

Another major risk of IUI is that many gynecologists perform endless rounds of artificial inseminations in the lack of other alternative methods (in vitro fertilization). This can ultimately generate frustration in infertile couples, they lose confidence in doctors and in the medical services provided.

A common problem of this procedure is that many gynecologists persist in doing IUI even when men have a low sperm count (oligospermia). Despite the fact that the injected sperm is previously processed and more concentrated than the ejaculated semen, the rate of success is relatively low and in these cases an IVF associated with ICSI would be a much better option.

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