IUI (Intra Uterine Insemination)
Intrauterine insemination is the deposition of washed and capacitated sperm into the uterine cavity and remains one of the most popular ART techniques for patients with mild endometriosis, low sperm counts, poor sperm motility, greater percentage of abnormal sperms, sexual dysfunction (faulty technique or inadequate deposition of sperm in the vagina), some cases of one sided tubal block, polycystic ovaries and also those with unexplained infertility.
To enhance the success rate we need the following criteria / investigations
• Age < 35 years
• Duration of infertility < 5 years
• Serum AMH > 2
• Serum FSH < 8
• Sperm wash yielding adequate high speed sperm in a case of sperm problems.
• HSG or Laparoscopy showing one normal and open tube.
• Transvaginal ultrasound showing normal uterus or ovaries (polycystic is acceptable).
Also, we need to stimulate the ovaries of the wife to get more eggs, improve the quality of eggs, enhance the lining of the uterus and be able to time the insemination perfectly with injections
Ovarian Stimulation for IUI
One of the easiest and most cost effective protocols for COHS in IUI is the Clomiphene (CC)-IUI protocol - Tablets of CC are administered in a dose of 50 - 100 mg once daily from day 2 or 3 of menses - Transvaginal USG follicular monitoring being performed daily from day 7 of cycle until the lead follicle (Egg) reaches 17 - 18 mm in mean diameter and endometrium (lining of the uterus) reaches thickness of > 8 mm when 5000-10000 IU of hCG (ovulation trigger injection) is administered and IUI is performed at 36-40 hours post hCG. Luteal phase support is with hCG 1000 IU administered on days 1,4 and 7, assuming day 0 as day of follicular rupture or more recently, with micronized progesterone vaginal capsules 200 mg twice a day
CC-Human Menopausal Gonadotropin (HMG):
CC is administered in a dose of 100 mg daily from days 3 - 7 of menses. Inj.hMG 150 IU is then administered from day 7 of the cycle on a daily basis until the lead follicle reaches 17 - 18 mm in mean diameter. hCG 5000-10000 units is administered on that day and IUI performed on 2 days thereafter.
Follicle stimulating hormone (FSH)-IUI:
After a baseline scan on day 2 to ensure endometrial shedding and no residual ovarian cysts, Injections of FSH 150 IU are administered Intramuscularly daily. Ultrasound monitoring will start on day 6. If there are more than 3 follicles 12 mm in mean diameter, the same dose is continued. If less than 3 follicles 12 mm in diameter, the dose might be increased to 225 IU per day . The ovulation trigger of hCG 5000-10000 IU is then administered when the lead follicle reaches 18 mm in mean diameter followed by IUI on two days thereafter. the stimulation protocal varies with different female
• Agonist / Antagonist: Sometimes, doctor might combine a GnRh agonist or antagonist with the FSH stimulation for enhancing the results and better timing of ovulation. This would help 20% of patients where the follicles did not rupture or where the doctor wants to avoid IUI on a Sunday without compromising the result of the patient
Sperm Preparation for IUI
The sperm is prepared in the semen laboratory by either of two methods, namely layering or gradient and the final washed sperm is then loaded in a catheter and transferred to the womb (IUI).
The average success rate of IUI per cycle is 8 - 18 % depending upon the indication and the COHS protocol used.
Number of Cycles
The normal recommendations are 3 - 6 cycles of IUI prior to resort to more aggressive ART such as IVF & ICSI. For the unexplained infertility group, current recommendations are two cycles of CC-hCG-IUI, followed by two cycles of Pure FSH-hMG-IUI followed by two cycles of FSH-IUI with agonist or antagonist.
With modern day IVF being too successful, it would be wise to undergo not more than 3-5 cycles of IUI. Remember that the success rate with IUI using husband's sperm is @ 15% and with donor sperm is @ 20% owing to the limitations of the technique. In cases of unexplained infertility please remember that most of them suffer from infertility owing to failure of the sperm to fertilize the egg (inability to pierce the tough shell of the egg). This cannot be proved by any known test and therefore the couple is labeled as "Unexplained infertility" and often told that all is well and it is just a matter of time before they achieve pregnancy. Currently, we are not in favor of this school of thought and prefer more aggressive treatment such as ICSI-IVF (where the sperm is injected into the egg in the laboratory) to achieve pregnancy, especially after 2-3 attempts at IUI have failed.