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Intrauterine Insemination

An IUI -- intrauterine insemination -- is performed by inserting a very thin flexible catheter through the cervix (mouth of the uterus) and injecting washed sperm directly into the uterus. The whole process does not take very long - it usually only requires the insertion of a speculum and then the catheter, a process that maybe takes a couple of minutes. Sometimes when the cervix is hard to reach a tentaculum is used to hold the cervix, which makes the procedure easier.

Usually the sample is collected through ejaculation by masturbation into a sterile semen collection container in a private room at the clinic. From the time the sample is received, it takes about 1 hour 30 minutes to make the sample ready for insemination. The amount of time may vary depending on the sperm quality, as special techniques may be required.

Ideally, an IUI should be performed within 6 hours before or after ovulation. Timing is based on an hCG injection (given to release the egg) and the IUIs are usually done between 24 and 36 hours later. Typical timing would be to have a single IUI at about 36 hours post-hCG. If two IUIs are scheduled, they are usually spaced at least 12 hours apart between 24 and 48 hours after the hCG. Success rates are higher with two IUIs as compared to a single IUI. The egg is only viable for a maximum of 24 hours after it is released.

The results vary from centre to centre and may be as low as 6% to a maximum of about 20% per cycle. The low statistics are with one follicle, while multiple follicles resulted in as high 20 percent success. Another influencing factor is sperm count. Higher sperm counts increase the odds of success; however, there was little difference between success with good-average counts and those with high counts. The overall success rate seems to be between 15-20 percent per cycle. The rate of multiple gestation pregnancies is 23-30 percent. Our current success rates are > 20%.

Most women consider IUI to be fairly painless -- along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is the pain of the egg being released (ovulation) rather than from the IUI. The catheter usually does not cause pain as it is very thin and flexible and the cervix is already slightly open for ovulation.

Current research indicates that washed sperm can live 24-72 hours; however, it does lose potency after 12-24 hours. Another issue with IUI is that the sperm can keep on swimming beyond the fallopian tube, so the ideal window is really within 6-12 hours of the egg being released; with a larger margin before ovulation than after since the egg's viability is shorter. Sperm can live up to 5 days in fertile mucus, 2-3 days being common, so combining IUI with intercourse may provide better coverage.

We advise patients to lie down on the table for 30-45 minutes after the procedure.

Most people don't need to, but if you had cramping or don't feel well afterward it makes sense to take rest for a day or two. We advise against any heavy work or travelling by buses, rickshaws or scooters as the bumpy ride may reduce chances of conception.

This depends on your individual situation, but it usually should not be less than 3 days and not more than 7 days in order to ensure the best motility and morphology. We advise that you have an intercourse around the 7th or 8th day of your cycle and then abstain.

Usually you can have intercourse anytime after an IUI. We suggest waiting 48 hours to resume relations if you had any bleeding during the IUI or if a tentaculum is used.

Once the sperm is injected into the uterus, it does not fall out. There can, however, be increased wetness after the procedure because of the catheter loosening mucus in the cervix and allowing it to flow out.

According to different studies, 3-4 follicles gives one the best chance of getting pregnant, while more follicles beyond that simply increases the risk of multiples.

IUI can help patients taking only tablets containing clomiphene citrate where cervical mucus is a problem, and IUI increases the chance of success in patients on injections no matter what the sperm count. It does make sense to try IUI if you have tried but haven't had success with intercourse. It is important to note that with intercourse, only the best and strongest sperm make it through the cervical mucus and up into the uterus and fallopian tubes. With IUI, more number and better quality of sperms are available for fertilization.

A count above one million (after sperm preparation) appears necessary for success, with a significant reduction in pregnancy rates when the inseminated is count is lower than 5-10 million (in other words, in most cases one should consider 5 million a lower limit for success, 10 million for cost-effective). Higher success rates are with washed counts over 20-30 million, while increasing counts over 50 million did not appear to offer advantage.

It depends on what you can afford and what medication you are taking. One might do 1-2 IUIs on Tablets before moving on to Injectables, then do 3-4 cycles on Injectables. If one doesn't have success after four good ovulatory cycles on Injectables with well-timed IUI, it would be time to consider IVF. Age is also a factor, the higher the age, the more aggressive is the treatment required.

An IUI shouldn't be done at home without medical supervision because the sperms needs to be washed to prevent infection -- i.e., separated from the semen. A vaginal insemination can be done at home, but is no more successful than intercourse. Getting semen or air into the uterus could be quite dangerous -- perhaps life-threatening.

It doesn't usually happen, but it isn't uncommon. Some women also have light bleeding with ovulation.

Implantation takes place 6-12 days after ovulation - so 6-12 days after a well-timed IUI.

The IUI procedure and sperm washing and ultrasonography cost Rs. 4000, but the cost of medications can make a considerable difference. Someone doing a natural IUI cycle may spend only Rs. 4000, while someone on injectable medications with monitoring may spend Rs. 7000 to 8000.

Transvaginal Ultrasonography is done from Day 10 or 11 of the menstrual cycle to note the growth in follicular size and look for signs of ovulation like reduction in size of follicle, fluid in POD etc.

Follicles are usually considered mature once they have achieved a size of about 18 mm. Also, follicles continue to grow until they release, usually at a rate of about 1-2 mm per day. A woman may ovulate more than one follicle in a cycle, but the releases will occur within 24 hours. When hCG is not used, only follicles close in size are likely to release. The use of hCG induces ovulation in about 95 percent of women, and will get most mature follicles to rupture.

The main risks are some discomfort such as cramping, minor injury to the cervix that leads to bleeding or spotting. There are also risks of hyperstimulation associated with the use of ovulation induction medications such as clomiphene citrate (low risk) and gonadotropin therapy (higher risk). Proper technique and adequate monitoring reduce risks.

Most women don't need medication for pain associated with IUI. If there is cramping, it is best to avoid medications such as ibuprofen and naproxen (NSAIDS), but paracetamol is considered safe (but maybe not that helpful for cramps).

It is sometimes also called sperm preparation or spinning. It is a laboratory technique for separating sperm from semen, and separating motile sperm from non-motile sperm, for use in assisted reproduction (IUI, IVF). There are various techniques used to try and separate the 'good' from the 'bad' sperms as well as improve the quality of the 'not so good' sperms.

No. A tubal ligation is effective birth control because it prevents the sperm and egg from meeting. The process that leads to pregnancy is having an egg released from a follicle in the ovary and then beginning the journey to the uterus through the fallopian tube. Sperm will travel from the vagina, through the cervix, through the uterus, into the tube where fertilization occurs. IUI bypasses the need for the sperm to travel through the cervix, but that's it. It doesn't get the egg to the other side of the obstruction, so fertilization won't take place. The only way to get pregnant after tubal ligation or blocked tubes is by having reversal surgery or an assisted reproduction technology that includes egg retrieval, such as in vitro fertilization (IVF).

In case of any doubts contact your doctor or Gouri at Care IVF.

Instructions before IUI

Some antibiotics are given in the initial part of treatment to take care of infections. It is important that both partners take the medications. Make sure you understand correctly, what medications are required to be taken.
For your convenience, injections are available at the Centre at wholesale rates. There is however NO COMPULSION that you have to buy medicines from the centre.
Sub cutaneous injections should be given under the skin, either on the forearm or the thigh. Spirit should not be used to clean the area.
It is important that you and your partner 'stay together' on either Day 7 or day 8 of the periods so that the semen sample on the day of IUI be between 3 to 7 days old.
Once the eggs are mature (average of 18 - 20 mm size), an hCG injection would be given to you to release the mature eggs. If at any point of time after the injection you feel any pain in the lower part of your tummy, call the doctor immediately. The IUI may need to be re scheduled.
IUI does not require any admission in the Nursing Home. However, do come with 2-3 hours in hand.
Inform the Centre once your periods start so that a booking for Follicular Study (Ultrasonography) can be made on Day 2 and then again on Day 10. If it happens to be a Sunday, come on Saturday, not Monday.
After IUI, a medication needs to be inserted vaginally twice a day. In the morning, lie down for one hour after the insertion. At night, insert at the time of going to bed. Some of the medication may come out in a liquid form, do not get alarmed.

Information of certain Drugs used in IUI cycles

Aspirin (Ecosprin75mg)

Low dose aspirin treatment is started either from the D1/D2 of periods or immediately after IUI. This enhances blood flow in multiple different organ systems. Studies have shown dramatic improvement in follicle development, pregnancy rates and implantation rates. ( Rubinstein et al; Fertil Steril 1999; 71: 825-9).

Progesterone (Naturogest/Micpro)

Progesterone hormone is produced after the follicle ruptures and releases the egg. This hormone supports the lining of the uterus and prepares it to receive the fertilized egg, i.e. the embryo. This phase after rupture of the follicle till the next periods occur is called the Luteal phase. Some women have a natural defect in their luteal phase which is aggravated when drugs like Clomiphene Citrate (Siphene) are given or when extensive down regulation is done as during IVF (with drugs like Lupride). Thus after IUI, progesterone supplementation is done to provide extra care and support to the lining of the uterus as well as reduce the irritability of the uterus to increase chances of pregnancy.

Anti-Oxidants (Genew or Lycored)

Stress, Smoking, Excess Alcohol and Environmental pollution lead to generation of ROS or Reactive Oxygen Species that cause damage to sperms and oocytes. Anti Oxidants reverse this to some extent and have been shown to increase pregnancy rates.

Estradiol (Progynova)

Estradiol is responsible for increasing the lining of the uterine cavity. As the level of the hormone increases you will find the ET or Endometrial thickness increasing on the folliculometry scan. Sometimes due to drugs, some hormonal problems or idiopathic reasons, the lining does not develop well. In these times, Progynova supplementation at the right time helps correct the problem.

11th December, 2011
The Telegraph, Kolkata
Modern-day technology has allowed us to create an environment outside the body which is almost as good as the environment inside the body.


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