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Intrauterine insemination or IUI is a safe treatment modality in infertility, aimed at overcoming the natural barriers to the passage of the sperms from the vagina to the fallopian tubes. It is one method of artificial insemination. Artificial insemination using husband’s or donor sperm has been practiced for more than 200 years.

In normal sexual intercourse millions of sperms are deposited in the vagina. Of these only a few thousands make their way past the cervix, through the uterine cavity and ultimately reach the fallopian tubes. Only 1% of the sperms survive this migration. Others are lost due to various factors in this journey.

IUI is the direct placement into the uterine cavity of adequate numbers of motile, normal sperms suspended in a nutrient medium. This is done around the predicted time of ovulation. The distance that the sperm must travel is greatly reduced and the amount of normal sperms available to the oocyte or egg is also increased. With IUI the number of sperms that reach the fallopian tube in increased as much as 25%.

As compared to IVF it is less expensive and less technically demanding.

Pregnancy rates with IUI are 10-20%. There has been no increase in the incidence of malformations or pregnancy complications as a result of IUI.

Indications

The ovary contains healthy oocytes or eggs.
The fallopian tubes are patent or open.
The uterus must be normal.
The semen sample contains a sufficient number of motile normal sperms.
The woman should be in good health, overall. The husband should have no genetic abnormality.

Timing of IUI

IUI may be performed at the time of ovulation in a natural menstrual cycle or in a cycle where the ovaries have been stimulated by certain drugs. Ovulation induction/stimulation (link) is an effective adjunct to IUI. Fertilization chances are increased because of the combination of increase in the number of available sperms as well as the number of oocytes.

Timing of ovulation can be determined by several methods (see ovulation induction). Most popular are the ultrasound and the ovulation predictor kit. A mature egg is capable of being fertilized for approximately 12-18 hours after ovulation, and sperms have the ability to fertilize for up to 48 hours.

Preparation of the semen sample

Abstinence is to be observed 3-4 days prior to the procedure. On the day of the insemination the husband gives a semen sample in a wide-mouthed sterile container. It can be either collected at home and brought to the clinic/laboratory within an hour or collected in a room adjacent to the laboratory. During transport from home it is to be kept at body temperature and hence is to be kept inside clothing in direct contact with the skin. Excessive cold or heat is to be avoided. After the specimen is left for processing the couple can return for the insemination after 1-2 hours.

Microscopic view of sperms

The semen sample is assessed for volume, count and motility. Semen contains normal motile sperms as well as abnormal sperms, nonmotile sperms and nonsperm cells. In a normal semen sample the sperms are present in a fluid called the seminal plasma. The seminal plasma contains a substance called prostagandins that will cause the uterus to contract and give rise to cramping pain. Processing or washing of the semen sample involves removal of the seminal plasma and other cells. Washing which in essence refines and concentrates the sperms enhances the fertilizing capacity of the semen specimen. Only motile normal sperms are obtained thereby eliminating all other contents. The sperms are suspended in a nutrient medium and this sample is used for insemination. Sample is drawn in a flexible plastic catheter called IUI catheter.

For IUI to be successful adequate normal motile sperms must be present in the washed or processed specimen.

Figures for this vary from 1-5 million. However pregnancies have been reported to occur even with sperm numbers far less than a million. The total volume of a non-pregnant uterus is only 0.5 ml. Therefore no more than 0.5 ml should be injected or inseminated. Otherwise the specimen goes out of the uterus. Frozen semen of the husband may also be used for insemination.In some cases the husband’s semen sample does not contain any sperms, a condition termed azoospermia. In these instances sperms from a donor can be used. This is termed donor insemination (see below).

The insemination procedure

There is no need for the woman to fast or rest before the insemination.
The technique for IUI is relatively simple and straightforward.
The woman is asked to pass urine so that her bladder is empty.
The woman lies on a couch or bed with her hips raised on a pillow.
The mouth of the uterus called the cervix is visualized by means of a speculum inserted into the vagina. The cervix may be cleansed of mucus. The anterior lip of the cervix is held with a forceps.
IUI catheter is gently introduced into the uterus
The processed semen is injected slowly into the uterus over 30-60 seconds.
The procedure takes only a few minutes and is rarely uncomfortable.
The woman remains in the same position for the next 30 minutes or so and then leaves.
She resumes her routine activities the same day immediately on return.

Insemination is usually performed on two consecutive days in any one cycle. The couples are put through 2 or 3 such cycles. If they fail to conceive their records are reviewed for reevaluation of the treatment strategy.

After-care

There is no restriction in activity. There is no need for bed rest, diet and travel restrictions. The woman can resume her exercises if she was on the same. It is preferable to refrain from intercourse on the days of insemination.

Sexual intercourse may be recommended 24-36 hours after the insemination as the orgasmic event may increase tubal motility moving along the egg, sperm, or embryo.The woman may be started on medications 1-2 days after IUI. The purpose of this is to make the uterine lining or endometrium very receptive to the implantation or settling of an embryo.

Side effects