Introduction to Intrauterine InseminationCHAPTER 1

Intrauterine insemination is considered as the first line of treatment when applicable, in many infertility centers as it is a simple and inexpensive procedure. Intrauterine insemination (IUI) has a long history 1, 2, 3, 4. It was introduced nearly 200 years ago by John Hunter in the 1770's. Since then it has undergone many changes and advances till date.

In Intrauterine insemination (IUI) washed and prepared sperms are introduced into the woman's uterus, timed with ovulation, with the aim of getting the sperms nearer to the ovum.

It is often used as the first line of treatment for couples with “unexplained infertility”. It is also recommended for women with mild endometriosis. IUI can also help couples who are not able to have intercourse because of difficulties such as premature ejaculation or disability, as sperm is introduced directly inside the uterus. Women whose husbands have total testicular failure, have no option but to use donor insemination in order to achieve pregnancy. IUI with donor sperm is being increasingly used by women who intend to become single mothers.

In the past, IUI was done without ovarian stimulation by fertility drugs (“unstimulated cycle” or “natural cycle” IUI). In unstimulated cycles, IUI is timed with natural ovulation, which is usually detected by monitoring of urinary luteinizing hormone (LH), using LH kits, starting daily from day 8 of the periods. IUI is done 12–16 hours after the LH surge is detected by such LH kits. Nowadays, IUI is often combined with fertility drugs (“the stimulated cycle”). Ovulation induction is often recommended in anovulatory infertility like (PCOD) or unexplained infertility and also in mild male factor and mild endometriosis cases. These drugs increase the chances of pregnancy by multifollicular development and by producing good quality oocytes. The drugs commonly used are clomiphene citrate, letrozole and injectable gonadotropins. Usually these medicines are given starting from day 3–5 of the menstrual cycle. Concurrently serial transvaginal sonography is done to monitor follicular development from day 6–8 of the period. When the leading follicule becomes 18–20 mm in size, human chorionic gonadotropin (hCG) trigger is given. IUI is planned 36-40 hours after the trigger. The husband is asked to collect a semen sample, preferably in the semen collection room in the vicinity of IUI lab, or alternatively, he can get the sample in a clean sterile, nontoxic container from home. The sample should reach the laboratory within 30–45 minutes. The best quality and most motile sperms are harvested by one of the different semen preparation techniques. 4The washed sperms are deposited in the uterine cavity by a flexible catheter. The patient is made to rest for about 15 minutes after the procedure. A pregnancy test (preferably Serum β-hCG) is done 14 days after the IUI.

The success rate of IUI varies from 5–25% depending upon the age of the female partner, the extent of male factor, the cause of infertility and the ranking of the laboratory which does the semen preparation (as assessed by the equipment, maintainance, and staff skills). IUI can help couples with low sperm count or poor motility. A post wash count of more than 5 million per mL and 50% progessive motility usually leads to good success rates.

The success rates for IUI with natural cycle is 5–7%, and with fertility drugs it is about 15% per cycle. Of course, as with any form of infertility treatment, there are variable factors which can affect how successful this treatment will be. It is not applicable for couples with:

The disadvantages of ovarian stimulation for an IUI cycle are the associated risks of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies.

But overall, it is a reasonable initial treatment that should be utilized for a maximum of about 34 cycles, where applicable, it being relatively simple, inexpensive and effective.