Counseling for Intrauterine InseminationCHAPTER 1

In the busy outpatient department (OPD), it is very difficult for a practicing gynecologist to spend time with the patients for counseling. I shall put forward a few suggestions from my side:

Such explanation or literature allows the patient to know what would be the management strategy for their problem and how are we going to deal with their problem and, therefore, they gain confidence and appreciate the treatment that is given.

Moreover, it also would be a great means of propagating the correct knowledge through patients, as they would discuss whatever they have read and understood by reading the book, with their friends. This is very important as if the correct information is not spread in the society, only misconceptions and myths prevail.

One very important suggestion that I would like to give to very busy practitioners—please allot a specific, separate time slot for patients with fertility problems, so that you can patiently listen to them and discuss about the solutions or treatment strategy with them. Remember that the initial counseling and the time spent with the couple play a very vital role in management of the patient.

Now let us elaborate as to how I discuss about various aspects of causes, counseling, and management of infertility.

As infertility is a social stigma in our culture, not only the couple (I mean the husband also) but concerned relatives should also be involved in counseling, so that they would allow the couple to take the correct treatment. The refusal of treatment in majority of cases is by in laws or parents. Therefore, it is very vital that all the people concerned and all those who are going to play a role in decision making as to whether to continue the treatment or not, should have correct information about infertility. Their myths should be washed out with proper explanation. Explanation should be done in local language, simple for a layman to understand. Eye-to-eye contact is very essential.

No invasive investigations such as laparoscopy should be done within these 2 years and nature should be given enough time to work for the couple to achieve pregnancy.

Among noninvasive investigations, semen analysis and midcycle/preovulatory scan are the two investigations that must be done. These will more or less prove the normalcy of the couple and then counseling only can help them conceive.

We have observed that such couples do conceive very often after the treatment is stopped. This is because the stress of treatment is relieved and the patient is relaxed. Moreover, when we are treating these couples, we become too enthusiastic doing some invasive investigation in every cycle one after the other such as Rubin's test (RT), hysterosalpingography (HSG), dilatation and curettage (D and C), laparoscopy, etc. Therefore, when this patient is exhausted and abandons treatment, she conceives spontaneously.

Therefore, remember that counseling is more important than overenthusiastic invasive investigations.

The couple must be explained that according to the recent World Health Organization (WHO) criteria 2010, 15 million sperms/mL, 30% motility, and 4% sperms with normal morphology are considered as normal physiological semen criteria. In spite of this even today, we read several laboratories quoting 40–60 million count as normal in their reports. Because of this wrong information and ignorance of laboratory officials and clinicians, several patients take medicines for long periods to increase their sperm count. Remember, when sperm count is 15 million/mL or more, no treatment is required. Up to 86% abnormal sperms is normal and physiological and even patient with 4–14% normal sperms can conceive either naturally or by intrauterine insemination (IUI). Only when <4% of sperms are normal, in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) may be required.

When the sperm count is <15 million/mL, semen analysis must be done at least three times—2 weeks apart and 2 months apart to confirm the diagnosis. These patients should directly not be subjected to IVF or ICSI. Instead, we must try medical treatment for these males to improve the sperm count, so that they can conceive naturally or with IUI. The whole moto of medical management of a subfertile male is not to increase the sperm count 5–10 times or to achieve excellent semen parameters. The moto is to increase the count by a few million so that ICSI can be converted to IVF, IVF to IUI, and perhaps IUI into natural conception. Medical management has been discussed in the chapter on male infertility.

I believe that even today, postcoital test (PCT) is very useful in infertility management. When more than seven sperms are seen per high power field of microscope, 10–12 hours after intercourse, it is an excellent PCT according to WHO standards.

Majority of assisted reproductive technology (ART) textbooks opine that PCT has no significance. I have found it very useful for counseling of the husband. Husband feels that he is normal when PCT is normal. He does not feel guilty and cooperates with his wife for all infertility treatment. So, it may not have a role in patients undergoing ART, but it has a place for IUI and more conservative infertility treatment. Many a times when the couple changes the gynecologist, semen analysis is asked for. If patient has a few reports done earlier, I will rely on PCT. The satisfaction is of highest level for the couple when they see moving sperms under the microscope after 10–12 hours of intercourse.

Moreover, when the patient is shown these moving sperms under microscope even after 12 hours of intercourse, it gives them confidence that both the partners are normal and that helps them conceive.

Patient is explained that these sperms may remain alive for 48–72 hours in most of the patients, and in few, they have also been seen after 7 days. There is a misconception in majority of the couples that intercourse must be done when ovulation occurs. Showing PCT to patients removes this misconception. 4Cervix acts as a reservoir for sperms, so after the sexual relation even if ovulation occurs in 2–3 days, conception can occur. We can therefore explain the patient that if for conception the intercourse was needed exactly when ovulation occurs, raped girls would not conceive easily. Couple should therefore be advised intercourse at least once in 2–3 days during 10–20 days of 28–30 days cycle. The couple should be clearly told that abstinence of >3 days is not advisable during this period, in natural cycle as well as in stimulated cycles for IUI.

The fertile window of menstrual cycle precedes the day of ovulation by 5–6 days and likelihood of pregnancy is highest when intercourse occurs 2 days before ovulation. Intercourse on the day of ovulation is less effective and success rate is almost zero on the day after ovulation.^1,2 Coital frequency of twice or thrice a week during fertile period is equally effective. But, once a week reduces the chance of pregnancy by 40%.

Majority of the couples believe that if IUI is done, it is better to have abstinence before to get good sperm count. But, this is not true. An abstinence of >3–4 days does not increase the count, instead the percentage of dead sperms in this semen increases. Therefore, intercourse should not be planned; it should be absolutely voluntary and can be done irrespective of the day of IUI.

Abstinence is one of the causes for failed IUI. Let me explain, why and how!! In majority of gynecology clinics, where there is no IVF setup, the semen preparation laboratory is not adequately equipped, and so the semen preparation is suboptimal and so chances of conception are less. Moreover, patient keeps abstinence before IUI, so the chance of natural conception also is denied. As a result, patient does not conceive when she is on treatment but conceives spontaneously when she abandons treatment. Remember, therefore, intercourse at regular intervals in the fertile period is absolutely essential.

Majority of couples with long-term infertility have lost the charm of their marital relations. Their intercourses are only planned and compulsory, only targeted for child bearing. They must be explained that child is only a byproduct. Main thing is the love and affection, intercourse is just an expression of this feeling and results in conception. Counseling can help them to regain the charm of their marriage. All myths regarding intercourse must be discussed and sorted out, e.g., posture, position, timing, washing, etc.

Majority of the patients have a wrong concept that D and C helps conception. This is a myth and should be clarified. D and C should not be done in modern infertility practice. The only role today of D and C is to exclude endometrial tuberculosis (TB) by either histopathology or TB polymerase chain reaction (PCR) of the endometrial sample along with culture. D and C must not be done to diagnose luteal phase defect or to check whether the endometrium is in proliferative phase or secretory phase.

Patient should be explained that at the time of ovulation, fimbrial end of the tube covers the ovary, a negative pressure of 1 mm of Hg is created due to movements of the cilia, this sucks the ovum from the follicle, into the tubal lumen. So, ovum does not separate and release from the follicle to roll into the tubal lumen, but tube is vital and instrumental to suck the ovum into tubal lumen. Therefore, it is important that tubo-ovarian relation should be healthy, a patent tube is not sufficient. HSG gives us only incomplete information about the patency of the tube. This can be replaced by sonosalpingography (SSG). This explains the patient that in spite of patent tubes on other tests, why is laparoscopy required.

Now, microsurgery is almost replaced by ART for pathological tubes. Results of microsurgery are very good in tubo-tubal anastomosis in patients with tubal ligation (TL) especially laparoscopic tubal ligation. Therefore, in young patients where TL is done and patient then again wishes a pregnancy, microsurgery should be offered as an alternative to ART, as it is a one-time procedure and patient gets a breathing time for up to 2 years.

The rationale for IUI is increasing the number of available motile sperms to reach the ovum, which is morphologically normal for fertilization.

Intrauterine insemination is unfortunately the least standardized management of infertility. IUI is blamed for low pregnancy rate. But, meticulous selection of patient, stimulation protocol, ultrasound monitoring, and good semen preparation combined with IUI give excellent pregnancy rate. It bypasses vaginal acidity and cervical hostility. But, simultaneously accurate timing of IUI is necessary as reservoir function of cervical crypts is escaped and sperm has to travel only a short distance to approach ovum.

“Treatment independent pregnancy among infertile couple” is a landmark paper for patients who have patent tubes and fair sperm quality.³

To maximize the health outcome of population with minimum possible use of resources, cost-effectiveness of intervention is an important consideration in any 6healthcare system. Infertility treatment in our country is not covered either by government or by insurance companies. So, the choice of treatment is driven by financial consideration rather than best effectiveness. Success rate should be considered by spending same amount of money rather than number of cycles. For example, the cost of one IVF is almost same, as it would cost for 4–6 cycles of IUI. Considering a patient of unexplained infertility, male subfertility, or dysovulatory infertility, pregnancy rate of 4–6 cycles will be much higher than one cycle of IVF. So, if proper counseling is done, patient will first opt for IUI.

Even the practice committee of American Society for Reproductive Medicine (ASRM), 2012 recommends starting with less invasive treatment such as IUI and move to more aggressive intervention such as IVF, if IUI is unsuccessful or when patient is elderly or it is long-term infertility.⁴

Counseling is to be for the whole procedure of IUI. Most of the patients come with previous IUI failures in many cycles. They believe that IUI, just the procedure, gives them pregnancy. It should be emphasized that each and every step of IUI is very important. If the all steps are not performed properly, IUI does not give the results. For example, following steps should be discussed:

All the steps combined together if done systematically, then and then, IUI can give good pregnancy rates.

I have discussed “counseling for IUI” in detail specifically because patients have wrong concepts and even consultants refer for IVF after few IUI failures, which are not done optimally.

Whenever patient is under treatment, she can do all her regular activities such as household work, exercise, office work, etc. All these activities do not decrease the pregnancy rate. On the contrary, they have the beneficial role for the patient.

Donor should be unknown and all the norms and standard operating procedures of Indian Council of Medical Research (ICMR) for donor semen should be followed strictly. Sample should be ordered from registered semen bank. Many a times, couple ask for relative as their donor, which should be strongly discouraged. Donor and couple should never know each other and these details should be kept confidential. Child in future can ask about the genetic prints after 18 years, but that information also should be given without personal identification of the donor.

Therefore, patients who do not have absolute indications for IVF should be given a chance of IUI instead of taking them for IVF because about six superovulations with IUI cycles cost the same as one IVF cycle, with more chances of success.