Intrauterine Insemination (IUI)
from the book How to Have a Baby:
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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Sometimes nature needs help to start a pregnancy - and the doctor can do this
by giving the sperm a piggy back ride through a fine tube into the body. This
procedure is called intrauterine insemination ( IUI) or artificial insemination
with husband’s sperm (AIH) - and effectively, the doctor is giving nature a
helping hand by increasing the chances of the egg and sperm meeting.
IUI is useful when:
- The woman has a cervical mucus problem - for example, it maybe scanty or
maybe hostile to the sperm. With an intrauterine insemination (IUI) the
sperm bypass her cervix and enter the uterine cavity directly.
- The man has antibodies to his own sperm. The " good" sperm which
have not been affected by the antibodies are separated in the laboratory and
used for IUI.
- If the man cannot ejaculate into his partner's vagina. This is usually
because of psychologic problems such as impotence (inability to get and
maintain an erection) and vaginismus ( an involuntary spasm of the vaginal
muscles so that vaginal penetration is not possible); or anatomic problems
of the penis, such as uncorrected hypospadias; or if he is paraplegic.
- The man suffers from retrograde ejaculation in which the semen goes
backward into the bladder instead of coming out of the penis.
- For unexplained infertility, since the technique of IUI increases the
chances of the eggs and sperm meeting.
- As an inexpensive alternative to GIFT, IUI is a reasonable first choice (
especially for younger couples) since it is so much cheaper and less
- If the husband is away from the wife for long stretches of time (for
example, husbands who work on ships or work abroad), his sperm can be frozen
and stored in a sperm bank and used to inseminate his wife even in his
- For male factor infertility, though this is a controversial area -
especially for the common problem of oligospermia (a low sperm count ). What
is the rationale behind using IUI for treating this problem? Remember that
infertility is a problem of the couple's - not just the oligospermic male's.
Whether a given couple will conceive or not depends on the sum of their
fertility potentials. Therefore, the fertility potential of the wife is
improved by superovulating her, so that instead of producing 1 egg per
cycle, she produces 2-4 eggs per cycle. In addition, the husband's sperms
are processed in the laboratory, and the best sperm are used for IUI. This
increases the chances of the best sperms being able to reach and fertilize
Methods for performing AIH
There are various methods of doing AIH (artificial insemination by husband).
The crudest and simplest technique involves simply injecting the entire semen
sample into the vagina by a syringe. However, this is a waste of time if used
for treating an infertility problem - after all, why go to a doctor to do
something which you can do for yourself at home? Remember, a syringe is no
better than a penis. It is only useful if the reason for doing AIH is the
inability of the husband to ejaculate in the vagina. However, a number of
doctors still use it as they do not offer anything better.
A refinement of this technique is that of using a spilt ejaculate. The first
squirt of semen which gushes forth during ejaculation is richest in sperm. This
is because the sperm "surf" on the wave of the seminal fluid which
carries them forward to the outside world. The man masturbates into a 2-part
container, so that this first part goes into one container, while the rest goes
into another. This is not as difficult as it sounds, and gets easier with
practice! The first bottle is saved and the contents used for artificial
insemination. This method is suitable for a small proportion of cases (for
example, for the uncommon problem of a large volume of semen, which
"dilutes " the sperm; or where laboratory facilities for sperm
processing are not available).
Intrauterine insemination (IUI)
In this method, the sperms are removed from the seminal fluid by processing
the semen in the laboratory and they are then injected directly into the uterine
cavity. It is not advisable to inject the semen direct into the uterus, as the
semen contains chemicals (prostaglandins) and pus cells which can cause severe
cramping; and even tubal infection.
Timing the IUI is very important - it must be done during the "fertile
period" when the egg is in the fallopian tube. Pinpointing the time of
ovulation accurately using either vaginal ultrasound or ovulation test kits is
crucial. A good clinic should provide this as a 7-day week service, since there
is a 1 in 7 chance that ovulation will occur on a Sunday - eggs don't take a
holiday! Often the wife's fertility potential is also simultaneously increased
by drugs so that she produces more than one egg per cycle (superovulation) to
increase the chances of conception.
The IUI is done either when ovulation is imminent or just after. The husband
masturbates into a clean jar - preferably in the laboratory or clinic itself,
and after at least three days of sexual abstinence to get optimal sperm counts.
Some men may have considerable difficulty producing a semen sample at the
appropriate time, because of the tremendous stress they are under, and the
" pressure to perform". For these men, using a previously stored
frozen sample can be helpful. Viagra ( sildenafil citrate) can also be used to
help them to get an erection, as can using a vibrator. The best sperm are
separated from the rest of the seminal fluid, by special laboratory processing
techniques. This separation takes about 1 to 2 hours. The actual insemination
procedure is simple and takes only a few minutes to perform. It is not painful,
though it can be uncomfortable. The wife lies on an examining table, and a
speculum is placed in the vagina. The doctor puts the sperm through a thin
plastic tube (catheter) through the cervix into the uterus. There may be a bit
of uterine cramping at this time; and some discomfort for about 12 to 24 hours.
Some patients may experience a little vaginal discharge after the procedure, and
they are worried that all the sperm are leaking out of the uterus. However, this
discharge is just the cervical mucus – the sperms cannot "fall out"
of the uterine cavity. No special bed rest is required after the IUI. Some
doctors may repeat the insemination after 24 hours. We usually encourage our
patients to have intercourse on the night of the IUI, and for 2-3 days after
this as well, to maximize the chances of the sperm and egg meeting.
Sperm processing allows the doctor to concentrate the actively motile sperms
into a small volume of culture fluid. Sperm do not remain alive in the culture
medium for very long unless maintained at the right conditions - hence a prompt
insemination after sperm processing is important. This is why processing should
preferably be done in the clinic itself, so that time is not wasted in
transporting the sperm after the wash.
There are different methods of processing the sperm, and all of these require
special laboratory expertise.
- The simplest method is that of washing the semen with a culture medium (by
centrifuging it and collecting the pellet) but this is a poor technique and
is not recommended.
- The swim-up method uses a layering technique, in which a special culture
medium is placed above the semen in a test-tube. The good quality sperm will
swim up into the culture medium; and after 45 to 60 minutes, this medium (
with the motile sperms) is removed and injected into the uterine cavity.
- The more sophisticated methods today use a density gradient column. This
method allows one to separate the good quality sperm from the immotile
sperm, the pus cells and the seminal plasma, because these are lighter than
the motile sperms. It provides the best recovery of motile sperms and is the
standard technique in use today, especially for poor quality sperm samples.
Of late, doctors have tried adding various chemicals to the washed sperm to
try to improve their motility, so as to increase the chances of their reaching
their goal. These chemicals include caffeine and pentoxyfylline and they may be
helpful in some patients.
During IUI, sperms are injected into the uterine cavity in the hope that they
will then swim up from here into the fallopian tubes where they can fertilize
the egg. But then, why not inject the sperms direct into the fallopian tubes
where the eggs is present? This feat was technically difficult to accomplish in
the past, because the tubes are so thin. Today, with specially designed
catheters ( Jansen-Anderson catheter sets), it is possible to do this in the
doctor's clinic. Thus, the processed sperm can be injected directly into the
tubes under ultrasound guidance, without anesthesia or surgery! This is an
intratubal insemination - also known as a SIFT - (sperm intrafallopian
Men may feel a loss of self-esteem because they feel that they need a
doctor's help to do what a "normal man" should have been able to do by
himself. They also feel guilty about having to subject their wife to the pain
and intrusion of insemination. Women may feel anger towards their husbands for
having the fertility problem. The insemination may also make patients feel that
someone has "intruded" into their sex life and this may affect their
Success Rates of IUI
The success rate of IUI depends upon several factors. First of all the cause
of the infertility problem is important. For example, men with normal sperm
counts who are unable to have intercourse have a much higher chance of success
than patients who are undergoing IUI for poor sperm counts. In addition, female
factors play an important role. If the female is more than 35, the chance of a
successful pregnancy is significantly decreased. Generally, the chance of
conceiving in one cycle is about 10-15%; and the cumulative conception rate is
about 60% over 5-6 treatment cycles. (Remember, Nature's efficiency for
producing a baby in one month is about 15 to 25 %). However, if IUI is going to
work for a couple, it usually does so within 6 treatment cycles. If a pregnancy
has not resulted in this time, the chances of IUI working for them are very
remote, and they should stop persisting with IUI and explore other
Risks of IUI
The major risk of IUI today is that of multiple pregnancy. Since the patient
is being superovulated, more than one egg may get fertilized, resulting in twins
or even triplets or quadruplets. Because the doctor cannot precisely control how
many follicles will grow or rupture, the risk of a multiple pregnancy is
actually even more after IUI rather than IVF . In fact, most of the infamous
cases of high-order multiple births ( such as sextuplets and octuplets) have
occurred after IUI. If you grow too many follicles, you may choose to cancel the
cycle. Some clinics can also offer you the option of saving the cycle by
converting it to IVF. This can be a cost-effective option, since it allows you
to make good use of the eggs you have grown.
In poorly equipped clinics, there is also a risk of developing an infection
after the IUI, if appropriate sterile precautions are not taken. This can
tragically actually cause infertility !
While many gynecologists today offer IUI treatment, many of them are not
specialized enough to provide a comprehensive service. This often means that
patients need to run around from the gynecologist to the ultrasound scan center
to the lab . Not only is this very time consuming and frustrating, it often
means that the care becomes fragmented because of poor coordination. Try to find
a clinic which offers all the services under one roof.
The Cost Factor
The cost of performing IUI varies from clinic to clinic, but is about Rs 3000
to Rs 8000 for the entire treatment cycle. Of course, if gonadotropin injections
are used for superovulation, the treatment then becomes much more expensive -
and can be as much as Rs 10000 for one month's treatment.
IUI is a simple, inexpensive, effective form of therapy, and can usually be
tried first, before going on to more expensive and invasive options. However, it
can be very stressful and close cooperation between the husband and wife (and
the doctor) is essential!
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.
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