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Intrauterine Insemination (IUI) is the placement of washed or processed sperm inside the women’s uterus at the time that she is ovulating. It is commonly performed after failure of natural conception or in instances of mild to moderate sperm problems. During this procedure, a thin catheter is passed through the cervix into the uterus to deliver the sperm closer to the fertile egg at the time of ovulation. IUI is especially useful when sperm has had difficulty reaching the egg and is often used in conjunction with the use of ovulation inducing drugs.
Intrauterine insemination (IUI) is a fertility procedure in which sperm are washed, concentrated and injected directly into a woman's uterus. In natural intercourse, only a fraction of the sperm make it up the woman's genital tract. IUI increases the number of sperm in the fallopian tubes, where fertilization takes place. IUI may be done in a natural cycle, but is commonly performed with fertility medications to enhance ovulation. Thus, for the infertility couple, IUI is commonly performed as a low-tech, cost-effective approach to enhancing their fertility.
IUI is typically the first procedure utilized if a woman cannot conceive either naturally or with the use of fertility medications alone. It may be recommended for several diagnoses of infertility, some of which include:
Intrauterine insemination is not considered to be an effective treatment for:
Because sperm are inseminated into the uterus, it is important that the woman has no serious fertility problems. Prior to initiating IUI treatment, the woman must have at least one documented open fallopian tube as demonstrated by a hysterosalpingogram (tubal dye study), and has a normal uterine cavity.
Because IUI relies on the natural ability of sperm to fertilize an egg within the reproductive tract, it is important that tests for male infertility indicate reasonable sperm function (count, motility and morphology). An average total motile sperm count of 10 million is the standard threshold utilized when deciding if IUI should be considered, or, if the couple should look at other options such as in-vitro fertilization (IVF) with Intracytoplasmic sperm injection (ICSI).
IUI is usually done with concomitant controlled ovarian stimulation using fertility medications, such as clomiphene citrate or injected gonadotropins. IUI can be timed via ovulation induction protocols, as when the patient’s ovulation is being monitored by her physician or, through the use of ovulation predictor kits that the woman can do herself. Response to ovulation medication via ovarian follicle growth (size and number of follicles) will be assessed through serial transvaginal ultrasound monitoring (Figure 1). This will determine the proper timing for the IUI procedure.
Prior to IUI, a semen sample will be collected from the male partner through ejaculation into a sterile container and then washed. Sperm washing refers to the laboratory technique that separates sperm from semen, and non-motile sperm from motile sperm. Approximately 2 hours are required to process the sperm. The IUI procedure usually takes place quickly after sperm washing has been completed.
To prepare for the IUI procedure itself, a speculum will be inserted into the woman’s vagina and then a thin, flexible catheter, or tube, will be placed into the cervix. Washed sperm (Figure 2a) are then injected directly into the uterus with a syringe (Figure 2b). The procedure is not uncomfortable for most women and takes 5-10 minutes from start to finish.
While complications of the IUI procedure itself are uncommon, they can include brief uterine cramping and infection. Risks of controlled ovarian hyperstimulation with IUI are increased when fertility medications are used. These include multiple pregnancy and Ovarian Hyperstimulation Syndrome (OHSS). OHSS is a serious complication, which may result in fluid imbalance, blood clotting problems, cardiopulmonary compromise, and rarely, even death. Thus, it is advised that IUI using controlled ovarian stimulation protocols be handled by a competent Reproductive Endocrinology and Infertility specialist.
It is suggested in most clinical guidelines that 3-6 repeat cycles of IUI may be done, granting that there are no serious causes of infertility identified. If unsuccessful, then in vitro fertilization or IVF is the next appropriate treatment option.
With clomiphene citrate and IUI, pregnancy rates average 7% per cycle. FSH ovarian stimulation (injectable gonadotropins) and IUI treatment have a reported pregnancy rate of 12% per cycle. However, there may be other factors that need to be considered in predicting possible success in IUI. These include age of the wife, quality of semen of the husband, and cause of the infertility.
In vitro fertilization (IVF) is a method of assisted reproduction in which a man's sperm and a woman's eggs are combined outside of the body in a laboratory dish. One or more fertilized eggs (embryos) may be transferred to the woman's uterus, where they may implant in the uterine lining and develop. Excess embryos may be cryopreserved (frozen) for future use. Initially, IVF was used to treat women with blocked, damaged, or absent fallopian tubes. Today, IVF is used to treat many causes of infertility, such as endometriosis and male factor, or when a couple's infertility is unexplained.
IVF was initially used to treat women with blocked, damaged, or absent fallopian tubes. Today, IVF is used to treat many causes of infertility, such as endometriosis and male factor, when a couple's infertility is unexplained or in women with advanced maternal age where her chances for pregnancy are rapidly declining and IVF remains as the best possible option.
The basic steps in an IVF treatment cycle are ovarian stimulation, egg retrieval, fertilization &embryo culture, and embryo transfer. During ovarian stimulation, medications or "fertility drugs," are used to stimulate multiple eggs to grow in the ovaries rather than the single egg that normally develops each month. Using ultrasound examinations and blood testing, the physician can determine when the follicles are appropriate for egg retrieval (Figure 1). Generally, eight to 14 days is required. When the follicles are ready, hCG or other medications are given.
Egg retrieval is done before ovulation occurs, usually 34 to 36 hours after the hCG injection. It is usually accomplished by transvaginal ultrasound aspiration, a minor surgical outpatient procedure (Figure 2) that is done with some form of analgesia administered. The eggs are aspirated from the follicles through the needle connected to a suction device with the guidance of ultrasound probe inserted through the vagina. Removal of multiple eggs can usually be completed in less than 30 minutes. In some circumstances, one or both ovaries may not be accessible by transvaginal ultrasound and laparoscopymay then be used to retrieve the eggs using a small telescope placed in the umbilicus. In the phase of fertilization and embryo culture,the retrieved eggs are examined in the laboratory for maturity and quality (Figure 3). Mature eggs are fertilized by micro-insemination or intracytoplasmic sperm injection (ICSI). The next day, the eggs are evaluated for signs of fertilization and are kept under special conditions to allow further growth and development. Depending on the program, developing embryos may be cultured in the IVF lab for two to six days after the egg retrieval and become.embryos from 2-cells to blastocysts (Figure 4).
During embryo transfer, the physician and the embryologist inform the couple about the quality and number of available embryos and discuss the options before the couple decides on the number of embryos for transfer. Once a decision is made, the embryologist loads the embryo/s into a transfer catheter while the physician prepares the patient. No anesthesia is necessary, although some women may wish to have a mild sedative. Once the catheter is prepared, it is quickly handed over to the physician who gently guides the tip of the transfer catheter through the cervix and places the fluid containing the embryos into the uterine cavity (Figure 5). The patient is then given additional medications for 2 weeks after which a serum pregnancy test is done.
The average time that is required to complete one IVF cycle (from start of ovarian stimulation to testing for pregnancy) is about four to six weeks, depending on the chosen ovarian stimulation protocol appropriate for your case.
Intracytoplasmic sperm injection (ICSI) is the step in the IVF process which aims to achieve fertilization for the collected eggs. In ICSI, a single sperm is directly injected into each mature egg (Figure 6). ICSI is usually performed when there is a likelihood of reduced fertilization, i.e., poor semen quality, history of failed fertilization in a prior IVF cycle, etc.
Your chances will depend on a few factors, most crucial of which are women’s age, presence of co-morbidities (endometriosis, previous ovarian surgery), and quality of husband’s sperm). In addition, success rates vary from center to center and between practicing clinicians. Generally, pregnancy rates from a single IVF cycle may range from 20% to 80% depending on the clinical picture per case. Do ask your doctor regarding your chances after full evaluation.
Patients themselves may help increase their chances by approaching their ideal body weight and by avoiding avoiding certain lifestyle habits (smoking, alcohol-drinking, caffeine-drinking). Studies have shown that women who are within normal body mass index (BMI) 20-24 kg/m2 tend to have a higher chance of success during IVF than women who have higher or lower BMI values. Similarly, some reports have shown that cigarette-smoking and alcohol-drinking, by either the wife or the husband especially during the time of IVF treatment significantly decreases their chances of a successful outcome. A similar recommendation regarding coffee-drinking has also been reported. For these reasons, these lifestyle habits must be avoided during an IVF try.
The average cost of one IVF cycle in CARMI should be around P250,000 to P300,000 unless certain other services were added to the specific programs. These rates are the lowest in the country and are comparable to the rates in Taiwan, Vietnam, and Thailand. All this for top-of-the-line services and excellent success rates.
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