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Intra-uterine insemination (IUI)

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 other major risk of IUI is that many gynecologists repeat it again and again, because they do not have anything better to offer. Rather than referring the patient for IVF, they keep on subjecting the patient to repeated cycles of IUI ( sometimes as many as 12 cycles !). Patients ultimately get fed up and frustrated, and lose confidence in doctors and themselves, as a result of which they deprive themselves of IVF

technology. Often, patients will change doctors, but the new gynecologist will repeat the same IUI treatment, even though the patient has already done many IUI cycles in another clinic.

The other common problem is that many gynecologists persist in doing IUI when the man has a low sperm count ( oligospermia). Their rationale is that we will concentrate the good sperm and inject them in the uterus. This is doomed to fail. Unfortunately, IUI is not a good treatment for oligospermia , because the problem is not just a low sperm count, but functionally incompetent sperm ! ICSI is a much better option for these couples !

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 %; and the cumulative conception rate is about 30% over 3 treatment cycles. (Remember, Nature's efficiency for producing a baby in one month

in fertile couples is only about 15 to 25 %). However, if IUI is going to work for a couple, it usually does so within 4 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 possibilities.

The Cost Factor

The cost of performing IUI varies from clinic to clinic, but is about Rs 5000 to Rs 10000 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 25000 for one month's treatment.

IUI is a simple, inexpensive, effective form of therapy, and can usually be tried first in some patients, 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!

Laboratory Techniques

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 arelighter 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.

Recent advances

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 transfer).