Intrauterine Insemination (IUI) |
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The objective of IUI is to introduce a quantity of sperm into the female partner's uterus, and thereby facilitate fertilization.
Because sperm (separated from the liquid portion of the semen) are inseminated into the uterus, it is important that the female partner has no other obvious fertility problems. Investigations should ideally show that the female is ovulating normally, has open fallopian tubes, and has a normal uterine cavity. Indeed, fertility tests are often normal in both partners, as IUI has been found useful in couples with no obvious cause of infertility. IUI may also be effective in women with ovulatory disorders, provided they respond adequately to fertility drugs. In such cases ovulation is stimulated by a course of hormone treatment, such that intrauterine insemination is timed to take place close to ovulation. Indeed, this technique of stimulating ovulation with hormones and introducing the sperm ( commonly referred to as 'washed sperm') just after ovulation has proved very effective in a variety of cases and is now the preferred method in couples with or without ovulatory disorder.
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).
There has been some success with IUI in cases where the female partner has endometriosis in the absence of mechanical distortion of the pelvic structures. This is a very common disorder, particularly in women in their thirties who have not had children, and may be associated with as many as one in four cases of infertility. The condition occurs when tissue from the uterine lining (endometrium) is spilled through the fallopian tubes, into the pelvis, and implants on the surface of the pelvic cavity and often the ovaries. Women with mild endometriosis are usually treated similarly to women with unexplained infertility.
Studies show that IUI will not be effective in cases where the male has very low sperm counts, poor motility, or poorly shaped sperm. Similarly, women with severely damaged or blocked tubes will not be helped by IUI.
The most recent studies of intrauterine insemination suggest that the best results are achieved when insemination is coupled with ovulation induced by fertility drugs. For this reason, the two procedures are often linked together as ovulation induction followed by IUI.
Because fertility drugs can produce several eggs, careful monitoring is important during ovulation induction in order to ensure that any side effects of treatment and/or the risk of multiple pregnancy are reduced. Monitoring of treatment is carried out by measuring estrogen concentration in blood samples, and by following the development of preovulatory follicles by ultrasound. If too many follicles develop, too many eggs mat be released and thus, increase the risk of multiple pregnancy. Therefore, the usual aim in controlled ovarian stimulation with IUI is to stimulate the release of at most two eggs. Iui differs from IVF in that the former aims to stimulate just one dominant follicle, while the latter aims to produce as many eggs as possible for laboratory fertilization.
When two or three follicles have reached preovulatory size, ovulation is induced with a further hormone injection (hCG) to stimulate the mid0cycle LH surge. Then, shortly thereafter (24-36 hours), around the time of expected and/or detected ovulation, a sample of fresh semen is collected by the male, washed, inserted through the cervix and placed high into the uterus of the female partner through a fine catheter. This is a painless procedure, comparable to the collection of a pap smear. It is also possible that in certain cases, a semen specimen would have been obtained at an earlier date and cyropreserved (frozen for storage by a laboratory procedure). At the time of IUI, it could be thawed and prepared as done for a fresh specimen for IUI.
- Drug Treatment, to stimulate the development of preovulatory follicles (eggs). Usually clomiphene citrate (oral) or ganodotropins (injectable) are used to stimulate the growth of follicles and cause ovulation.
- Monitoring of treatments, to measure the growth of follicles, individualize drug doses, and prevent serious side effects. By trans vaginal ultrasound scanning (two or three times during a treatment cycle). Measuring estrogen in a blood sample.
- Sperm sample, collected on the morning of actual ovulation, is washed and inseminated later that day.
- Pregnancy testing and ultrasound monitoring of early pregnancy.
New micromanipulation techniques of treating these difficult cases of male infertility have proven to be very effective. One of these microtechniques, intracytoplasmic sperm injection (ICSI), can be done as part of an in vitro fertilization (IVF) procedure and allows doctors to inject a single sperm into the center of an egg to induce fertilization. The success of this technique seems likely to make TDI less frequently used. IUI as a treatment differs from AID or TDI in that the male partner has better quality sperm and usually provides his own sample. The treatment, therefore, poses none of the emotional difficulties of AID or TDI, because no third party is involved.
While complications of IUI are infrequent, they can include infection, brief uterine cramping, or transmission of venereal disease (with AID?TDI unless appropriately screened). However, stringent screening processes and quarantine of donor specimens by sperm banks which include multiple times has decreased this risk dramatically. Risks of controlled ovarian hyperstimulation Syndrome (OHSS) (large ovaries and collection of fluid in the abdomen). In the early stages of the OHSS, ovaries become suddenly enlarged with an accumulation of fluid in the abdomen.
Early warning signs of OHSS to be aware of include :pelvic Pain, nausea, vomiting, weight gain and reduced urine production. In more severe cases, fluid may accumulate in the lungs, causing breathing difficulties. If an ovary ruptures, blood can also accumulate in the abdominal area. Other complications that may occur include severe fluid imbalances, which can also cause clotting problems such as inflammation of veins, stroke, and pulmonary embolism.
In rare cases, complications from ovarian hyperstimulation syndrome, including blood clotting problems and/or breathing difficulties, may be life threatening and could cause death. Some women, such as those with polycystic ovarian syndrome, run a higher risk of hyperstimulation and should be identified before treatment begins.
Careful monitoring and adjustment in the ovulation induction treatment regimen by the reproductive medicine specialist prior to ovulation may markedly reduce (but not eliminate) the risk of OHSS>
In cases where three or more preovulatory follicles develop to a diameter greater than 14 millimeters, there is an increased risk of multiple gestation which could mean abandoning treatment.