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What’s there in an IUI?

Intra Uterine Insemination is the most frequently done assisted conception technique.

It is the deposition of washed and concentrated semen sample inside the uterus to overcome the natural barriers for the passage of sperms into the uterus after natural intercourse.

IUI is the first line of treatment of infertility provided there are sufficient sperms and no tubal disease.

I think this should invoke some interest in you readers.

So is this unnatural?

Not at all. We are just helping the sperms to reach the egg faster. The egg would be inside the fallopian tube waiting for the sperms.

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‍What is the work up prior to IUI:

1. Basic ultrasound for the wife
2. Basic semen analysis
3. Atleast one normal tube confirmed by HSG(Hysterosalphingogram)-tubal testing by inserting a dye inside the uterus and taking X rays.

Procedure:

• The first visit is when the menses starts, a scan is done.
• A tablet called Letrozole or Clomifene citrate is started for 5 days with or without combination of injections.
• The next visit is for a scan on day 11 or day 12.
• The scan will show 1 or 2 follicles 18 to 20mm in diameter.
• There may be a need for 2 or 3 sittings for scans.
• HCG shot is given and IUI is done 36 hrs to 38 hrs later.
• Total motile sperm count should be 5 to 10 million.
• Soft catheter is used for insemination into the uterus in the lying down position.
• Bed rest for 10 to 15 mins post procedure is advisable.
• Single well timed IUI will give good results.
• Gentle atraumatic technique is important.

• IUI should be performed as soon as possible just after processing and within 90 minutes of collection to optimize the outcome
• The couple is advised to have intercourse the next day as the egg lives for a little more than 24 hrs.

• Progesterone hormonal tablets are given from the second day after IUI for 15 days.
• A date is given for Beta hcg, which is the pregnancy test.

This is all about the procedure.

It is less cumbersome.

Why should one go for iui?

• Subnormal semen parameters
• Sexual dysfunction: like impotence, anejaculation
• HIV discordant couples
• Ovulatory dysfunction/Anovulation
• Previous cervical surgery or infections
• Unexplained Infertility
• Failure of at least 3 naturally tried cycles.
• Minimal endometriosis
• Less than 5 years of infertility

When IUI should not be done?

• Bilateral tubal block
• Less than 1 million sperm count in postwash semen
• Severe Pelvic Infection

Critical factors for success are:

1. Patient Selection
2. Ovulation Induction
3. Timing the Insemination accurately
4. Post wash total motile sperms

Pros and Cons of IUI?

       Pros                                              Cons

First line treatment                    Limited indications

Simple and easy                        Low success rate

Economical                                Multiple pregnancy

Less invasive                             Ovarian hyperstimulation

Less psychological burden

Good compliance

Less complications

Minimal infrastructure

The clinical pregnancy rate in one cycle of IUI is between 10% to 20%.

The pregnancy rate is only so much because we have no control over the fertilisation of the egg and sperm. That has to happen naturally.

The reason for wide variation in success rate may be due to varied indication, duration of infertility, different stimulation protocol, no of IUIs etc

When to end this?

3 to 4 cycles of IUI are recommended before moving on to IVF.

Certain Facts about IUI:

• IUI is a poor treatment option for women over 40 yrs due to negligible pregnancy rate.
• It is better to move to higher form of treatment for women over 35 years and longer duration of infertility due to the age related decline in success.
• IUI should not be done if there are more than 3 big follicles.
• Ultrasound guided IUI offers no benefit and need not be routinely used.
• Lesser dose of ovulation induction to be done.

Overall ,the clinician needs to carefully choose the patients for IUI depending upon the age, indication, duration of infertility and plan the stimulation accordingly.

After a maximum of three to four unsuccessful cycles, case should be reviewed and move towards IVF is a reasonable approach.

So IUI remains the first line simple treatment for childless couples, there is no need to panic.