What is OI/IUI?
The principle of OI/IUI is to stimulate the ovaries (with fertility drugs) to produce one or more eggs, but no more than three. The man’s semen is then prepared to separate out the high quality sperm and this is placed (insemination) into the woman's womb with a fine plastic tube. Fertilisation of the eggs then can occur naturally. The insemination is timed to coincide with the ovulation.
Patient will be monitored by ultrasound and hormone blood tests to maximise the chance of pregnancy and at the same time minimise risks such as overproduction of eggs and hence reducing the risk of multiple pregnancy.
Why has OI/IUI been suggested to us?
This treatment may be appropriate if:
- The woman does not ovulate and simpler treatments such as oral ovulation agents have not worked
- The semen analysis show mild abnormalities
- The cause of infertility is unexplained
- Where donor insemination has failed to achieve pregnancy in natural cycles
Why might OI/IUI help?
If your fertility problem is due to problems with egg production (anovulation), the aim of treatment is to make the ovaries produce one egg.
However, if your problem is unexplained, or due to a mild male factor the aim is to produce two or three mature eggs. The idea being that a pregnancy is more likely if there are two or three eggs rather than the one that is normally produced. The idea behind the intra uterine insemination is that the preparation of the sperm removes the poor sperm and concentrates the good sperm, causing them to swim more efficiently. They are then deposited into the uterus so that they do not have to swim as far. In this way a much higher number of sperm make it into the tubes, thus increasing the chance of fertilising the egg(s).
How many treatment cycles will I have?
This is usually two or three cycles. If you are not pregnant after this the doctor will review you and it may be suggested that you move on to other methods such as in vitro fertilisation.
What happens in a treatment cycle?
The first step in OI/IUI involves stimulation of the ovaries with fertility hormones (gonadotrophins). It is administered to encourage the ovaries to produce one or more eggs.
Insemination needs to be performed around the time that your ovaries release the egg(s). The eggs are formed in small fluid filled sacs within the ovary called follicles. These follicles reach about 18 mm in size before the egg is released. The growth of the follicles is monitored by regular vaginal ultrasound scans and by blood tests to measure the levels of hormone produced by the follicles (oestrogen).
Ovulation is timed by detecting a hormone in the blood called Luteinising Hormone (LH). This hormone is released about 36 - 40 hours before the egg is released. Sometimes, ovulation may be triggered by an injection of a drug called human Chorionic Gonadotrophin (hCG), which simulates the effects of LH.
On the day of insemination, the man produces a semen sample at the clinic. The scientist will prepare to separate out the high quality sperm and this is placed (insemination) into the woman's womb with a fine plastic tube. The insemination procedure takes about 10 minutes and is usually painless.
In the second half of the cycle the lining of the womb has to be supported with hormone injections or vaginal pessaries of progesterone to help the embryo implant in the womb. This is called “luteal phase support” and ensures that the lining of the womb undergoes the necessary changes to allow implantation of a fertilised egg. We will usually give you progesterone pessaries ( 200mg twice daily) to use for two weeks after insemination.
There is no need for you to curtail your normal activities during or after treatment, and sexual intercourse can continue as normal.
On the fourteenth day after the IUI procedure a pregnancy test will be carried out to determine the result of the treatment.
What is the chance of success?
Your own chance of success will be influenced by a number of factors and may be different to the overall results. We will discuss these issues before you start treatment
The main influence on the success of treatment is the age of the woman. The chance of success decreases with age. Other factors that influence the cycle adversely are the duration of infertility, the number of previous attempts and the semen quality. If the woman has had previous pregnancies then she has a higher chance of conceiving.
Overall the success rates for OI/IUI are around 8-20% per treatment cycle.
What are the risk of OI/IUI?
If drugs have been used to stimulate the ovaries before insemination there is a greater risk of multiple pregnancy (usually twins or triplets). About 10-15% of all OI/IUI pregnancies will be multiple.
There are many serious risks associated with multiple births. Multiple births can lead to much higher risk of:
- Complications during pregnancy
- Premature birth and low birth rate
- Disability (cerebral palsy)
Multiple birth can create enormous strains for the parents, including financial difficulties an emotional and physical exhaustion.
There is also an increased risk of a pregnancy in the fallopian tube (ectopic). This is why the early pregnancy scans are important to establish where the pregnancy is and that it has a heartbeat.
There is always a small risk (around 2%) that a baby will have some abnormality and SIUI does not protect you from this, but the chances are certainly no greater than for a natural conception.
The drugs used to stimulate the ovaries can occasionally cause the ovaries to over respond and this can lead to a potentially serious condition called Ovarian Hyperstimulation syndrome (OHSS). OHSS is a condition whereby the ovaries become large and cystic with leakage of fluid into the abdomen. This causes swelling and discomfort. The leakage of fluid can cause dehydration and this can make the blood more likely to clot and can affect the way the kidneys and other organs work. Fortunately most cases of OHSS are usually mild to moderate, but in a few cases, if left untreated, it may become severe. If a patient who suffers OHSS becomes pregnant the pregnancy hormones produced by the baby may make the condition temporarily worse.
Ovulation Induction IUI Cycle Stimulation
Ovulation induction and Intrauterine Insemination is the generally the first line of treatment for most fertility patients who have been through a workup and diagnosed with:
Unexplained Infertility
Ovulation disorders
Male Factor with reasonable sperm count, motility and normal morphology
Women using Donor Sperm
Women who have had surgery to correct Tubal or Uterine Factor issues
The goal of OI/IUI is to recruit 2 or 3 eggs, rather than the single egg that is produced in a “natural cycle” and schedule an intrauterine insemination of a prepared semen sample on the day of ovulation. This means that more eggs are in the right place at the right time and are exposed to more sperm in the fallopian tube to enhance the likelihood that fertilization will occur.
OI/IUI cycles take place over the course of a menstrual cycle. Fertility medications are generally started on Cycle Day 2, 3, 4 or 5 when it is possible to recruit more than one follicle/egg. Some physicians may start all IUI patients on Clomid/Serophene for several months; others may start with injectable gonadotropins. Clomid/Serophene drives the pituitary gland to release more endogenous FSH than it would in a “natural cycle” while injectable gonadotropins (Bravelle, Follistim, Gonal-F, Menopur, Repronex) are the actual hormones that the pituitary produces to stimulate the ovaries to produce follicles/eggs. Ovarian response is generally monitored by TVUS (transvaginal ultrasound) and blood estradiol after 5 days of medication. The dose of injectable gonadotropins might be adjusted up or down based on response and may be continued for a total of 7 to 10 days. Once there are enough mature follicles containing eggs, the gonadotropins are discontinued and a one- time dose of an injectable HCG product (HCG, Novarel, Ovidrel, Pregnyl) is given in the evening. This cause ovulation (release of the matured eggs) 36 to 40 hours later which allows the IUI to be scheduled 2 days following HCG administration.
A semen sample is obtained and prepared in the Andrology Lab so that the sperm are separated from the seminal fluid which would never enter the uterine cavity after intercourse and thus cannot be injected into the uterus. The “washed” sample is then drawn up in a small syringe with an insemination catheter attached. A speculum exam allows visualization of the cervix, the opening to the uterine cavity. The catheter is inserted through the cervix into the uterus and the sperm are “injected” into the uterine cavity. This allows greater numbers of motile sperm to reach the fallopian tubes by placing them much closer than they would be in the vagina after intercourse. Women generally rest for 10 to 15 minutes after the insemination and then can go about their normal activities. A pregnancy test is generally scheduled 14 days after the IUI.
If there is no pregnancy after a reasonable course of OI/IUI (generally 2 to 4 cycles) more aggressive therapy such as IVF should be discussed.
