IUI: Optimizing results, minimizing complications

Abstract

Intrauterine insemination is a procedure in Assisted Reproductive Techniques (ART) where processed and concentrated motile sperms are placed directly into the uterine cavity. Although NICE [2013] recommends In Vitro Fertilisation over intrauterine insemination after 2 years of unprotected intercourse, Intrauterine Insemination (IUI) appears to be a low cost and effective option before proceeding for In Vitro Fertilisation (IVF). Minimal requirement for IUI is patency of at least one fallopian tube. Adequate number of motile sperms should be present in pre wash specimen of semen. At total sperm count 3–5 million, pregnancy rate is less than 1% per cycle. In unexplained infertility there may be undetected subtle functional defects in follicular development, maturation and ovulation like luteinised unruptured follicle, luteal phase defect. Ovarian stimulation increases the number of dominant follicles and improves their quality resulting in improvement in pregnancy rate. Single IUI has benefits of fewer visits, less cost and stress. Evidence suggests no difference in clinical pregnancy rate between single versus double IUI. WHO recommends ejaculatory abstinence of 2–7 days before semen collection (WHO, 2010), for diagnostics and semen preparation. Shorter time interval between processing and insemination leads to less sperm chromatin decondensation & sperm DNA fragmentation and higher Pregnancy Rate. The luteinizing hormone surge can be detected almost 36 hours before ovulation in serum and 24 hours before ovulation in urine. The optimal time interval between human chorionic gonadotropin (hCG) injection and IUI seems to be between 12 and 36 hours; 24 hours after leutinising hormone (LH) Surge. Nature of sperms is the best guide for choice of technique. “Swim up” techniques are recommended in cases of normozoospermia and “Density Gradient” should be chosen in cases of any pathology of semen. The pregnancy rate per cycle is highest in the first three treatment cycles. Most couples show acceptable cumulative ongoing pregnancy rates after six cycles of IUI with ovulation induction. In vitro fertilization should be considered after 3–6 cycles taking all factors into consideration.