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Artificial Insemination

Artificial Insemination (AI) also called intra uterine insemination (IUI) can be used as a treatment for many causes of infertility, provided you can produce an egg, there is a reasonable quality semen test and there is at least one fallopian tube working. However, depending on the cause(s) of infertility there can be other treatments that might also be successful. Disorders of egg production can be treated with a variety of medicines to bring on ovulation. Surgery might be an option for some forms of Fallopian tube problems. More severe abnormalities of semen, or blocked tubes are best treated with IVF. If you aren’t clear about why IUI is the best option for you at this present point in time, discuss your specific situation with your specialist or nurse.

IUI has the advantage of lower costs than most other forms of treatment. It is less intrusive than IVF. The disadvantages compared with IVF include the lower success rate and depending upon how it is managed, a possibly higher risk of multiple pregnancy.

IUI stands for Intra Uterine Insemination – which literally means that sperm are placed inside the uterus. Insemination was beginning to be used as early as 1780 in the animal world. The technique has been refined and the success rates of treatment have increased greatly since the early days. IUI is still undergoing a process of evolution to try to maximize pregnancy rates, minimize the risks and make it as easy as possible for couples.

The Basic Steps

In order to achieve a pregnancy, you need to produce one or more eggs, and your partner needs a reasonable quality semen sample. In some couples they don’t need any extra help with this. Medications may be administered to stimulate the ovary to produce eggs if there is a problem with egg production.

During your IUI cycle you will be monitored to see how you are responding during the cycle and to give you the best chance of a successful outcome.

Semen collection is done by masturbation either at your home or at the clinic depending upon how far from the clinic you live and what is most comfortable for your partner. The sample is then dropped into the laboratory on the day of the planned insemination.

The IUI Process:
Stimulation Phase

If you have no trouble with egg production (or ovulation) then you may not need to use any medications, however, if there are some difficulties with egg production then either oral or injectable medications may be used. The most commonly used oral medicine for stimulation purposes is Clomiphene citrate (Clomid), which gently stimulates the ovary to produce an egg, or more than one egg. Some clinics are also using Letrozole which works very similar to Clomid.

Even if you ovulate on your own, the use of Clomiphene or Letrozole may be advised to improve your chance of success.

Occasionally Clomiphene or Letrozole is not able to bring on ovulation. If this happens then there maybe other choices offered to you. These choices include – ovarian drilling surgery, metformin therapy, or FSH injections. Women with polycystic ovary syndrome who don’t respond to Clomiphene often benefit from ovarian drilling surgery. This is a laparoscopic procedure that involves making a small cut in the belly button and inserting a telescope so that the internal organs including the ovaries can be seen. Other small cuts are made to insert additional instruments and a number of small holes are made in the surface of the ovary using an electric current (diathermy). This can result in women being able to ovulate on their own, or at least make them respond better to Clomiphene or Letrozole.

Also for women with polycystic ovary syndrome, metformin can be used in addition to Clomiphene?Letrozole to help the medication to work more effectively. Metformin tablets are more commonly used in treating diabetes.

If neither of these is appropriate or they haven’t worked then stimulation of the ovary can be carried out using a low daily dose of follicle stimulating hormone (FSH) given as an injection. This is the same hormone used in IVF, but with IUI it is used in a much lower dose so that only one or 2 follicles develop.

Monitoring

Each woman’s cycle is different each month, whether we are using medicines to stimulate the cycle or not. Hence it is important for us to monitor how you are responding.

If you are using your own natural cycle, then at the very least you should be asked to test your urine for leuteinizing hormone so you know when you are about to ovulate.

For stimulated cycles a combination of blood tests and ultrasound scans are often used for your monitoring. The blood tests are looking at your oestradiol level, which is produced by the ovary. This gives a rough idea of what is happening in terms of egg production.

The ultrasound scans are done as transvaginal procedures. This permits a close look at the ovary to see what is going on. What we are looking for are the black collections of fluid in the ovary called follicles. Generally each follicle will be home to one egg, never more. We can count how many there are, and measure how big they are. Once the follicle is 18 mm or more in size the eggs are generally ready for ovulation.

Monitoring Artificial Insemination

Generally you need between 1 and 2 ultrasound scans during your cycle, sometimes more.

As a consequence of your monitoring it might be recommended that you –

  • not make any changes at all to the original treatment plan,
  • increase or decrease the number of days before your insemination,
  • cancel your cycle and stop your treatment completely. This may happen if you have more than 2 mature follicles on scan before your insemination.
Trigger Shot

Once your ultrasound confirms the presence of a mature follicle or two, one of two things may occur. At Fertility Solutions you can start on urine testing kits for leuteinizing hormone (LH) to pick when you are ovulating or you will be given an injection of LH so insemination can be planned for the same day or the day after the trigger shot.

Semen Preparation

If you are using your partners’ sperm for the insemination then the clinic will require the sample to the laboratory about a 1 ½ before the scheduled time for your insemination. The scientist will then assess the quality of the sample and compare it with any previous samples.

Any sperm that are not moving vigorously are washed out of the sample, along with some chemicals normally found in semen that can cause strong cramping in the uterus. The remaining sperm are concentrated into a very small volume of culture medium ready to be used for the insemination. This process can take around 2 hours.

Intrauterine Insemination (IU)

Insemination

Putting the semen sample into your uterus is a pretty straight forward procedure that will happen in the clinic. In fact it is very similar to having a pap smear. You will be asked to remove your underwear, and sit in a special chair that allows easy access. A warmed speculum is placed in the vagina so that the cervix (neck of the womb) can be seen. A thin tube is passed through the cervix into the lower part of the uterus and the sample or prepared sperm is placed into the uterus. The speculum is then removed and you will be asked to rest in that position for a minute or two. You are then free to get dressed and go.

Controlled Ovarian Hyperstimulation (COH), Intra-Uterine Insemination (IUI)

After the procedure you may find that some of the sample leaks back out again-THIS IS NORMAL. Don’t panic, this happens to everyone and doesn’t affect your chances of success. The clinic should supply you with a panty liner to wear to make the after procedure time more comfortable.

Possible Problems With The Insemination Procedure

It can sometimes be difficult inserting the insemination catheter through the cervix into the uterus. Whilst this is very uncommon, it it occurs you may be asked to drink some water so that your bladder fills which can help with the insemination procedure. It doing this and changing positions does not help, an instrument called a tenaculum might be used to hold your cervix and pull down on it to straighten it out in order to insert the insemination catheter. This can be uncomfortable and can cause bleeding. This bleeding will not alter the success rates of your treatment.

Even though many of the chemicals have been “washed” out of the semen sample that can cause cramping, this can sometimes occur. It generally passes quickly. A hot water bottle can help. You can take Panadol if it is more serious, but do not to take any other pain relievers unless you have spoken to your care provider first.

Very rarely the process of insemination can push germs from the vagina into the uterus and cause an infection. If this happens you would develop some or all of the following – an offensive vaginal discharge, worsening pain, fevers, general feelings of being unwell, and sometimes spotting.

If you think that this is happening please contact the clinic as soon as possible.

After Your Insemination Procedure
Luteal Phase Hormonal Support

In a normal cycle the time between ovulation and the next period (or not if you are pregnant) is called the luteal phase. This is a time when the body makes large amounts of progesterone hormone. Progesterone prepares the uterine lining for the embryo and supports the early development of the embryo after implantation. Without adequate progesterone the lining of the uterus can start to breakdown early.

If you have used your own natural cycle or Clomiphene/Letrozole then generally your body does a pretty good job of producing its own progesterone. Sometimes it might be recommended that you are given extra hormone support during this time to improve your chance of pregnancy.

There are different ways that can be used to keep your progesterone levels high at this stage. One option is to have an injection of Pregnyl on specific days post insemination. These injections stimulate the ovary to produce progesterone. The disadvantages to this are firstly, that it’s an injection and secondly it can increase your chance of developing a complication called Ovarian Hyperstimulation Syndrome. The use of these injections can also produce a false positive pregnancy test as the hormone injected is the same hormone that your body produces when it is pregnant.

Progesterone can also be given as a vaginal gel called Crinone or in a pessary form – like a bullet shaped tablet that goes in the vagina. The progesterone is absorbed very well through the skin of the vagina. It can’t be taken as an oral tablet as stomach acid destroys the hormone. Whichever one of these you use it can get a bit messy by the end of your cycle, and you will find it more comfortable with a panty liner.

If you have been commenced on luteal phase hormonal support then you need to keep taking it until you have spoken to the clinic on the day of your pregnancy test. If you have a positive test you may be asked to continue hormone support. Your doctor will decide when to decrease and then stop this.

What To Do After Your Insemination

The basic principle is to get on with your life, without overdoing anything. You certainly don’t need to spend 2 weeks in bed with your legs up the wall! Heavy physical work or extremes of temperatures (like a sauna) are not a good idea. Basically you should behave like you would during a pregnancy in terms of alcohol intake, diet and any medications you might use.

Do watch out for any unusual pain, bloating, vomiting or bleeding at this stage. If anything unusual is happening let your clinic know what is going on.

Pregnancy Testing

Pregnancy Testing after artificial inseminationSixteen days after your insemination we want you to do a pregnancy test. Any good quality brand name test from the chemist will do. Follow the instructions in the pack. If you are on luteal phase hormonal support they can stop you from having a period even if you aren’t pregnant so please don’t assume that no period means that you are pregnant. Likewise you can get some bleeding around period time and still have a successful pregnancy.

Once you have tested please ring the clinic and let your Nurse know the outcome. You will be given further instructions about what to do next.

The Dreaded Two Week Wait….

The time between your insemination day and your pregnancy test sometimes feels like the longest time in the world, with wild swings in your emotions. This can be in part due to the effects of any hormones you are on which can give you really strong premenstrual symptoms. Being warned in advance that it might be like this can help. Plan to take it easy during this time, as you aren’t going to manage big stressful situations as well as you normally would. Plan some pampering time for you, both on your own and together as a couple.

The clinic’s nurses and counselors’ are available to you if it all gets to be too much and you need someone to talk to.

It is fairly standard to have up to 3 IUI cycles depending upon your individual situation.

Further Reading: You may also enjoy our recent blog post “Understanding Artificial Insemination“.