IUI

Intrauterine insemination (IUI) is a first-line infertility treatment that consists of placing prepared sperm within the uterus around the time of ovulation. The IUI procedure is used to treat infertility due to slightly low sperm concentration or motility, poor cervical mucus, coital difficulty and unexplained infertility. IUI can be done with partner’s fresh or frozen sperm or with frozen donor sperm.

The live birth rate per cycle is about 10-12%. The likelihood of success with IUI depends on the type and severity of the infertility problem and the woman’s age. According to California Health and Safety Code Section 1644.5, male partners must be checked for the following infectious diseases before the IUI procedure can be performed: HIV (causative agent of AIDS), hepatitis B & C, HTLV and syphilis (RPR). Sperm donors, whether directed or anonymous, undergo a much more rigorous screening and testing process dictated by the FDA regulations.

The preparation or washing of semen by gentle centrifugation accomplishes two things:

• It removes the seminal fluid’s white cells, bacteria and prostaglandin hormones which can cause painful uterine contractions and allergic reactions.
• It selects the most active, vigorous sperm which are suspended in a small volume of fluid for placement within the uterus.

IUI is an office procedure. The doctor passes a small tube or catheter with the sperm through the cervix into the uterus, depositing the sperm in the uterine cavity. Most of the time, this is a simple procedure that causes minimal, if any, discomfort. Occasionally, it can be technically difficult and uncomfortable. The IUI procedure is very safe, but carries a small risk of introducing infection into the uterus and tubes. 

Ovarian Stimulation

Ovarian stimulation can be accomplished either with synthetic oral medication, such as clomiphene or letrazole, which makes your body release more FSH (follicle stimulating hormone) or with injectable preparations containing FSH. FSH is normally secreted by the pituitary gland. The currently available brand names of FSH preparations are: Follistim, Gonal-F and Bravelle. Menopur is the brand name of an FSH/LH preparation.

Gonadotropins are used primarily in two groups of women: 

1) those who do not ovulate regularly and/or have failed to ovulate and/or conceive with oral agents such as clomiphene and letrazole; 

2) women who ovulate on their own but may benefit from simultaneous ovulation of multiple eggs and the accompanying enhanced hormonal environment.

In most cases, ovarian stimulation is combined with an IUI procedure which places more sperm in proximity of the eggs than usual. Current California regulations require that male partners be tested for HIV (causative agent of AIDS), Hepatitis B and C, HTLV and syphilis (RPR) before their sperm can be used for an IUI procedure.

FSH and LH are natural but potent hormones. Their use is generally safe but requires experience and close monitoring. Like all medications, gonadotropins have side effects. Ovarian enlargement, known as OHSS (ovarian hyper-stimulation syndrome) is the most common serious complication of gonadotropin use. Mild forms of OHSS can be treated by bedrest, but in severe cases, intravenous fluids, drainage of excess fluid from the abdomen and even hospitalization might be necessary.  

The risk of multiple births after gonadotropins is approximately 20%, with the majority being twins. Some older reports have linked the use of fertility drugs, such as gonadotropins and clomiphene, with increased risk of developing ovarian tumors, including cancer of the ovary, later in life but more recent larger studies have not supported this association.

You may experience small amount of bleeding, pain or redness at the injection sites.  Warm soaks with wet washcloths may help alleviate the discomfort.  Some women report fatigue and/or headaches. If you have a headache while on gonadotropins, you can take acetaminophen (Tylenol) but we do not recommend aspirin. In some cases gonadotropins are used together with clomiphene, leuprolide (Lupron) or ganirelix/cetrotide.

Gonadotropins are usually started 2-5 days after the onset of menses. If your period starts before 4:00 p.m., call our office at (510) 649-0440 in order to schedule a baseline ultrasound.  If your period starts after 4:00 p.m., call the office the next day.  On weekends and holidays, leave a message on the answering machine. The first day of your period is defined by onset of regular flow, not just spotting. Prior to starting the injections, a baseline ultrasound is done to detect any pre-existing ovarian cysts. A vaginal probe is used so a full bladder is not necessary. Small simple cysts are common and they usually resolve on their own. However, if a large cyst is found, the treatment cycle may be delayed.

Bring your medications to the baseline ultrasound appointment so the nurse can review the injection technique and provide you with additional supplies. Response to FSH varies greatly from woman to woman. The particular protocol, start date, dosage and length of treatment will be tailored specifically for you. Please make sure we have your current phone numbers as frequent communication is necessary. 

After 2-4 days of injections you return for an estradiol blood test and/or an ultrasound. Estradiol hormone is secreted by the growing follicles. The blood is drawn in our office  between 8:30 and 10:00 AM and ultrasounds are generally scheduled at the same times. In the afternoon of the days on which you have a blood test, we call you with instructions about the dose of gonadotropins for that evening and the following day as well as the time of your next blood test and/or ultrasound. If you have any questions about your instructions, please call our office at (510) 649-0440 by 4 PM.

Eggs are contained within follicles (fluid-filled sacs) which are readily seen with ultrasound. Ultrasound is harmless to you and the developing eggs. Depending on the growth of the follicles and the estradiol levels, variable doses of gonadotropins are given for a total of 6-10 days. When the ultrasounds and blood tests indicate that the follicles are mature, a single injection of hCG (human chorionic gonadotropin) or leuprolide is given to trigger ovulation. Based on when you receive your hCG injection, you will be given instructions about the timing of IUI or intercourse. HCG is a natural hormone similar to LH hormone which triggers ovulation in a spontaneous cycle. The common brands of hCG are Ovidrel, Novarel and Pregnyl. Novarel needs to be mixed in our office before use. 

Following IUI most  patients take vaginal progesterone which may delay your menses even in the absence of a pregnancy. If you are not pregnant, your period is expected about 14 days after the day of insemination.If your period is more than 2-3 days late, please call the office to schedule a quantitative HCG test before stopping progesterone supplementation.

Selecting Donor Sperm

You may choose to pursue conception with frozen sperm from an anonymous sperm donor. A partial list of licensed sperm banks currently registered with the FDA is provided below. In order to minimize transmission of infections through donor sperm, the FDA mandates extensive screening and a 180-day quarantine followed by repeat screening before the specimens are released to consumers. When the sperm is shipped or brought into the office, it has to be accompanied by the Summary of Records which details that all the tests required by the FDA were done. Without this document we cannot perform the IUI.

Most sperm banks provide IUI-ready specimens which have been “washed” before freezing and can be used immediately upon thawing. If you order a specimen which was not “washed” before freezing (at times called ICI-ready i.e. suitable for intra-cervical insemination), such a specimen needs to be processed after thawing and before the IUI at an extra charge. 

Recipient Screening: CMV IgG Antibody & Rh Factor

It is our recommendation that recipients have the following tests in advance of IUI: Blood type and Rh factor (+ or -), Rubella IgG Antibody, Varicella IgG Antibody, HIV Antibody, Hepatitis Bs Antigen, Hepatitis C Antibody, RPR and CMV IgG Antibody. 

For maximum safety women who test negative for CMV IgG Antibody may wish to use a sperm donor who is also negative for the CMV IgG Antibody. If the recipient has either tested negative for CMV IgG or has not been tested for CMV IgG but has chosen a sperm donor who is positive for CMV IgG, she will need to sign a waiver before the IUI is performed. Likewise, women who are Rh- may wish to select an Rh- donor.

Open Identity Donors

Whereas sperm donors have been traditionally anonymous and thus not open to future contact with the offspring, recently some sperm banks have recruited donors who are willing to have their identity released when the child reaches maturity.

Our IUI patients come to us from the Bay Area, Berkeley, Oakland, Sacramento, San Francisco and neighboring locations.