Artificial Insemination

Background

Infertility is defined as the inability to achieve a pregnancy after a year of spontaneous attempts. Infertility affects about 10% to 15% of the reproductive-age population, though the rate varies depending on the age of the women. Infertility is less common in younger women and more common in older women. When a couple is unable to conceive, an evaluation is performed; a treatment plan is developed based on this evaluation and the couple's personal history.

Intrauterine insemination (IUI) with or without controlled ovarian hyperstimulation (COH) is typically recommended for women with an ovulatory problem, unilateral tubal disease, cervical origin early-stage endometriosis, or no identifiable causes (so-called unexplained infertility). This treatment has a number of advantages. The medication required is minimal, the procedure is noninvasive, the laboratory requirements are not overly complex, and most importantly, it is inexpensive.

The efficacy, on the other hand, is not very high. During each cycle, a healthy young couple attempting to become pregnant naturally has a 25% chance of success. IUI pregnancy rates range from 10% to 20% (per cycle), and cumulative pregnancy rates range from 30% to 45%. Aside from the relatively low success rates, another issue with IUI is the risk of multiple gestations, particularly high order multiple gestation, when multiple follicles are stimulated to grow.

Intrauterine insemination (IUI) Definition

Intrauterine insemination (IUI) is a technique for assisting conception that involves the placement of a processed sperm sample in the upper uterine cavity, overcoming natural barriers to sperm ascent in the female reproductive tract.

It is a cost-effective, noninvasive first-line therapy for patients with functionally normal tubes and infertility caused by a cervical factor, anovulation, moderate male factor, unexplained factors, immunological factor, and ejaculatory disorders, with clinical pregnancy rates per cycle ranging from 10 to 20%.

Despite revolutionary advances in the field of assisted reproduction, such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and subzonal insemination (SUZI), intrauterine insemination (IUI) continues to be an inexpensive, noninvasive, and effective first-line therapy for selected patients with cervical factor, moderate male factor, unexplained infertility, immunological infertility, and infertility due to ejaculatory

Though the technique of IUI has essentially remained the same, several advances in stimulation protocols, gonadotropins, sperm preparation techniques, and ultrasound monitoring have resulted in promising IUI success rates.

Age of the patient, duration of infertility, stimulation protocol, infertility etiology, number of cycles, timing of insemination, number of preovulatory follicles on the day of hCG, processed total motile sperm > 10 million, and insemination count > 1 106 with > 4 percent normal spermatozoa are all important prognostic indicators of success with IUI.

Alternative insemination techniques, such as Fallopian tube sperm perfusion, intracervical insemination, and intratubal insemination, offer no advantage over IUI. Individualizing the treatment protocol based on the patient characteristics with a strict cancelation policy to limit multi-follicular development may help optimize IUI pregnancy outcomes. A complete couple workup that includes patient history, physical examination, and clinical and laboratory investigations is required to justify the choice in favor of IUI and guide alternative patient management.

IUI can take place with or without ovarian stimulation. Controlled ovarian stimulation, particularly with low-dose gonadotropins, combined with IUI provides a significant advantage in terms of pregnancy outcomes when compared to natural cycle or timed intercourse, while also reducing associated COH complications such as multiple pregnancies and ovarian hyperstimulation syndrome.

When is Artificial Insemination helpful?

There are numerous reasons why couples struggle to conceive. Some of them may benefit from IUI.

Unexplained causes:

When no cause of infertility is found, IUI is most commonly used. Infertile women may take medications (by mouth or injection) that cause their ovaries to mature multiple eggs at the same time. The goal is to increase the likelihood of pregnancy by bringing more sperm into contact with more eggs.

Cervical stenosis or abnormalities:

When a woman's cervix has scarring that prevents sperm from entering the uterus through the vagina, IUI can help. This is common in women who have had cervix surgery (cryosurgery, cone biopsy, Loop Electrosurgical Excision Procedure, etc.). IUI can also help when a woman's cervix is abnormally shaped, preventing sperm from passing through.

Problems with sperm delivery:

IUI can also be used in couples where the male partner is unable to become or remain erect, or is unable to ejaculate effectively or at all. Retrograde ejaculation, for example, occurs when sperm are released backward into the bladder rather than through the penis during male orgasm. Retrograde ejaculation can be caused by previous surgeries or medical conditions such as diabetes. IUI may also be beneficial if the man has an abnormal urethral opening.

Lack of ovulation (anovulation):

Women who do not release an egg on a regular basis (ovulate) can usually become pregnant through intercourse. IUI can be beneficial in some cases.

Fertility preservation:

Before having a vasectomy, testicular surgery, or radiation/chemotherapy treatment for cancer, men can collect and freeze (cryopreserve) their sperm for future use. The sperm can be thawed and used for IUI later.

Third-party reproduction:

IUI is used to have a baby when a couple uses sperm from a man who is not the woman's partner. This is known as donor insemination (DI). DI is used when the male partner lacks sperm or when the quality of his sperm is so poor that it cannot be used for conception and in vitro fertilization is not an option. DI can also be used if a man has certain genetic diseases that he does not want his children to possess. DI may also be considered by single women or lesbian couples who want to have a baby.

Disadvantages of A.I:

• It necessitates well-trained personnel and specialized equipment.
• It takes longer than natural services.
• On the part of the operator, knowledge of the structure and function of reproduction is required.
• Inadequate cleaning of instruments and sanitary conditions may result in decreased fertility.
• The spread of genital diseases will be accelerated if the bull is not properly tested.
• The market for bulls will shrink, while the market for superior bulls will grow.

How you prepare?

Intrauterine insemination involves careful coordination before the actual procedure:

• Getting the sperm sample ready. At the doctor's office, your partner provides a sperm sample, or a vial of frozen donor sperm can be thawed and prepared. Because nonsperm elements in sperm can cause reactions in the woman's body that disrupt fertilization, the sample will be washed to separate highly active, normal sperm from lower quality sperm and other elements. Using a small, highly concentrated sample of healthy sperm increases the likelihood of achieving pregnancy.

• Monitoring for ovulation. Because the timing of IUI is critical, it is critical to watch for signs of impending ovulation. You could use an at-home urine ovulation predictor kit to detect when your body produces a surge or release of luteinizing hormone to accomplish this (LH). Transvaginal ultrasound is another imaging method that allows your doctor to see your ovaries and egg growth. You may also be given an injection of human chorionic gonadotropin (HCG) or medications to induce ovulation of one or more eggs at the appropriate time.

How are sperm collected?

There are several methods for obtaining the sperm required for IUI. Typically, the man masturbates into a sterile glass or plastic cup provided by the doctor's office or andrology laboratory, a laboratory that specializes in male health issues. Sperm can also be collected during sex using a special condom provided by the doctor. If a man has retrograde ejaculation, sperm can be extracted from urine he has collected in a laboratory.

Men who have difficulty erectioning or ejaculating despite medication, as well as men with a spinal cord injury, may be able to produce a sperm sample with the assistance of vibratory stimulation or electroejaculation. Vibratory stimulation is most commonly used in the workplace and is performed with a handheld vibratory device.

Electroejaculation is a technique that uses electrical stimulation to produce a sperm specimen. Electroejaculation is commonly performed in the office for men with a complete spinal cord injury, whereas patients with an incomplete spinal cord injury may have an electroejaculation procedure performed under anesthesia in the operating room.

SEMEN STORAGE

The discovery that bull sperm can be successfully frozen and stored for indefinite periods of time has transformed AI in cattle. In 1949, British scientists discovered that adding glycerol to the sperm extender improved sperm freezing resistance. Glycerol acts to remove water from the sperm cell prior to freezing, thereby preventing the formation of cellular ice crystals, which would otherwise damage the sperm.

Dry ice and alcohol (-100 degrees F) and liquid nitrogen are the two methods for freezing and storing sperm (-320 degrees F). Because there is no evidence of fertility deterioration with age, liquid nitrogen is preferred. Fertility gradually declines in dry ice-alcohol-stored sperm.

If the proper temperature is maintained, frozen sperm can be stored indefinitely. A calf was born from frozen sperm that had been stored for 16 years, according to a recent report. Fresh, liquid sperm can be successfully stored at 40 degrees F for 1 to 4 days. Glass ampoules are commonly used to store sperm. Other methods, particularly the French-straw method, appear to be promising.

Several AI companies have solely relied on this method. To differentiate one breed from another, artificial coloring is frequently added to sperm extenders. Each individual semen container must bear a complete identification of the bull.

How is the procedure performed?

The cervix controls the number of sperm that enters the uterus. This means that only a small percentage of the sperm in the ejaculate enters the fallopian tubes. IUI is a procedure that places sperm past the cervix and into a woman's uterus around the time of ovulation. This shortens the path to the fallopian tubes, increasing the likelihood that more sperm will encounter the egg. The purpose of this procedure is to increase a woman's chances of conceiving.

The semen processing time, processed total motile sperm count, rapid progressive motility after processing, sperm morphology before and after processing, inseminating motile sperm count (IMSC), IUI insemination time, and 24-h sperm survival are all parameters that must be considered in an IUI program. Delaying semen processing from 30 minutes to 1 hour and/or IUI from 90 minutes to 2 hours after collection jeopardizes pregnancy outcomes in gonadotropin-IUI cycles.

Uterine contractibility is thought to be a powerful prognostic factor in predicting the outcome of embryo transfer. Furthermore, prostaglandins, which are produced by cyclooxygenase from arachidonic acid, are known to stimulate uterine contractions. As a result, using anti-inflammatory and relaxant agents to suppress the inflammatory response and contractions is expected to increase the success rate of embryo transfer and artificial insemination.

Insemination can take place at various times around ovulation, and it can be done once or several times. In the majority of published studies, insemination occurs 32–36 hours after hCG administration. Because it is assumed that the timing of insemination relative to ovulation is critical for an optimal success rate, it is surprising that few studies have been designed to determine the optimal time for insemination.

During the procedure

You put your legs into stirrups while lying on an exam table. Your doctor inserts a speculum into your vagina, similar to how a Pap test is performed. During the procedure, the doctor or nurse will do the following:

• A vial containing a sample of healthy sperm is attached to the end of a long, thin, flexible tube 
• Inserts the catheter through the vaginal opening, into the cervical opening, and into the uterus.
• Pushes the sperm sample into the uterus via the tube.
• Removes the catheter, then the speculum.

What is IUI’s Success Rate?

Several factors influence the success of IUI. If a couple undergoes the procedure every month, success rates can reach as high as 20% per cycle, depending on factors such as female age, the cause of infertility, and whether fertility drugs were used, among others.

IUI is most effective in patients with unexplained infertility, women with a cervix that restricts sperm passage, and men who can't ejaculate effectively. For example, in the case of unexplained infertility, IUI has a pregnancy rate that is twice that of no treatment.

IUI is less effective for men who produce few sperm or have severe sperm abnormalities, and it is ineffective for women who have severe fallopian tube disease, moderate to severe endometriosis, or a history of pelvic (lower belly) infections. For these patients, other fertility treatments are preferable.

Overall, success rates can improve if inseminations are performed once a month with fresh or frozen sperm. The success rate is affected by the use of fertility medications, the age of the woman, the diagnosis of infertility, and other factors.

While IUI is a less invasive and less expensive option, the pregnancy rate is lower than with IVF. If you believe you might be interested in IUI, consult with your doctor to go over your options. Some couples prefer to try more traditional or over-the-counter methods before considering infertility procedures.

Wait at least two weeks before using an at-home pregnancy test. Testing too soon could result in the following:

• False-negative. If pregnancy hormones have not yet reached detectable levels, the test result may be negative when you are, in fact, pregnant.
• False-positive. If you're taking ovulation-inducing medication, such as HCG, the medication that's still circulating in your body could indicate that you're pregnant when you're not.

Are there any risks?

Some women experience mild cramps similar to menstrual cramps, but the risks of IUI are minimal.

There is a slight risk of developing ovarian hyperstimulation syndrome if you use fertility medication to stimulate ovulation. There's also a chance you'll have more than one child, which carries additional risks for both you and your children. All children, whether conceived naturally or through IUI, have a 2% to 4% chance of having birth defects. The likelihood of developing an infection following an IUI is low.

Contraindications

IUI is not recommended in women who have cervical atresia, cervicitis, endometritis, or bilateral tubal obstruction, as well as in the majority of cases of amenorrhea or severe oligospermia.

Artificial Insemination Cost

The cost of artificial insemination varies depending on whether a couple uses their own sperm or donor sperm, as well as the procedure used. Most doctors report that the cost of intrauterine insemination ranges between $300 and $1000 per cycle, with intracervical insemination costing less.

Many couples will first try artificial insemination before moving on to more expensive in-vitro insemination (IVF). Because the success rate isn't particularly high, some people will try more than one round of this treatment. Some health insurance policies may cover the procedure for at least one round, as well as some of the additional costs associated with the procedure, such as scans or medications.

The cost of IVF is much higher, but so is the success rate, with studies showing that in-vitro fertilization works in approximately 54 % of all cases, particularly if the woman is under the age of 35.

Conclusion 

IUI is a simple, cost-effective, noninvasive first-line therapy for cervical factor, anovulatory infertility, moderate male factor, unexplained infertility, and immunological infertility with clinical pregnancy rates ranging from 10 to 20%. 

Controlled ovarian hyperstimulation with close monitoring of folliculogenesis and ovulation to avoid adverse complications, such as ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies, may be used to obtain the adequate number of follicles. 

IUI is the preferred conception-enhancing technique for women < 35 years, functional tubes, short period of infertility, and moderate male infertility, particularly in technology-limited settings, and four to six IUI cycles may be performed before considering alternate therapy such as IVF . It is the method of choice versus timed intercourse or natural cycle IUI .