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Artificial Insemination/IUI and Other Fertility Treatments
Although in vitro fertilization is a very well-known fertility treatment procedure, only 20 to 30 percent of patients will undergo IVF. The majority of couples will succeed in becoming pregnant through traditional or surgical treatments. At our offices in the Chicago, Illinois area, infertility treatment such as artificial insemination (usually IUI, or intrauterine insemination) is offered for patients who can benefit from such procedures.
Traditional Medical Treatments
Infertility treatment procedures labeled as "traditional" or "conventional" involve increasing the chances of natural conception without actually manipulating the fertilization process. This includes ovulation induction, in which fertility medications are given to stimulate the ovaries, and intrauterine insemination, in which washed and sorted sperm are placed directly into the uterine cavity.
This type of infertility treatment is beneficial for women who do not ovulate regularly, couples with mild to moderate male factor infertility, and many patients who have unexplained infertility. Artificial insemination is also an effective method for bypassing hostile cervical mucus and other obstacles to conception.
Artificial Insemination / Intrauterine Insemination (IUI)
Couples who struggle with fertility problems such as poor sperm quality or inhospitable cervical mucus can often benefit from artificial insemination. This is generally accomplished through intrauterine insemination (IUI), which makes it possible to bypass the cervix and cervical mucus and deliver a concentration of living, healthy, motile sperm directly into the uterus.
The IUI Procedure
The IUI procedure is a simple process that takes very little time and involves minimal discomfort. Just before ovulation takes place, the sperm is collected and processed. Once prepared, the sperm will be deposited into the uterus by means of a small catheter that is placed through the cervix.
It is extremely important to correctly time this procedure so that artificial insemination coincides with ovulation. The woman's natural cycle can be monitored by blood testing, ultrasound examinations, or with the use of a special kit that detects increased luteinizing hormone (LH) in the urine. A spike in luteinizing hormone precedes ovulation and indicates when a woman is most fertile. In some cases, fertility medications may be used to induce ovulation as well.
At FCI, we perform IUIs seven days a week. Your husband/partner can collect his specimen at home in the sterile container that we provide, or he can use the collection rooms available at each of our offices. The specimen should ideally get to us within one hour of collection at home. If you have to bring in the specimen, you will spend more time in the office waiting for the sperm to be prepared. If he can bring it in or collect in the office, you spend far less time in the office.
It takes approximately one hour to process the sperm. Sperm washing is performed to separate out the sperm from the debris and chemicals in the semen that don't belong inside the uterus. Then a "swim up technique" is used to separate out the better swimmers to improve the motility of the specimen.
During the IUI procedure, a thin, soft plastic catheter is used to deposit a few concentrated drops of millions of highly motile sperm into the top of the uterus. This procedure takes one to two minutes and is generally painless or very mildly uncomfortable. Thousands of motile sperm will make it to the fallopian tubes. Then we have you rest, lying down for 10 minutes in order to minimize uterine contractions. After that there are no restrictions.
Most studies indicate that with Clomid® therapy, one IUI per month is almost as good as two, but there are exceptions such as when using frozen sperm. If the man's sperm count is reasonable we will often suggest two IUIs per month. One week after the IUI, we check progesterone levels and supplement it with natural progesterone as needed. Then, we perform a pregnancy test two weeks after the IUI.
Artificial Insemination with Donor Sperm
Artificial insemination with donor sperm is an infertility treatment option for couples with severe male factor infertility or those who wish to avoid passing a genetic condition from father to child. It also offers single women and lesbian couples the opportunity to become pregnant. For patient safety, all donated sperm must be processed, cryopreserved, and quarantined for six months before use.
Ovulation induction is a common infertility treatment that uses fertility medications to stimulate the ovaries and induce ovulation. Women with ovarian dysfunction or other fertility complications may increase their chances of conceiving through ovulation induction.
The most common type of fertility medication used to stimulate ovarian function is clomiphene citrate, which is packaged under the brand name Clomid®. By mimicking the chemical structure of estrogen, clomiphene citrate triggers the body to release follicle stimulating hormone (FSH), which is responsible for the development of ovarian follicles and maturation of the eggs within. Clomiphene citrate is taken orally for five days, beginning on cycle day three, four, or five, during which time the ovaries will be monitored via ultrasound. When ovulation is imminent, sperm should be introduced via intercourse or artificial insemination within 24 to 38 hours to maximize the chances of conception. With IUI, the timing is very important. We will usually perform an ultrasound four or five days after the last Clomid® pill has been taken. If the follicles are mature (19 mm or larger) we give the patient an injection of HCG hormone, a pregnancy hormone which mimics the LH (luteinizing hormone) surge. This HCG injection will ideally cause one to ovulate within 24 to 38 hours later, allowing for excellent timing. We perform IUI seven days a week to ensure appropriate timing. Clomid® with IUI is relatively easy to perform, and is less expensive and less risky than other options.
To learn more, read Dr. Jacobs' article about Clomid® and IUI (PDF)
Gonadotropin (FSH) injections have some significant advantages as well as disadvantages compared to Clomid®. There are many excellent FSH medications, including Bravelle®, Follistim®, and Gonal-F®. FSH injections are more potent than Clomid®, and we therefore expect more egg development; however we ideally want to see no more than two or three mature follicles. With FSH injection medications, any follicle 16 mm or larger will usually ovulate. Unfortunately, on rare occasions follicles as small as 14-15 mm may ovulate, leading to a higher risk of ovarian hyperstimulation (OHSS) and/or multiple births. Another advantage of the FSH therapy is that the cervical mucus quality is much improved compared to Clomid® since the patient will produce larger amounts of estrogen as more follicles develop. Another advantage of the higher estrogen levels is that the uterine lining will be much better stimulated than with Clomid®. For these reasons (more eggs, improved cervical mucus, and a better uterine lining) the pregnancy rates with FSH therapy are higher than with Clomid®.
However, the disadvantages of FSH therapy compared to Clomid® include:
More labor intensive monitoring of the patient's ovaries (lab and ultrasound) is necessary:
The average woman may require 7-10 days of injections. We teach our patients to perform the injections; however, patients will need more intensive monitoring and may have four or five visits to the office for ultrasound and estrogen blood tests. This helps determine the appropriate dose of FSH so that we can achieve a safe stimulation of the ovaries with a handful of mature eggs being released.
Considerably higher cost:
When performing FSH injections, the average couple can spend $2000-$3000 or more than with Clomid®, because more blood tests and ultrasounds are needed and the medication costs more. However, most insurance companies that pay for infertility treatment will cover this therapy.
Higher risk of multiples:
With FSH, we can expect approximately 20 percent twins compared to 6-8 percent with Clomid®; 4 percent triplets for FSH compared to approximately 1 set of triplets in 500 pregnancies with Clomid®. On rare occasions, we see quadruplets or more due to the inability to control exactly how many eggs will release when using FSH injections.
Combination of Medications
Occasionally, we will use a combination of five days of Clomid®, plus a few days of FSH injections. This "combo" therapy may improve pregnancy rates over Clomid® alone, and involves less monitoring, cost, and risk than FSH therapy alone.
It is not uncommon for infertility to be caused by a physical blockage of some kind that prevents the egg and sperm from meeting. In many cases, such blockages can be removed surgically, allowing conception to happen naturally thereafter. Whenever possible, minimally invasive surgical techniques, such as laparoscopy and/or hysteroscopy, are used to reduce discomfort and recovery time for the patient.
A laparoscopy is a minimally invasive surgical procedure that allows physicians to view and/or operate on the structures in the abdominal cavity. Laparoscopy may be performed during infertility treatment in order to look for and correct physical abnormalities on the exterior of the uterus, fallopian tubes, and ovaries. Conditions that are typically addressed with laparoscopy include ovarian cysts, endometriosis, and pelvic adhesions.
Laparoscopy is performed while the patient is under general anesthesia. During the procedure, tiny incisions are made through the navel and along the pubic line, and the abdomen is gently inflated with carbon dioxide to allow better access and visibility. A very thin camera and specially designed instruments are inserted through the incisions in order to perform the procedure.
Once the operation is complete, the carbon dioxide is released from the abdomen and the incisions are closed. Patients will be observed in a recovery room for about two hours before being sent home.
Laparoscopy is no longer performed routinely as part of the fertility diagnostic workup, since it adds very little benefit diagnostically for most patients.
A hysteroscopy is a diagnostic procedure that focuses on the interior of the uterine cavity. By threading a tiny camera and specially designed instruments through the opening in the cervix, the doctor can identify and address such conditions as uterine polyps, fibroids, scarring, or anatomical abnormalities such as a septum.
Carbon dioxide or fluids may be used to inflate the uterus, improving visibility and accessibility during the operation. After the procedure, the patient will spend about two hours in the post-operative recovery area before being discharged.
A tubal cannulation is an infertility treatment performed to clear a blockage in the section of the fallopian tube nearest the uterus. With the patient under conscious sedation, a thin catheter is threaded through the cervical opening and into the uterine cavity. In order to confirm a blockage, X-ray sensitive dye is injected through the catheter and its movement is observed. If the dye fails to move into the tube and out into the abdominal cavity, a blockage is present. To clear it, a second, thinner catheter and guide wire are inserted into the fallopian tube in order to push out the debris.
This infertility treatment is effective for women who have both fallopian tubes blocked. After a tubal cannulation, the chances of natural conception are significantly improved, although, in some cases, a procedure such as artificial insemination/IUI may be used to help maximize the probability of success.
Contact Our Chicago, Illinois-area Infertility Treatment Center
Contact our practice in the Chicago, Illinois area to learn more about artificial insemination, IUI, or other infertility treatment options.