What is Reproductive Therapy
Center head : Good evening all, myself Center head. And I would like to welcome Dr. Garima Sharma. We are having, rather we are facing so many misconceptions and myths regarding the assisted reproductive therapy or the treatment, and for the same thing like clearing all our doubts about it, Dr. Garima is here. So, I again welcome Dr. Garima Sharma.
Dr. Garima: Thank you Center head. So, welcome all of you back. I am Dr. Garima Sharma, Consultant Reproductive Medicine & Fertility Specialist, attached to Currae Hospital. So, as very rightly said by Center head, there are a few general queries, myths, which are related to day to day procedures of ART, specifically IUI. So, we decided to let’s try to do justice in clearing all the doubts and myths and also bring about the various facts that are related to a very simplified treatment, which is called us intrauterine insemination. Thank you once again, Center head, for inviting me for this.
Center head: Thank you, Garima. Basically, we hear the word IUI, it is a very common word nowadays, so I would like to know like what exactly IUI means and who needs IUI.
Dr. Garima: Okay, so IUI basically stands for intrauterine insemination. So, as the very name suggests, the meaning is there in its name; intra meaning your inside, uterine is the uterine cavity, and insemination is installation. This is the procedure whereby the semen sample is prepared and this prepared sample is instilled into the uterine cavity of the female partner, using a very fine catheter. And this is done usually around the time of ovulation of the female and this is a day care procedure, which does not require any anaesthesia.
Center head: That’s so nice, but then how does it work, I mean how does IUI increase the chances of pregnancy?
Dr. Garima: Yeah, so before coming onto that question, it is imperative for us to understand who actually are the candidates or who are the couples who would require this kind of a modality.
Center head: Right.
Dr. Garima: So to list a few ones would be a couple where there is a mild male factor in terms of mild derangement in the semen parameters, whereby the count is affected or the motility or the morphology or a combination of them. Another couple who would benefit from IUI would be those who have unexplained infertility. So, when I use this word, ‘unexplained infertility’, these are the couples who basically have everything normal. When you investigate them in terms of biochemical profile, the ultrasound assessment, the semen parameters, the tubal patency has been ensured, but despite taking certain normal or the basic fertility treatments, they have not been able to achieve pregnancy, so this subset would definitely benefit from IUI. There are other couples: in few cases like females with minimal-to-mild endometriosis; couples facing issues with coital problem, this is something which we are seeing day-to-day, particularly with the working class whereby the couples have a travelling job, the couples don’t get time to meet during the ovulatory phase or because of the stress-related issues, there are certain erectile issues which these couples face. Another subset would be typically PCOS females who have undergone you know those basic fertility, ovulation induction treatments and still they have not been able to achieve pregnancy. So, these would be a few indications where I would recommend IUI as a treatment option for fertility management. So now, addressing to your next question, how does IUI… so I would not say how does IUI bring about success, I would say how does IUI optimize your pregnancy rate over and above the natural conception or the basic fertility management.
Center head: Right, right.
Dr. Garima: The idea is you are using a prepared sample and why do you need to prepare that, you tend to increase the intensity or the density of the motile sperm count and also you want to remove the seminal plasma which basically contains certain antigens that are detrimental to the success of the fertility treatment. Secondly, when I do an IUI, I said that the sample is instilled directly into the uterine cavity, so the idea is you want to bypass all those negative barriers which these sperms face at the level of the cervix.
Center head: Right.
Dr. Garima: Also, by this procedure, you are actually reducing the distance that now the sperm has to go and meet the egg in order to achieve the pregnancy. And last of all, because the timing is around the ovulation, so you are increasing the chance that the sperm meets the egg at the right time and that’s how all these four mechanisms will optimize your pregnancy chances.
Center head: So, it’s like assisting the sperms to just go…
Dr. Garima: Exactly, you are… it’s a…
Center head: Yeah, right.
Dr. Garima: It’s a kind of a supernatural you know intercourse, whereby we are pushing this sperm to reach its destination.
Center head: That’s very nice. Are there any conditions where IUI cannot be done or it is contraindicated and all that?
Dr. Garima: Again, this is a very gray area, but there would be two conditions where I would say straight no to an IUI: one where the female has you know blocked fallopian tubes, both of them are affected, and secondly with the severe male factor that is severe reduction in the sperm count, motility and the morphology. Other parameters like severe endometriosis, prolonged duration of marriage, IUIs can be attempted but with little less success rates.
Center head: Okay. So, it seems it’s like very useful procedure, but then like, does the female patient, like she has to undergo various investigations before IUI or the male partner has to… like what are the investigations?
Dr. Garima: So per se, for the procedure of IUI, you don’t need any specific investigations because most of these couples are already investigated for the same. So, we clinicians have a checklist whereby we ascertain that your ovarian function, the endometrial thickness on an ultrasound, tubal patency, and the semen parameters have been ascertained and then we go about the IUI.
Center head: Okay. Can be like just enlist few factors which might increase the success rate of IUI?
Dr. Garima: Okay, so there are huge… there are a couple of factors which determine your success rate, so I would broadly classify them into two categories. There would be factors which are static that is they are just there and you cannot do anything about them, so to enlist them would be age, like age of the female more than 35, a prolonged duration of infertility which is counted as more than 5 years of infertility, severe endometriosis or severe male factor as the cause of infertility, and higher BMI generally considered as greater than 30 kg/ meter square for the Indian population. Now, these are static factors whereby you cannot make much changes except for yes, of course, for BMI, you can still ensure weight loss regimes. But for the other factors, the IUI success rates are little lower. Now, coming on to the dynamic factors which we clinicians can do, so as to improve our success over in terms of pregnancy rates, would be what kind of a cycle do you want to do, you want to stimulate the ovaries or you want to take it a natural cycle. If you are stimulating the ovaries, how many follicles do you actually target during your stimulation, the semen parameters, the way of preparing the semen sample, the timing of the IUI, number of IUI attempts that you would advocate or advice to the couple before resorting on to the further advanced technologies, the luteal phase support, whether to consider a single IUI or double IUI, so these factors generally in the hands of a clinician can improve your IUI success rates when done properly.
Center head: All right. So as you said, like the ovulatory what we say like stimulation, is it like mandatory?
Dr. Garima: So, I would not say ovulation induction is mandatory, you can attempt a natural cycle IUI but this is of benefit to those females where the issue is with the male partner and all the investigations or all the tests for the females are okay. In other subset, we prefer doing minimal ovarian stimulation and this rationally attached to it. So the idea is that you want to have one or two follicles so as to improve your pregnancy chances and also this minimal stimulation will take care of your subtle periovulatory defects, which are not predictable on the routine investigations. So by these two techniques, the minimal stimulation improves your chances a little better compared to doing a natural cycle IUI.
Center head: Okay, but this ovary stimulation must be requiring some drugs, some medications?
Dr. Garima: Of course, yes.
Center head: So, like do those medications have side effects?
Dr. Garima: So, when we talk about the medications that we use to stimulate the ovaries, the idea is it’s very minimal stimulation that is to be considered in cases of IUI, because you want to form maximum of two follicles, thereby maximizing your pregnancy chances and simultaneously you want to prevent the multiple pregnancies. So, the drugs can be either oral or injectables. The short-term side effects are seen when it’s an unsupervised stimulated cycle, so you can have side effects like multiple pregnancy or hyperstimulated ovaries. So, a proper care and supervision during the procedure of stimulation is mandatory. Otherwise, there are not many significant long-term side effects attached to these medications.
Center head: That’s great. During IUI, we just covered the ovary part. Coming towards semen part, so what are the factors that will influence on the IUI procedure, like the semen factors?
Dr. Garima: Okay, so that’s one, the cornerstone, which determines your success rate. They are not defined cut-off points, which I would say that you know, beyond this, you will have a success rate, and below this, IUI will not work. However, through various scientific evidences that we have, we have certain threshold limits whereby we say, “Okay, if the values are above these threshold limits, you definitely benefit with your IOI and if the values are little lower compared to, in comparison to these threshold limits, the success rate diminishes.” So, basically talking about these factors, we take into regard four factors, the first one is you want to check the total sperm count in the native sample that the husband or the male partner gives, and the cut-off we take is 10 million per ml. The next one you want to assess is the total motility in that native sample and the motility threshold is greater than equal to (=>) 30%. Another important factor is the inseminating motile count, that is having prepared your semen sample, how much fraction of the motile count do you get, and generally, it is regarded that greater than equal to ( =>) 1 million is the count which is required for an IUI to be successful. And last of all, we don’t have to forget about the morphology that is the make of these sperms, so that has to be more than equal to 4% when ascertained by the strict criteria, this is basically the international WHO Guidelines, which have laid down certain paranorms to see the sperm morphology. Over here, I want to emphasize on the role of an andrologist, what we forget about is how important andrologist is, who gives us the semen sample which is going to determine your IUI success rates. Only those andrologists who have been trained and certified to assess the semen sample as per the WHO criteria are the ones which should be working in the Certified Fertility Centers.
Center head: That’s really a difficult job, I guess. You just mentioned in earlier, your lines, that the semen sample which you will be collecting, I mean it needs a wash.
Dr. Garima: Yeah.
Center head: So, why that wash is needed?
Dr. Garima: See, when you are using a native sample, okay, the problem with the native sample is: one, it can sometimes induce pelvic infection when instilled directly into the uterine cavity, and secondly, because the seminal plasma is still there, this seminal plasma has certain substances like prostaglandins, which are going to irritate the uterus resulting into uterine contractions and therefore reduced success rates. So it’s always imperative that you have to use a washed, prepared semen sample for the process of intrauterine insemination.
Center head: And what is the time, best time rather, to go for IUI post hCG injections?
Dr. Garima: Generally speaking, 36 to 42 hours after your trigger injection is widely acceptable norm, and there is no specific time limit that you have to do it at this particular hour, so 36 to 42 hours window is acceptable.
Center head: And once the sample is collected, like how long one can wait?
Dr. Garima: It’s better that you inseminate it as soon as the sample is ready, but then we say that for any XYZ reasons, if there is some delay, the delay should not be more than 2 hours, and during this particular period, the ambient environment which is required for the semen sample, that is in terms of your temperature, CO2 and pH, everything should be maintained.
Center head: You mentioned about single IUI and double IUI, so what is it and whether like double IUI is more beneficial for the treatment?
Dr. Garima: Yeah, I purposefully brought this question over here because there is a notion, “yeh dil mange more,” so you know, double IUI means better but the answer to it is “No.” The role of double IUI is only and only in certain cases where there is a severe male factor and the couple is not ready to go ahead with the advanced ART Technologies. In this condition, the second sample is taken immediately like within first 1 to 3 hours after collecting the first sample, and the idea is you just want to pool the sample so that you can have the maximum yield of the motile sperms and also it has been seen in these men, the second sample gives you little bit of motile sperm count. However, for any other condition, it’s the single IUI which gives you the success rate as good as the double IUI. The double IUI would only add the cost without giving anything much to it.
Center head: So, I think you have more transparent doctor, as the treatment part is… that’s really great.
Dr. Garima: No, it is, I think that’s important.
Center head: Yeah, that is very important. Another question that comes into my mind like, how many times one should go for these IUI cycles and/or then then when can move towards further treatment part?
Dr. Garima: Yeah, so again very important and a very practical question that has been brought into the picture is usually we recommend good 3 to 4 consecutive, stimulated IUI cycles before recommending any other advanced fertility management for these couples.
Center head: Okay. Another very common question which comes to the females mind is like if I am working then how much time should I take leave, how much bed rest is required, and all those things.
Dr. Garima: So bed rest, again big “No.”
Center head: Oh!
Dr. Garima: So, any prolonged immobilization or bed rest is not advisable. You have to remember, uterine cavity is a potential space, it’s a closed cavity, once we have inseminated the sample, you jump, you walk, the sample is not going to come out; so you are very well fit to go back to your work and resume your activities. Yes, of course, we do tell the female, not to go ahead with the weight-bearing exercises but her life continues the way it was before coming on to the IUI table.
Center head: That is really awesome, I mean really great tool. You said multiple pregnancy…
Dr. Garima: Yeah.
Center head: So, how much is the risk of multiple pregnancy?
Dr. Garima: So, if I am doing a natural cycle IUI, the risk is negligible. The risk averages between 5-15% depending on what drugs are you using to stimulate the ovaries. So as I said earlier also, any stimulated cycle has to be very well supervised because you want to avoid multiple pregnancy rates and simultaneously you don’t want to compromise on your pregnancy success rates.
Center head: Okay. So, as we said, like there are chances of multiple pregnancy or whatever, the babies who are born after IUI, so do we expect any abnormalities or anything like that?
Dr. Garima: Right… yeah, so that’s a question which worries any couple…
Center head: Yes.
Dr. Garima: …because at the end of the day, you want to take the healthy baby back home. So fortunately, all the scientific evidences that have been done so far, have said that IUI per se as a procedure does not cause any kind of birth defect or developmental delays in the baby. However, whatever pregnancy complications we see are mainly because of the multiple pregnancies rather than because of procedure per se, so you monitor the cycle well and avoid multiple pregnancies.
Center head: Right. So, like after hearing all these things, can we say that IUI is 100% successful?
Dr. Garima: There is no 0 and there is no 100% when we talk about any fertility treatments, starting from the basic fertility treatments to as high as IVF policies. When I talk about the success rates per cycle in an IUI treatment, the success rate averages between 15-25% based on all the parameters that I have discussed. So on an average when I say that good 3 to 4 consecutive cycles are advisable, roughly by the end of the 4th cycle, we expect 55-60% of the females getting pregnant, it can be the 1st cycle, 2nd, 3rd, or the 4th, which I cannot predict. But by the 4th cycle, if the female does not get pregnant, it is high time to move to the next line of management or to look out for other roadblocks for your fertility success.
Center head: Okay. So, I think we broadly heard about IUI and we learned so many things. So, what is the take-home message?
Dr. Garima: So, IUI is a very simple technique.
Center head: Yeah.
Dr. Garima: It’s non-invasive, quite cost effective, very minimal stimulation is required and therefore minimal monitoring is required. And side effects related to ovarian hyperstimulation and multiple pregnancy are also low. So as a result of all these modalities, it’s quite a couple of friendly and quite a couple compliant modality of infertility regimes that we have to date. So IUI when done properly does bring us good success rates.