Ovulation Induction and
Artificial/Intrauterine Insemination (IUI)
Artificial insemination involves two key steps:
- Ovulation Induction
Induction of Multiple Ovulations
(follicles or eggs)
Ovulation induction—also called Controlled Ovarian Hyperstimulation, COH or ovarian stimulation—is sometimes used to improve the chances for pregnancy. Ovulation induction may be used prior to intrauterine insemination (IUI) or in vitro fertilization (IVF) and is offered to some couples who have:
- Unexplained infertility (after a complete evaluation)
- Anovulatory infertility
- Cervical factor infertility
- Male factor infertility
- Mild endometriosis
- Persistent infertility despite other treatment
The technique involves the controlled stimulation of the ovaries by medication to increase the available number of eggs that can be fertilized per cycle. Additionally, the technique allows for precise timing of artificial or intrauterine insemination when sperm is placed directly into the uterus through the cervix.
Medication is used to induce (bring on) ovulation of multiple eggs. Oral medication with Clomid (clomiphene citrate) and injectable medication containing Follicle Stimulating Hormones (FSH) or Human Menopausal Gonadotropins (hMG) are used to induce multiple egg development and maturity. The medications are given in a set sequence determined by your doctor.
Depending on the type of medication used, the medications can be taken orally or are given as shots beginning on the third day of the cycle and are continued until it is time to induce ovulation. Human Chorionic Gonadotropin (hCG) can be given by shot at the time selected by your doctor to complete the maturation of the eggs and induce ovulatory response.
These medications have been used extensively and are usually safe and effective when administered with careful supervision. No increase in either congenital abnormalities or birth defects has been associated with these medications. In addition, you may receive another medication, GnRH antagonist, daily by injection or by nasal spray to enhance the ovarian response.
Clomid and IUI have an 8 to 10 percent success rate per cycle for unexplained infertility of three years duration, with an 8 percent chance of multiples. Side effects of Clomid are usually mild and include the possibility of mood changes, hot flashes, headaches, vaginal dryness or thinning of the endometrial lining. If you experience visual disturbances such as spots, contact your doctor and discontinue the medication.
Gonadotropin and IUI have a 15 to 18 percent success rate per cycle for unexplained infertility of three years duration and a 15 percent chance of multiples (including higher order multiples).
During the time you are taking medications to induce ovulation, your response will be carefully monitored to ensure your safety and improve success with induction. In addition to physical examinations, two other monitoring systems will be utilized.
- Hormonal Monitoring
Blood samples will be drawn for assessment of the hormonal response of the ovaries during ovulation induction. Blood will be drawn early in the day, usually between 8 a.m. and 9 a.m., for estradiol (E2) levels at intervals determined by your doctor.
- Ultrasound Monitoring
Ultrasound is a simple and safe technique, which allows assessment of the ovarian response to stimulation, namely the size and number of ovarian follicles. Ultrasound will be performed with a vaginal probe. The procedure takes 5 to 10 minutes to perform. Ultrasound monitoring will be performed prior to the start of the medications and at intervals thereafter as determined by your doctor.
The desired response is to obtain two to four eggs capable of ovulation per cycle. If more than four eggs develop, the cycle may be cancelled due to the risk of multiple pregnancy and/or ovarian hyperstimulation syndrome (OHSS), a condition that may result from ovulation induction characterized by enlargement of the ovaries, fluid retention and weight gain.
Reasons for Cancellation of a Treatment Cycle
There are several possible reasons for canceling an ovulation induction/IUI treatment cycle, including:
- Inadequate follicular development or hormonal response
- Excessive number of available follicles or inappropriate maturation
- Inability to obtain a semen specimen on the day of insemination
- Complications of ovulation stimulation
Artificial insemination (AI) refers to the technique of placing sperm directly into a woman's reproductive tract. Artificial insemination (AI) is usually performed for couples with infertility due to a problem with male fertility. However, studies have shown that it enhances the pregnancy rate in couples with unexplained infertility when combined with ovulation enhancement. It also may enhance the per-cycle pregnancy rate in other types of infertility, except bilateral tubal disease.
Intrauterine Insemination (IUI) is the most common type of AI performed. In this procedure, sperm are placed high into the uterus using a small catheter. By placing sperm directly into the uterus, the number of sperm that may potentially meet an egg is greatly increased. During intercourse, for every 14 million sperm deposited into a woman's vagina, only one to 10 reach the fallopian tube.
In cases of severe male fertility problems, ejaculation issues or an absent male partner, insemination may be performed with donor sperm. There are a number of reputable sperm banks where you can choose from detailed characteristics among donors. When choosing a sperm bank, make sure to look for one that adequately prescreens donors, especially in regards to genetic and viral testing. In addition, donors need to be screened again six months after giving specimens for virally transmitted infections (for example, HIV) before the frozen specimen is released. See this page for a list of reputable sperm donor banks.
Sperm Preparation and Insemination
For insemination, it will be necessary to obtain a semen sample on the day of insemination. Please check with your cycle coordinator or doctor for specific instructions, but here are some general guidelines:
- Abstinence for 48 hours is recommended prior to sample collection.
- The sample must be collected in a sterile manner in a container supplied for the male partner.
- The sample should be kept near body temperature (98.6 F).
- The male partner must deliver the sample to the lab within about one hour of collection.
- The male partner must show government issued photo identification when delivering the sample.
- Approximately two hours prior to the insemination, the semen sample must be at the lab.
In the laboratory, the semen sample will be prepared using specialized techniques that allow laboratory staff to collect the most motile (active) sperm. The process of preparing the sperm usually takes about two hours. Afterward, the specimen is stable for a few hours when kept at 98.6 F
The sperm sample will be inseminated into the woman’s uterus (intrauterine) by placing a small catheter through the cervix into the uterus. While some patients experience mild cramping, the procedure is usually painless and requires only 1 to 2 minutes to perform. The woman is then asked to rest quietly for 10 minutes before she leaves the exam room.