Trivector helps you with IUI, IVF, ICSI Training and Lab Set Ups

Intrauterine insemination (IUI), the injection of sperm into the uterus by means
of a catheter directed through the cervix, has been practiced for many years. T
he premise of this procedure is that sperm can reach and fertilize the egg more
easily if placed directly into the uterine cavity.
In the early â 60s, physicians were injecting small quantities of raw, untreated seme
n, (sperm plus the seminal plasma) directly into the uterus at the time of expec
ted ovulation. However, when more than 0.2 ml of semen was injected in to the ut
erus, serious and sometimes life endangering shock-like reactions often occurred
. It was subsequently identified that the reason for such reactions related to t
he presence of prostaglandins within the seminal plasma. This led to the practic
e of injecting small amounts (less than 0.2 ml) of raw semen. However, the pregn
ancy rates were dismal, and side effects such as severe cramping and infection w
ere rampant.
Soon after establishing the Northern Nevada Fertility Center in Reno in 1982 (th
e Nationâ s first private in vitro fertilization (IVF) program), we began to recogniz
e the potential advantage of washing and centrifuging raw semen, so as to separa
te sperm from the seminal fluid, and thereby remove the prostaglandins that caus
e most of the problems. We subsequently introduced and, thereupon, became the fi
rst to publish on intrauterine insemination (IUI) in the Journal, Fertility and
Sterility (April 1984).
Indications for Intrauterine Insemination (IUI)
Artificial insemination using frozen (donor) sperm: The recognition of HIV infec
tion as a sexually transmitted disease, coupled with the fact that the virus is
present in semen months before it can be detected in the blood, mandates that al
l donors have their semen cryopreserved (frozen) and stored for at least six mon
ths, whereupon, they be re-tested for HIV infection. Only upon confirmation of a
negative test should the cryopreserved semen specimen be thawed and used for in
semination. Since cryopreservation inevitably reduces sperm motility and functio
n, it is not adequate to simply thaw the frozen specimen and then inseminate the
raw semen into the vagina. Rather, the semen specimen should be processed for I
UI. Provided that the recipient is ovulating normally, there is no need to admin
ister fertility drugs such as Clomiphene, Pergonal, etc.
Artificial insemination with partnerâ s sperm: In cases of sexual dysfunction (impote
nce, retrograde ejaculation, etc.) or timing issues, the partnerâ s sperm may need to
be collected and processed in preparation of IUI.
Cervical mucus hostility: Sometimes the cervical mucus acts as a barrier to the
activation and passage of sperm as it passes through the cervical canal. Such ho
stility may be due to poor physical qualities of the mucus, cervical infection,
or the presence of antisperm antibodies. In all but the latter situations, IUI c
an readily be performed during natural cycles, unless the woman has ovulation dy
sfunction. However, when infertility results from the presence of antibodies in
the cervical mucus, IUI will likely be ineffectual and should be replaced by in
vitro fertilization (IVF).
Absent or dysfunctional ovulation: In some cases where the woman requires the us
e of fertility drugs to induce normal ovulation, the concomitant performance of
IUI might improve pregnancy rates.
Selecting the Fertility Drugs for Intrauterine Insemination (IUI)
Clomiphene citrate (Serophene, Clomid): Clomiphene citrate is taken orally for 5
days starting on day 2 to 5 of the menstrual cycle. Ovulation will usually occu
r 10 days later. In some cases, hCG is used to trigger the ovulation but this is
often unnecessary. Clomiphene is a relatively inexpensive and safe method for i
nducing ovulation and this is why it is so commonly prescribed to women undergoi
ng IUI. However, women receiving clomiphene have about a one third lower pregnan
cy rate per cycle than is the case when using injectible fertility drugs. But th
ere are draw-backs to clomiphene citrate. Here are a few reasons why:
Clomiphene citrate is an anti-estrogen. Ordinarily, women who ovulate normally (
without exposure to clomiphene) produce a single dominant follicle which produce
s enough estrogen to promote optimal cervical mucous production and an adequate
endometrial lining (>9mm) However, when clomiphene is used to induce ovulation,
its anti-estrogenic effect blunts this response. In fact, women on clomiphene re
quire much more estrogen to override this effect, such that unless at least 3 la
rge follicles develop to allow the blood estradiol levels to rise above 400pg/ml
, cervical mucus production and endometrial development will usually be insuffic
ient to allow a healthy pregnancy to occur. Younger women with normal ovarian re
serve (Day-3 FSH of less than 9miu/ml)>3 follicles, whereas women over 40 years
of age and those with diminished ovarian reserve (regardless of age) will rarely
do so, and thus are very unlikely to achieve viable pregnancies on clomiphene.
Clomiphene-induced ovulation is associated with a 15-20% chance of a condition c
alled luteinized unruptured follicle (LUF) syndrome where the hormonal changes t
hat precede, accompany and follow ovulation (including a rise in blood progester
one level) occur, but this happens without ovulation occurring. LUF syndrome thu
s leads to the erroneous conclusion that an egg has been released when, in fact,
it remains â trappedâ in the ovarian follicle.
More than 3 consecutive (back to back) cycles of clomiphene will result in a ver
y significant increase in the anti-estrogen effects referred to in 1&2 above, su
ch that unless a break of at least 1 full menstrual cycle is taken, the likeliho
od of a viable pregnancy declines to less than 10%, regardless of the womanâ s age or
her ovarian reserve. This explains why >80% of successful clomiphene pregnancie
s occur within the first 3 months of treatment, and why the vast majority of clo
miphene pregnancies that occur after >3 consecutive (back-to-back) cycles of tre
atment are lost (usually due to early miscarriages).
Clomiphene causes the pituitary gland to produce increased amounts of FSH and LH
. FSH promotes follicle growth development while excess LH causes the ovary to p
roduce male hormones such as testosterone. While a little testosterone is indisp
ensable to follicle and egg development, too much testosterone can have the reve
rse effect and harm egg development. This effect is even more deleterious in wom
en with diminished ovarian reserve (elevated FSH levels) and those over 40 whose
ovaries tend to produce more testosterone-like hormones.
The good news is that upon discontinuation of Clomiphene for 4-6 weeks, adverse
effects disappear, leaving the slate clean.
The real benefit of clomiphene lies in its oral route of administration, low inc
idence of side effects, and its low cost. The birth rate per clomiphene IUI is a
bout 7-10% per cycle of treatment (about 1/3 lower than when injectible fertilit
y drugs are used).
Letrozole(Femara): Letrozole, like clomiphene, is an oral agent used to induce o
vulation that causes the pituitary gland to release large amounts of FSH as well
as LH. The advantage that Letrozole has over clomiphene is that unlike the latt
er, it is NOT anti-estrogenic, and thus does not compromise development of the u
terine lining or adversely affect the production of cervical mucus. However, as
is the case with clomiphene, Letrozole causes increased LH release that can lead
to overproduction of male hormones (e.g. testosterone) by the ovaries with pote
ntially adverse effect on egg/embryo quality.
Thus, while Letrozole does have potential advantages over clomiphene, the exagge
rated LH-induced testosterone effect, especially in women over 40 years of age a
nd/or those with evidence of diminished ovarian reserve, limits its value.
Gonadotropins (Menopur, Gonal-f, Folistim and Puregon): Women with absent or abn
ormal ovulation who require fertility drugs in preparation for IUI should receiv
e gonadotropins. Granted, these agents are more expensive than clomiphene, but t
hey have no anti-estrogenic properties.
The birth rate with gonadotropin IUI in women under 35 years of age (in the abse
nce of male infertility, where it is much lower) is about 10-15%. However, succe
ss is affected by, and contingent upon, the procedure being performed (1) for th
e correct indications, (2) avoiding the performance of IUI when contraindication
s exist (see below) and, (3) where the woman is ovulating normally on her own. S
uccess rates decrease as a womanâ s age advances. In women 35-40 years of age the bir
th rate is 5-10% per cycle and for over 40 years, the birth rate per cycle is un
der 2%, declining to less than 1% after age 43.