Q from U: Should I do my IUI at home?

September 13, 2013Carole No Comments »

Today I received a question from a patient which I thought might be a good one for the Questions from You  (Q from U) series.

Question: We have been trying to conceive for 8-9 mo  without any success and recent semen analysis showed poor results. We are thinking to try IUI at home before we go fertility clinics and do IUI there. What are your thoughts about it? Is safe to perform it at home just using needless syringe and catheter?

The short answer is that No, I would not recommend an intra-uterine insemination (IUI) at home. Most of the reasons why I think at home insemination is not a good deal for many patients are because of what you don’t get at home.

Semen Analysis. Whether you are using your partners’ sperm or purchased donor sperm, a semen analysis on the sample used for insemination can tell you whether you have a reasonable chance of getting pregnant with the sample. If you are buying frozen sperm, the company typically guarantees a minimum number of motile sperm post-thaw or you get your money back or a new shipment. You don’t get this  sperm count information when you do insemination at home– and in my experience getting refunds for patients, even when semen analysis is done in the lab, the sperm bank wants to have evidence of a semen analysis performed by someone who is qualified to perform it.  That minimum number of sperm that the bank will guarantee is usually around 20 million motile (swimming)  sperm per preparation. Using this same rule of thumb for a fresh partner sample is a good indicator of how likely IUI is to work for you. If your partner’s semen analysis reveals that the number of motile sperm in the whole ejaculate is less than 20 million, insemination is probably not the best plan for you.  If sperm numbers are this low, you might want to discuss the option of in vitro fertilization (IVF) with your doctor.

Sperm washing. If you are using a partner’s fresh sample for IUI, it must be processed to remove the seminal plasma before used for insemination into the uterus. The seminal plasma is the fluid part of the ejaculate, not the cells.  This fluid has a lot of components, including prostaglandins,  hormones which cause painful uterine contractions if unprocessed semen is introduced into the uterus.  During intercourse, these fluids are diluted naturally by the vaginal and cervical fluids so it is not a problem. For insemination, the seminal plasma is removed from the ejaculate by adding a sterile solution to the ejaculate and centrifuging the sample at least twice in the lab to separate the cells from the seminal fluids. You end up with a pellet of cells in a sterile solution. The pellet is shook up to release the cells into the solution before loading into the catheter.  Sometimes, a second sperm count is performed if the sample is TOO concentrated, to adjust the concentration by adding more fluid. Sperm washing also removes debris and dead cells from the prep.

IUI prep v. ICI prep. When you buy a frozen sample from a sperm bank, you have the choice of two types of prepped samples. Samples that are pre-washed specifically for IUI (sometimes called IUI ready)  just need to be thawed and loaded into the catheter. Physician offices often use this type if they have no staff available to wash the samples for IUI. One caution- if your physician’s office does not do a semen analysis before using your frozen sample, you will not be able to get a refund based on insufficient cells- the guarantee offered by the bank isn’t valid without proof that the cell count was low. So it is worth asking ahead of time whether they do a sperm count in the office on samples for IUIs. An eyeball estimate under the microscope to see that some sperm are there, without counting them, does not count.  The other type of sperm prep is ICI ready. ICI stands for intracervical insemination.  This prep is minimal and is designed  for inseminations where the semen will be deposited OUTSIDE the uterus, in the vagina or just in front of the cervix.  The ICI prep is the type of processed semen sample that patients buy for vaginal insemination at home. Be sure you follow the directions for thawing that come with your commercial donor sperm.

Insemination at home. When patients do insemination at home, it is NEVER  into the uterus, it  is always into the vagina, as close to the cervix as possible. The uterus- like any internal organ- is sterile and should be kept that way. If you give yourself a uterine infection by introducing a non-sterile catheter into the uterus, you risk your fertility, if not your life.   This is why IUI should only be done by a medical professional using sterile technique. The vagina, on the other hand, is not sterile. The vagina is the front porch to the uterus.  The cervix is a small opening (the door to the house) at the far end of the vagina which leads to the uterus. Depending on the stage of your cycle, it is more or less open to sperm.   There are several methods patients have used at home for insemination. A sterile syringe (without needle!!) can be used to inject sperm into the vagina. Sperm can be put into a clean cervical cap (without spermicide!!) and placed over the cervix to allow sperm to enter the uterus on their own. There is also a device that is basically a cervical cap attached to a catheter that can fit over a syringe, allowing sperm to be placed  in front of the cervix. The last method probably requires the most skill for proper placement and is usually used within a professional medical setting.

Sperm quality. All of these cervical methods for insemination only work if the sperm is really good sperm with strong swimming ability because sperm still have to make their way through the cervix and into the uterus just like they would with intercourse. If sperm quality is poor, ICI is probably not your best option. IUI gives sub-optimal sperm a slightly better chance because they are processed to increase their concentration, to select for the best swimmers and then placed directly into the uterus, so half of the work has been done for them. Sperm used for IUI still have to have some decent swimming ability because they still need to swim out of the uterus and into one of the Fallopian tubes to find and fertilize an egg. So slow, weak swimmers are still at a disadvantage, even with IUI. IVF is probably best for really poor sperm because they only have to swim to the egg sitting in a dish with them and then  have to have enough residual energy to push their way into the egg. If sperm don’t have the ability to swim or push into the egg, sperm can be injected directly into an egg using a technique called intracytoplasmic sperm injection (ICSI). ICSI allows men with rare sperm, or perm with poor or no motility,  to fertilize an egg.

Timing and ovarian response. If you have insemination performed in an office, you will be offered some guidance as to the best time for insemination based on lab tests (or ovulation detection kits) that can tell you when you are about to ovulate naturally. If you have trouble ovulating on your own, and need medications to induce ovulation, you will be prescribed them as part of the IUI cycle. If you have no infertility issues and don’t need any medications to stimulate your ovaries to produce at least one egg, then at home insemination might work for you.  However, if you do need medications to stimulate your ovaries (even Clomid) , your ovaries need to be monitored by ultrasound (by a medical professional)  to make sure that your ovaries are producing some, but not too many, follicles. One very real danger of not monitoring follicles during a medicated cycle is that you could produce many more follicles with eggs than you want. Once ovulated, eggs in the tubes are fair game for fertilization and unlike IVF, there is no way to control the number of embryos that might end up in the uterus and implant. Too many implanted embryos increase the risk of miscarriage and severe obstetrical complications. This risk is minimized by good monitoring to ensure that insemination occurs only if sufficient –but not too many –follicles are available.

The take home message is this:

1. IUI at home is NOT safe because most patients don’t have the medical training to introduce a sterile catheter safely into the uterus to avoid infection and uterine trauma. Also, IUI requires washing and centrifugation protocols  to process the semen that patients normally can’t access at home.

2. ICI at home can be safe, but may not be effective if you have suboptimal sperm or need some help with ovulating and/or producing mature follicles.

3. If you need ovarian stimulation drugs to produce follicles, you need the professional monitoring you get with an IUI.

It is always a good idea to discuss your fertility treatment options with your doctor before starting any medical protocol.

 

 

© 2013, Carole. All rights reserved.

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