Practical Guide to Intrauterine Insemination (IUI) Chaitanya Nagori, Sonal Panchal
INDEX
Page numbers followed by, f refer to figure, and t refer to table.
A
Adenomyosis 8
Alyce's forceps 52
American Fertility Society 15
American Society for Reproductive Medicine 6
Anorexia 55
Anti-Mullerian hormone 12, 20
Antisperm antibodies 11, 16
Antral follicle count 12, 19, 20, 21f, 24
Assisted reproductive technology 3, 15, 48, 57
Asthenospermia 16
Athletes 55
Azoospermia 17
B
Baseline scan and deciding stimulation protocol 19
Baseline scoring system 24t
Body mass index 8, 24, 70
Body temperature chart 42
C
Carbon dioxide incubator 73, 75f
Catheter 53
Centrifuge 73
machine 74f, 78
Cervical factor 14, 16
counseling for 3
Cervical mucus 54
Cervix 4, 16
Chlamydial antibody test 12
Chronic low-dose protocol 37, 38f
advantages of 38
Clomiphene 36
citrate 14, 36, 38, 48f, 55, 56
Collection insemination time 70
Color Doppler 6, 22f, 25f, 47
Complete blood count 10
Conception rates 14t
Controlled ovarian hyperstimulation 49
advantages of 36
Corpus luteum 31
low-resistance blood flow of 32f
Cusco's speculum 53
Cytomegalovirus 67
D
Density gradient method 79f
Donor insemination 53
counseling for 6
Donor sperms 14, 17
artificial insemination of 17
Dual trigger 58
Dysovulatory infertility 6
E
Earle's balance
media 74
salt 75
Ejaculation
premature 17
retrograde 17, 80
Endometrial Doppler parameters 31t
Endometrial vascularity 28, 29f
Endometrial volume 30
Endometrioma 8, 9f
Endometriomyometrial junction 27f
Endometriosis 14, 15, 55
Endometrium 30t, 32f
B-mode features of 27
Doppler features of 28
multilayered 32f
secretory 32f
Energy, glucose for 74
Estradiol 44
Ethylene oxide sterilized semen collection jar 73f
F
Fallopian tube 16, 17
FertiCult flushing media 75
Flow index 23f
Flushing medium 75
Follicle
leads, rupture of 30
stimulating hormone 10, 14, 38f, 40, 55
Fothergill's surgery 16
Fradient method 80
Frozen sample intrauterine insemination 14, 17
G
G sperm 75, 77
Gamete intrafallopian tube transfer 53
Genetic disorders 17
Glucose tolerance test 10t
Gonadotropin 6, 23, 3739
cycle, luteal phase support in 56
protocols for 37
releasing hormone agonists 42, 43, 57
protocol 55
trigger 47, 55, 57
contraindications of 44
releasing hormone antagonist
protocol 55
role of 39
stimulation 55
type of 40t
Grade endometrium, B-mode ultrasound image of 27f, 28f
Gradient method 78, 79
H
Hemorrhage, postpartum 66
Hepatitis
B
surface antigen of 10
virus 67
C virus 67
D virus 67
Herpes simplex virus 67
High-resistance
corpus luteal flow 33
endometrial flow 33
uterine artery flow waveform 29
Human chorionic gonadotropin 37, 37f, 38f, 42, 43, 47, 55, 65
disadvantages of 62
supplementation 62
Human immunodeficiency virus 67
discordant males 14, 17
positive sample 80
Human menopausal gonadotropin 14, 36, 38, 40
Human serum albumin 74
Hydrosalpinx, B-mode ultrasound image of 9
Hypertension, pregnancy-induced 66
Hypoprolactinemia 55
Hypospadias 17
Hypothalamic-pituitary
dysfunction 55
ovarian axis 56
Hysterosalpingocontrast sonography 12f
Hysterosalpingography 2, 11
I
Immunological infertility, clinical risk of 16
Implantation rate 38
Impotence 17
In vitro fertilization 3, 14, 36, 49, 65, 74
counseling for 6
Indian Council of Medical Research 6
Infections 55, 65
Infertility management, backbone of 1
Insemination, site of 53
Insulin
resistance 10
severe 10
response test 10t
Intensive luteal support 58
Intracytoplasmic sperm injection 3, 16, 74
Intramuscular progesterone 58
Intrauterine insemination 5, 8, 14, 16, 17, 19, 36, 42, 47, 48f, 52, 55, 57, 65, 69, 72
cannula 73, 75f
complications of 65
counseling for 1, 6
indications of 14
luteal phase support for 55
stimulation protocol for 36
technique of 52
time interval for 70
L
Laminar air flow 73, 74f
Laparoscopy 2, 5
Lesser multiple pregnancy rates 38f
Letrozole 39, 55
cycle 56
Leukemia inhibitory factor 56
Leukocytes 74
Linear correlation 20
Low-dose beta-human chorionic gonadotropin 58
Low-dose follicle-stimulating hormone protocol 39
Low-resistance perifollicular flow, pulse Doppler image of 25f
Luteal phase defect 31t
Luteal phase
defect, causes of 55
deficiency 43
scan 12, 19
support 6, 44, 5557
duration of 62
Luteinizing hormone 10, 31, 36, 55
M
Makler's chamber 73f
Male subfertility 14, 15
Mature follicle
B-mode features of 24
B-mode ultrasound image of 24f
color Doppler image of 10f
Mixed antiglobulin reaction test 16
Monofollicular development 38
Motile count 74
Multiple pregnancy 23, 38, 65, 66
N
Natural micronized progesterone 59
Natural nonassisted reproduction technology 55
Neubar's chamber 73
Nonapoptotic sperm selection 80
Non-in vitro fertilization 62
O
Obesity 55
Oligozoospermia, severe 17
Ovarian artery perfusion 30
Ovarian blood flow 22
Ovarian dysfunction 14, 15
Ovarian hyperstimulation syndrome 36, 38f, 57, 65
Ovarian reserve 20
Ovarian stimulation 36
Ovarian stromal flow 22f
Ovarian volume 20
Ovulation 47
induction 9, 36
trigger 42
drugs for 42
Ovulatory derangement, correction of 15
P
Peak systolic velocity 19, 24, 30, 47
Penicillin 74, 75
Perifollicular flow 48f
Perifollicular vascularity 25f
Phenol red 74
Polycarbophil 61
Polycystic ovarian syndrome 6, 10, 37, 55, 56, 70
Polycystic ovary, B-mode ultrasound image of 10f
Polymerase chain reaction 4
Polyp, endometrial 9f
Postcoital test 11, 11f
abnormal 11
Pregnancy rate 53
Preovulatory follicle 24, 30t
Preovulatory scan 19
Progesterone 10, 44, 58
correlation of 32
gel 61
progressive diffusion of 59f
subcutaneous aqueous 61
vaginal effervescent tablets 59
Prothrombin time 10
Pulsatility index 30
Pulse
Doppler 22f, 30
Doppler image 25f, 29f
repetition frequency 25
Puresperm 79
Pyruvate 75
R
Reactive oxygen species 75
Receptive endometrium, power Doppler image of 10f
Recombinant follicle-stimulating hormone, dose of 24t
Recombinant human chorionic gonadotropin 43
Recombinant luteinizing hormone 58
Resistance index 19, 24, 30, 47
Ringer's lactate 52
Routine ovarian reserve tests 12
Rubin's test 2, 11
S
Scandinavian 75
media 77
method 79
Segmental uterine artery perfusion 28, 30
Semen
analysis 10
counseling for 2
jar 73
parameters, normal 11, 15t, 75t
preparation 6
sample 72f
collection of 72
volume of 74
Seminal parameters 11, 15, 75
Serum albumin 75
Serum progesterone 70
Serum thyroid-stimulating hormone 10
Sexual disorders 14, 17
SilSelect gradient method 79
Singleton live birth rate 54
Sodium
bicarbonate 74
pyruvate 74
Sonosalpingography 5
Sperm 3
aggregation of 16
hyperactivated 72f
nonhyperactivated 72f
preparation 67, 72, 73
laboratory 73
media 7477, 77t
methods 74
Split ejaculation collection 73
Step-down protocol 37
Stimulation protocol 6, 36, 65, 66
Streptomycin 74, 75
Streptopenicillin 75
Stress 55
Stromal blood flow 22
Subcutaneous aqueous injections 61
Supernumerary follicles, aspiration of 66
Suprasperm 79
method for 79
Surrogate luteinizing hormone surge 42
Swim up
methods 75
reagents for 75
Synthetic serum replacement 74
Syringe 73
T
Total motile sperm count 11
Transdermal progesterone 61
Transvaginal sonography 27
Tubal factor 11
counseling for 4
Tubal ligation 5
Tuberculosis, endometrial 4
U
Ultrasound 19
monitoring 19
scan 8
Unexplained infertility 5, 14, 14t, 16
Urinary luteinizing hormone 47
Uterine factor, counseling for 4
Uterine first-pass effect 59f
Uterus 53
fundus of 59f
subseptate 9f
V
Vaginal progesterone rings 60
Vaginal route 58
Vaginal suppositories 58
Vaginismus 17
Vascular endothelial growth factor 42
Vascularity flow index 23f
Virtual organ computer-aided analysis 21f, 22, 23f, 26f
Viscosity 74
W
White blood cell 72
World Health Organization 3
Guidelines 11t, 15t, 75t
Z
Zwitterions-buffered medium 76
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Chapter Notes

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Counseling for Intrauterine InseminationCHAPTER 1

 
INTRODUCTION
Counseling is the backbone of infertility management. The correct explanation about reproduction and dialogue with the patients help them to conceive. Insler has mentioned in his book that “many patients conceive when they are sitting outside the consulting room”. This means that there should be literature placed in the waiting room, handouts given to patients, and there should be elaborative explanatory displays placed in the waiting room that patients can read and would help them clear a lot of their misconceptions about reproduction, which they might be reluctant to clear in person.
In the busy outpatient department (OPD), it is very difficult for a practicing gynecologist to spend time with the patients for counseling. I shall put forward a few suggestions from my side:
  • There should be good posters placed in the waiting room explaining the physiology of conception.
  • Attractive and interesting literature regarding reproductive physiology, causes of infertility, and outline of management should be placed in the waiting room, which should be easily accessible to them.
  • We have prepared a small booklet regarding the same in local language, national language, and in English (Figs. 1A and B), and is given to every patient once I have done a detailed consultation about their problems with them.
    zoom view
    Figs. 1A and B: Our information booklet for patients in different languages.
    2This booklet helps the patient to read and understand the things that are discussed once again and take a correct decision about the management of their problem.
Such explanation or literature allows the patient to know what would be the management strategy for their problem and how are we going to deal with their problem and, therefore, they gain confidence and appreciate the treatment that is given.
Moreover, it also would be a great means of propagating the correct knowledge through patients, as they would discuss whatever they have read and understood by reading the book, with their friends. This is very important as if the correct information is not spread in the society, only misconceptions and myths prevail.
One very important suggestion that I would like to give to very busy practitioners—please allot a specific, separate time slot for patients with fertility problems, so that you can patiently listen to them and discuss about the solutions or treatment strategy with them. Remember that the initial counseling and the time spent with the couple play a very vital role in management of the patient.
Now let us elaborate as to how I discuss about various aspects of causes, counseling, and management of infertility.
As infertility is a social stigma in our culture, not only the couple (I mean the husband also) but concerned relatives should also be involved in counseling, so that they would allow the couple to take the correct treatment. The refusal of treatment in majority of cases is by in laws or parents. Therefore, it is very vital that all the people concerned and all those who are going to play a role in decision making as to whether to continue the treatment or not, should have correct information about infertility. Their myths should be washed out with proper explanation. Explanation should be done in local language, simple for a layman to understand. Eye-to-eye contact is very essential.
When to start the treatment?
85% of the couples conceive within the 1 year of unprotected intercourse and 95% in 2 years. Therefore, if a couple comes earlier than a year and a half of continuous unprotected intercourse (active married life), which is very common at district level and in lower socioeconomic class of people, explaining the above said fact will increase their faith in you and your treatment.
No invasive investigations such as laparoscopy should be done within these 2 years and nature should be given enough time to work for the couple to achieve pregnancy.
Among noninvasive investigations, semen analysis and midcycle/preovulatory scan are the two investigations that must be done. These will more or less prove the normalcy of the couple and then counseling only can help them conceive.
We have observed that such couples do conceive very often after the treatment is stopped. This is because the stress of treatment is relieved and the patient is relaxed. Moreover, when we are treating these couples, we become too enthusiastic doing some invasive investigation in every cycle one after the other such as Rubin's test (RT), hysterosalpingography (HSG), dilatation and curettage (D and C), laparoscopy, etc. Therefore, when this patient is exhausted and abandons treatment, she conceives spontaneously.
Therefore, remember that counseling is more important than overenthusiastic invasive investigations.
 
COUNSELING FOR SEMEN ANALYSIS
In 40–50% of couples presenting with fertility problems, male factor is responsible either partially or completely. In our social setup 3even today, males do not accept this fact and, therefore, they do not agree for examination or investigations. This problem is more prevalent in people who are less educated. Proper counseling is a must with the male partner before subjecting the female partner for treatment for infertility.
The couple must be explained that according to the recent World Health Organization (WHO) criteria 2010, 15 million sperms/mL, 30% motility, and 4% sperms with normal morphology are considered as normal physiological semen criteria. In spite of this even today, we read several laboratories quoting 40–60 million count as normal in their reports. Because of this wrong information and ignorance of laboratory officials and clinicians, several patients take medicines for long periods to increase their sperm count. Remember, when sperm count is 15 million/mL or more, no treatment is required. Up to 86% abnormal sperms is normal and physiological and even patient with 4–14% normal sperms can conceive either naturally or by intrauterine insemination (IUI). Only when <4% of sperms are normal, in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) may be required.
When the sperm count is <15 million/mL, semen analysis must be done at least three times—2 weeks apart and 2 months apart to confirm the diagnosis. These patients should directly not be subjected to IVF or ICSI. Instead, we must try medical treatment for these males to improve the sperm count, so that they can conceive naturally or with IUI. The whole moto of medical management of a subfertile male is not to increase the sperm count 5–10 times or to achieve excellent semen parameters. The moto is to increase the count by a few million so that ICSI can be converted to IVF, IVF to IUI, and perhaps IUI into natural conception. Medical management has been discussed in the chapter on male infertility.
 
COUNSELING FOR CERVICAL FACTOR
The cervical factor of infertility is rare at present, as surgeries are not often done on cervix. Frequent D and Cs may damage endocervical glands and epithelium. Cauterization of cervix should be discouraged.
I believe that even today, postcoital test (PCT) is very useful in infertility management. When more than seven sperms are seen per high power field of microscope, 10–12 hours after intercourse, it is an excellent PCT according to WHO standards.
Majority of assisted reproductive technology (ART) textbooks opine that PCT has no significance. I have found it very useful for counseling of the husband. Husband feels that he is normal when PCT is normal. He does not feel guilty and cooperates with his wife for all infertility treatment. So, it may not have a role in patients undergoing ART, but it has a place for IUI and more conservative infertility treatment. Many a times when the couple changes the gynecologist, semen analysis is asked for. If patient has a few reports done earlier, I will rely on PCT. The satisfaction is of highest level for the couple when they see moving sperms under the microscope after 10–12 hours of intercourse.
What information we get from a normal PCT?
  • Preovulatory cervical mucus is normal.
  • Sperm count is normal.
Moreover, when the patient is shown these moving sperms under microscope even after 12 hours of intercourse, it gives them confidence that both the partners are normal and that helps them conceive.
Patient is explained that these sperms may remain alive for 48–72 hours in most of the patients, and in few, they have also been seen after 7 days. There is a misconception in majority of the couples that intercourse must be done when ovulation occurs. Showing PCT to patients removes this misconception. 4Cervix acts as a reservoir for sperms, so after the sexual relation even if ovulation occurs in 2–3 days, conception can occur. We can therefore explain the patient that if for conception the intercourse was needed exactly when ovulation occurs, raped girls would not conceive easily. Couple should therefore be advised intercourse at least once in 2–3 days during 10–20 days of 28–30 days cycle. The couple should be clearly told that abstinence of >3 days is not advisable during this period, in natural cycle as well as in stimulated cycles for IUI.
The fertile window of menstrual cycle precedes the day of ovulation by 5–6 days and likelihood of pregnancy is highest when intercourse occurs 2 days before ovulation. Intercourse on the day of ovulation is less effective and success rate is almost zero on the day after ovulation.1,2 Coital frequency of twice or thrice a week during fertile period is equally effective. But, once a week reduces the chance of pregnancy by 40%.
Majority of the couples believe that if IUI is done, it is better to have abstinence before to get good sperm count. But, this is not true. An abstinence of >3–4 days does not increase the count, instead the percentage of dead sperms in this semen increases. Therefore, intercourse should not be planned; it should be absolutely voluntary and can be done irrespective of the day of IUI.
Abstinence is one of the causes for failed IUI. Let me explain, why and how!! In majority of gynecology clinics, where there is no IVF setup, the semen preparation laboratory is not adequately equipped, and so the semen preparation is suboptimal and so chances of conception are less. Moreover, patient keeps abstinence before IUI, so the chance of natural conception also is denied. As a result, patient does not conceive when she is on treatment but conceives spontaneously when she abandons treatment. Remember, therefore, intercourse at regular intervals in the fertile period is absolutely essential.
Majority of couples with long-term infertility have lost the charm of their marital relations. Their intercourses are only planned and compulsory, only targeted for child bearing. They must be explained that child is only a byproduct. Main thing is the love and affection, intercourse is just an expression of this feeling and results in conception. Counseling can help them to regain the charm of their marriage. All myths regarding intercourse must be discussed and sorted out, e.g., posture, position, timing, washing, etc.
 
COUNSELING FOR UTERINE FACTOR
This is to be discussed with the patient after a 3D ultrasound, as this is a gold standard for congenital uterine malformations and endometrial pathologies. Patient also can see and understand these 3D pictures and the optimum management then can be easily explained. Fibroids <4–5 cms in size and not touching the endometrium do not require removal. Patient can also be convinced explaining them how the embryo traverses from the tube to the uterus and implants in the endometrium.
Majority of the patients have a wrong concept that D and C helps conception. This is a myth and should be clarified. D and C should not be done in modern infertility practice. The only role today of D and C is to exclude endometrial tuberculosis (TB) by either histopathology or TB polymerase chain reaction (PCR) of the endometrial sample along with culture. D and C must not be done to diagnose luteal phase defect or to check whether the endometrium is in proliferative phase or secretory phase.
 
COUNSELING FOR TUBAL FACTOR
Patient must be explained that fertilization occurs in fallopian tube and after 4–5 days, embryo comes to settle in the uterus. 5This explanation is also useful to counsel, if the patient gets an ectopic pregnancy. Tubal evaluation is very important in infertility practice. RT should not be done. Laparoscopy is the gold standard for evaluation of the tubes and tubo-ovarian relationship.
Patient should be explained that at the time of ovulation, fimbrial end of the tube covers the ovary, a negative pressure of 1 mm of Hg is created due to movements of the cilia, this sucks the ovum from the follicle, into the tubal lumen. So, ovum does not separate and release from the follicle to roll into the tubal lumen, but tube is vital and instrumental to suck the ovum into tubal lumen. Therefore, it is important that tubo-ovarian relation should be healthy, a patent tube is not sufficient. HSG gives us only incomplete information about the patency of the tube. This can be replaced by sonosalpingography (SSG). This explains the patient that in spite of patent tubes on other tests, why is laparoscopy required.
Now, microsurgery is almost replaced by ART for pathological tubes. Results of microsurgery are very good in tubo-tubal anastomosis in patients with tubal ligation (TL) especially laparoscopic tubal ligation. Therefore, in young patients where TL is done and patient then again wishes a pregnancy, microsurgery should be offered as an alternative to ART, as it is a one-time procedure and patient gets a breathing time for up to 2 years.
 
COUNSELING FOR OVARIAN CAUSES
Patient should be counseled that ovum is released from the ovary only once in a month and it survives for 6–8 hours. Sperms that are stored in the cervix can stay live for at least 48 hours to up to maximum 7 days, and these can reach the ova and conception can occur. Though patient should also be explained that the chances of conception are maximum, if the sperms are available for the ovum soon after ovulation. That would also explain them the importance of the time of IUI. Ovulation can be confirmed by serum progesterone levels assessed on day 21–22. Daily sonography is not required just to confirm whether the ovulation has occurred or not, if no intervention such as IUI or ovulation trigger for timed intercourse is planned. Basal body temperature record and cervical mucus do not help much in deciding the time of ovulation and mode of management.
 
UNEXPLAINED INFERTILITY
About 5–10% of patients are infertile in spite of everything being normal. They have normal semen analysis, normal endoscopy, normal luteal phase, and normal endocrinological reports. These are the ideal patients for IUI. Six cycles of superovulation with IUI must be tried before subjecting the patient for ART when the patient's age is <35 years. IUI is the choice of treatment for idiopathic/unexplained infertility rather than IVF.
The rationale for IUI is increasing the number of available motile sperms to reach the ovum, which is morphologically normal for fertilization.
Intrauterine insemination is unfortunately the least standardized management of infertility. IUI is blamed for low pregnancy rate. But, meticulous selection of patient, stimulation protocol, ultrasound monitoring, and good semen preparation combined with IUI give excellent pregnancy rate. It bypasses vaginal acidity and cervical hostility. But, simultaneously accurate timing of IUI is necessary as reservoir function of cervical crypts is escaped and sperm has to travel only a short distance to approach ovum.
“Treatment independent pregnancy among infertile couple” is a landmark paper for patients who have patent tubes and fair sperm quality.3
To maximize the health outcome of population with minimum possible use of resources, cost-effectiveness of intervention is an important consideration in any 6healthcare system. Infertility treatment in our country is not covered either by government or by insurance companies. So, the choice of treatment is driven by financial consideration rather than best effectiveness. Success rate should be considered by spending same amount of money rather than number of cycles. For example, the cost of one IVF is almost same, as it would cost for 4–6 cycles of IUI. Considering a patient of unexplained infertility, male subfertility, or dysovulatory infertility, pregnancy rate of 4–6 cycles will be much higher than one cycle of IVF. So, if proper counseling is done, patient will first opt for IUI.
Even the practice committee of American Society for Reproductive Medicine (ASRM), 2012 recommends starting with less invasive treatment such as IUI and move to more aggressive intervention such as IVF, if IUI is unsuccessful or when patient is elderly or it is long-term infertility.4
Counseling is to be for the whole procedure of IUI. Most of the patients come with previous IUI failures in many cycles. They believe that IUI, just the procedure, gives them pregnancy. It should be emphasized that each and every step of IUI is very important. If the all steps are not performed properly, IUI does not give the results. For example, following steps should be discussed:
  • Stimulation protocol with gonadotrophins
  • US monitoring by at least color Doppler
  • Proper timing of IUI and its method
  • Luteal support
  • Semen preparation
All the steps combined together if done systematically, then and then, IUI can give good pregnancy rates.
I have discussed “counseling for IUI” in detail specifically because patients have wrong concepts and even consultants refer for IVF after few IUI failures, which are not done optimally.
Whenever patient is under treatment, she can do all her regular activities such as household work, exercise, office work, etc. All these activities do not decrease the pregnancy rate. On the contrary, they have the beneficial role for the patient.
 
COUNSELING FOR DONOR INSEMINATION
Counseling for donor insemination should be done to all the patients who have very low count or azoospermia before proceeding to ICSI. Many patients who cannot afford ART may opt for AID.
Donor should be unknown and all the norms and standard operating procedures of Indian Council of Medical Research (ICMR) for donor semen should be followed strictly. Sample should be ordered from registered semen bank. Many a times, couple ask for relative as their donor, which should be strongly discouraged. Donor and couple should never know each other and these details should be kept confidential. Child in future can ask about the genetic prints after 18 years, but that information also should be given without personal identification of the donor.
 
COUNSELING FOR IN VITRO FERTILIZATION
There are lots of misconceptions prevailing for IVF treatment regarding three aspects:
  • Indications
  • Results
  • Cost
 
Indications
It must be clearly understood that IVF is the first choice in only those patients who have bilateral tubal block, severe endometriosis, or severe male factor infertility. IVF may be done in patients with unexplained infertility only when six well-tried superovulations with IUI cycles have failed to give pregnancy. Dysovulatory infertility such as polycystic ovary syndrome (PCOS) is not an indication of IVF.7
 
Results
Patients believe that IVF is like a fast food and a sure shot solution to infertility. They have been misled about the same. They must be explained that the results of IVF in the best centers of the world are:
  • 30% in first cycle
  • 40–45% in second cycle
  • 50–55% in three cycles
  • 60–65% in four cycles
  • 65–70% in five cycles
  • 70–73% in six cycles
Therefore, patients who do not have absolute indications for IVF should be given a chance of IUI instead of taking them for IVF because about six superovulations with IUI cycles cost the same as one IVF cycle, with more chances of success.
 
Cost
In vitro fertilization is a very expensive procedure. Its cost includes charges for gonadotrophins and medicines, which comprises the largest amount, nearing ₹ 60,000–80,000 depending on the consumption by the patient. The second highest cost is of disposables and media. This is also about ₹ 10,000–15,000. Over and above this, the cost also includes that of the IVF consultant, embryologist, anesthetist, etc. Therefore, it must be understood when we try to cut off the cost, one has to compromise on drug quality and disposables. This would definitely compromise with the results also. Many a times when packages are fixed, compromise occurs in treatment.
REFERENCES
  1. Stanford JB, Dunson DB. Effects of sexual intercourse patterns in time to pregnancy studies. Am J Epidemiol. 2007;165(9):1088–95.
  1. Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and Infertility. Optimizing natural fertility. Fertil Steril. 2008;90(5 Suppl):S1–6.
  1. Collins JA, Wrixon W, Janes LB, Wilson EH. Treatment-independent pregnancy among infertile couples. N Engl J Med. 1983;309(20):1201–6.
  1. Van den Boofard NM, Bensdorp AJ, Rengerink KO, Barnhart K, Bhattacharya S, Custers IM, et al. Prognostic profiles and the effectiveness of assisted conception: secondary analyses of individual patient data. Hum Reprod Update. 2014;20(1):141–51.