Is cycle monitoring necessary?
Yes! It is important that the IUI be done at the time when the eggs are being released by the ovaries (ovulation). Just before ovulation, your body produces a surge or release of luteinizing hormone (LH). It is therefore important to monitor patients for the LH surge, which precedes ovulation by 36 – 39 hours.
How is cycle monitoring done?
Cycle monitoring can be done in two ways:
- The simplest technique is by using urinary LH kits, which detect an LH surge. These kits are generally available over the counter at your local pharmacy. These kits are not 100% accurate. Therefore, when a LH surge is detected (often with a color change or some other indicator), we bring patients in for a confirmatory blood test (estradiol, LH and progesterone level) and ultrasound (dominant follicle(s) with a diameter >18 mm). Ovulation is then triggered with an injection called hCG (human chorionic gonadotropin, Ovidrel). IUI is then done 12 and 36 hours after the hCG injection. Some patients may be advised to have intercourse the night of the hCG injection with a single IUI done 36 hours later.
- Cycle monitoring can also be done with serial blood tests (estradiol, LH and progesterone levels) and ultrasounds. Close monitoring is mandated in patients on fertility injections (gonadotropins, Follistim, Gonal-F, Menopur, Repronex, Bravelle). These injections are fairly potent and the dose often needs to be finely tuned. If the dose is low, the ovarian response will be sub-optimal. If the medication dose is high, the patient may develop too many follicles and be at risk for high-order multiple pregnancy (we will usually cancel such a cycle). With a high dose, another risk is that of hyper response by the ovaries (ovarian hyperstimulation syndrome). It should be noted that some patients are very sensitive and will hyper respond even to a routinely used dose of gonadotropins. Once again, when the follicles are the correct size, ovulation is triggered with hCG and followed by IUI.
Why do we trigger ovulation with hCG?
For two reasons, firstly, hCG acts like a surrogate LH surge. When the hCG (trigger) injection is given, ovulation will occur approximately 39 hours later. The hCG injection therefore helps with timing of the IUI procedure. Patients on oral medications can ovulate on their own. It, however, will be difficult to time IUI if you do not know precisely when ovulation has occurred!
Secondly, the hCG injection stimulates the ovary (more precisely the corpus luteum, which is the structure that is left behind in the follicle after the egg has been released) to release progesterone. Progesterone is a hormone that is vitally important for pregnancy to occur. The hCG injection boosts progesterone for approximately one week.
The hCG injection thus helps with timing of IUI and also promotes pregnancy.
What are the risks associated with IUI?
IUI is generally a safe procedure. The risk of Infection as a result of the procedure is less than 1%. Multiple pregnancies can occur particularly when IUI is co-ordinated with ovulation-inducing medications. The risk of mutiple pregnancy with IUI will be discussed in detail in a subsequent blog.
Sue Beckman has discussed the actual IUI procedure in her recent blog titled “Date Night or intrauterine insemination.”
What happens after the procedure?
After IUI, you may be asked to lie on your back for a few minutes. Prolonged bed rest after IUI is not necessary and does not increase your chances of conceiving. We in fact recommend that patients go about their normal daily activities. There may be some bloating and/or cramping because your ovaries may be enlarged from the fertility drugs. There may also be some light spotting for a day or two after the procedure.
You may be started on some form of progesterone supplementation on the day after the IUI. Progesterone is generally given vaginally as a gel (Crinone), tablets (Endometrin, Prometrium) or a suppository. Some patients may be asked to come in a week after IUI for a blood test to measure progesterone. Patients with a low level (generally < 15 ng/mL) are then started on progesterone supplementation.
The pregnancy test is done approximately two weeks after IUI. Testing too soon could result in a false-positive in patients who received the trigger hCG shot! You could do a home pregnancy test, but a blood test is generally more accurate.
The following is a link to a short video that beautifully depicts the IUI procedure:
http://www.youtube.com/watch?v=qCdIiLLF0vw
Comments