Step 1. Ovarian Stimulation
Patient is usually administered with medications, either by oral medicine and/or intramuscular inject medicine, to stimulate the ovary to produce one or two mature oocytes only, but NOT multiple eggs. Artificial insemination (AI) is then timely performed to coincide with ovulation.
Step 2. Ovulation Detection
- This is a treatment cycle monitoring. Generally, First Monitoring Visit is started on Day 5 of ovarian stimulation with fertility medications, such as Follistim, Bravelle, Gonal-f, or Repronex.
- Regular office visits are now begun, starting with Day 5 of ovarian stimulation and then continuing every 2 days until or near follicle maturation.
- During each visit, which takes about 30-40 minutes, a transvaginal ultrasound and a blood test for Estradiol (E2) will be performed. Patient should call at the end of the day about 3:00 p.m. to obtain the results of the blood test and to receive further instructions for continued medication.
- Blood Test for Estradiol (E2): As the follicles (containing the eggs) mature, the eggs secrete the Estradiol (E2) hormone. Therefore measuring the level of Estradiol (E2) hormone in the blood gives us a good idea as to how the ovaries are responding to the medications. The Estradiol (E2) level increases over the next several days as the oocytes are maturing and the follicles are growing. Generally, when Estradiol (E2) level reaches 300 pg/mL indicating that one egg is formed.
- Urine Test for Luteinizing Hormone (LH): As the follicle grows, most often on day 12-13, LH will surge, i.e., LH level suddenly increases in plasma, then ovulation will occur in about 36 hours. A repeated urine test may be needed to monitor ovulation.
- Transvaginal Ultrasound Examination: The purpose of this examination is to visualize the ovaries, measure the size of follicle, and estimate the maturity of follicle. A follicle is the fluid-filled sac that contains the egg. One follicle usually contains one egg. By measuring the size of the follicle, it will provide the information about the maturity of the egg. When a woman continues to take the fertility medications, the follicle will grow about 3 mm in 2 days (or 2 mm in 1 day) and at a certain point of time they will become mature.
- Immediately after we check the size of follicle under ultrasound, the thickness and pattern of the uterine lining will also be evaluated to know the endometrium growth. This is crucial for the ultrasound examination since a poor uterine lining is unlikely to sustain a conception.
- Follow-Up Visits: Following the initial visit, the patient will be told when she should return for follow up visits.
Usually another visit will be made 2-3 days after first monitoring visit. During this follow-up visit, a blood test for Estradiol (E2), urine test for LH, and an ultrasound examination to evaluate the growth of the follicle will be performed again.
The patient will again be given further instructions on what to do on a daily basis. A total of 4-5 visits are usually required for the IUI cycle.
Step 3. Ovulation Induction (HCG Injection)
Generally it is performed on Day 8-12 of ovarian stimulation, or on Day 12-16 of menstrual cycle (most often on Day 12-13).
Ovulation may be triggered by nature, or is triggered with an injection of Human Chorionic Gonadotropin (HCG), which will be administered when the follicle is evaluated by doctor to be mature and there is lack of LH surge, or for the purpose of summation of LH level. Generally when the size of follicle reaches 18 to 20 mm in diameter and the Estradiol (E2) hormone level is elevated appropriately; it is the correct time for ovulation induction (HCG injection). HCG is most often prescribed on Day 12-13 of the menstrual cycle.
The timing of HCG administration is very important, because artificial insemination will be performed 36 hours after HCG injection.
- This medication is crucial. It will potentiate the eggs to their final course of maturation and will release the eggs from their attachments to the walls of the follicles to float inside the follicular fluid. The HCG should be administered correctly at the exact time. Since HCG injections are given at night (usually between 8 PM and 10 PM), the artificial insemination is scheduled 36 hours after the injection, which falls two days later in the morning between 8 AM and 10 AM. For instance, if the HCG is given on Monday at 8 PM, then artificial insemination will be performed on Wednesday at 8 AM.
Step 4. Semen Collection
Semen specimen is produced at home (or in our medical center) by masturbation after 2-3 day sexual abstinence.
Step 5. Sperm Separation
Semen is treated and selected in our laboratory. By this process, the sperm is separated from the other components or impurities of the semen.
Sperm is finally concentrated in a small volume, about 0.25 - 0.5 mL. In our medical center, we use the “Wang Tube Real-Time Sperm Micro-Separation Technology”, which has been proved the first of choice as well as the modality in sperm selection methodologies. This system is in the world a unique technology that can really obtain microorganism-free, highly-motile, morphologically-normal, normal-chromatin and fertilizable sperm for clinical fertility applications without complications,such as post-insemination abdominal cramping pain, sub-clinical or clinical infection of patient and/or fetus, post-insemination tubal adhesion/blockage.
Step 6. Artificial Inseminations (AIs)
The separated and purified fraction of highly motile sperm is loaded in a thin and soft catheter, and then transferred in uterine cervix (intracervical insemination, ICI), high in the uterine cavity (intrauterine insemination, IUI), or in peritoneal cavity (intraperitoneal insemination, IPI). In our center, patient will be advised to remain in a supine (lying down) position for about 15-20 minutes following the procedure of in vivo artificial insemination.