Question 44. What complications can occur after IUI?

Years ago in Long Island I had a patient experience an allergic reactions to an IUI. She got very bad hives and even began to have a bit of laryngospasm (throat tightening). She was taken to the ER and did fine with a dose of epinephrine and some steroids. Such reactions are really really rare but it was so surprising given the number of IUIs that I have done over years without any weird reactions. Clearly the more concerning complications after IUI are those of multiple pregnancy and OHSS. Both have plagued our specialty for years. However, the risk of both can be somewhat mitigated (but not eliminated) through judicious use of fertility medications.

First of all, no one ends up with a litter without seeing it coming. A patient does not have one follicle on Monday and 14 on Tuesday. Secondly, if there are more than 2 follicles > 15-16 mm at trigger then there can be more than 2 babies. It may be too risky to try an IUI when so many follicles can ovulate so often we discuss 3 major options to try to prevent the patient from having to deal with a pregnancy with > 3 babies or having to make a decision about performing a selective reduction. I do not view Jon and Kate plus 8 as a good outcome....

1. Cycle cancellation: stop the medications and let the follicles all regress and avoid intercourse for 2 weeks.

2. Follicle reduction: perform an IVF like egg collection but then just discard the extra eggs and go forward with the IUI leaving behind only 2-3 follicles. This option can be effective and egg collection would be scheduled like we do for IVF using an HCG trigger. I like to have the embryologists at least look at the fluid to tell be how many eggs I retrieved. If the eggs have already ovulated then this option will not be helpful as the "horse is out of the barn."

3. Convert to IVF: simply go for egg collection as if this had been the plan all along. Patients may experience an LH surge before HCG trigger so consideration can be given to using a GnRH antagonist as soon as the decision is made to convert to IVF. Personally, I have not had any patients surge in this setting but the chance of an LH surge is probably 20% so I may just have been lucky so far!

In spite of impeccable logic: "But Dr. Gordon I have a history of recurrent miscarriage and I am 37 years old and I failed IVF....so how is there any chance that I would end up with triplets???" I have ended up with just that in such cases.....Oh well. It's biology and not engineering.....So good luck and as I tell all my patients in these settings: "remember I don't babysit so let's not have any multiples!"

With that introduction, here is today's Question of the Day from 100 Questions and Answers about Infertility.

44. What complications can occur after IUI?


Complications related to the actual IUI procedure are very rare. IUI is a simple, in-office, nonsurgical procedure, usually performed by nurses. Occasionally patients may experience mild to moderate uterine cramps as the catheter is passed through the cervix into their uterus. These cramps usually last 10 to 15 minutes. Infection rarely occurs (its incidence is less than 1%). Many infertility specialists routinely obtain cervical cultures prior to initiating an IUI cycle, and the culture media used to prepare the IUI specimen commonly contains antibiotics. Occasionally, patients may note some light spotting after placement of the IUI catheter, but this is not an indication of a complication or a problem. Multiple pregnancy can occur in any situation when two or more mature follicles are present at the time of HCG. Your physician should discuss with you the risk of multiple pregnancy in cycles using fertility medication to induce the growth of multiple follicles. Similarly, patients with an excessive response to fertility medication can also be at risk for ovarian hyperstimulation synderome (OHSS). However, both multiple gestation and OHSS can result from the stimultion of the ovary with hormones regardless of whether an IUI is performed or not.