Professional Documents
Culture Documents
Intrauterine Insemination
The rationale
is that
increasing
the density
of both eggs
and sperm
near the site
of
fertilization
will increase
the likelihood
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- severe infertility
hypospadias, • Cervical factor
retrograde infertility
ejaculation • Husband is away
Patient’s selection
Natural cycle or
Controlled Ovarian stimulation.
Monitoring of treatment, to measure
the growth of follicles, individualize
drug doses, and prevent hyper
stimulation.
Sperm preparation
Insemination
Luteal support.
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Selection of patients
A Valid indication for IUI
Normal or mildly abnormal semen
parameters (Semen analysis within 3
months of the planned IUI)
No evidence of intrauterine disease and
patent tubes (at least one) as
shown in a Recent HSG or (laparoscopy /
hysteroscopy)
Female age < 43 years ?
(Day 3 FSH < 10-15
mIU/Ml, if age > 37 yrs)
Protocol of natural
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cycle IUI
Monitoring begins 16 days before
expected menses by TVS for follicular
maturation.
Once a mature sized follicle of 18-24
mm & > 9mm trilaminar endometrium
are obtained the woman will monitor
urinary LH every 4-5 hours.
Intrauterine insemination is timed 36-
40 hours from the LH surge and will be
repeated within 12 hours if the oocyte
had not released as yet.
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menstrual cycle
n
io
Brown 1978
at
ul
ov
•
e
Intercycl
FSH
menstrual cycle
Controlling the timing of occurrence of
inter-cycle increase in FSH :
Timely use of E2 (2 mg estradiol
valerate, PO BID starting 3 days before
the onset of menses of the previous
cycle.
Short-term use of the OC pill for 7 to 21
days in the cycle preceding stimulation
cycle.
12
3500
E2
3000 n = 183
(pmol/L)
2500
2000
1500
1000
500
0
0 5 10 15 20
After Zeev Shoham Endometrium (mm)
Cancellation :
≥ 6 follicles ≥ 15 mm irrespective of E2
level
Estradiol ≥ 1500 pg/ml.
17
Sperm processing
Rationale
Concentration of progressively motile
and morphologically normal
spermatozoa into a small volume of
culture fluid.
Elemination of seminal PG,
lymphokines, cytokines and infectious
agents
Reduce the number of free oxygen
radicals.
18
Sperm processing
Sperm processing
Fixed protocol:
• Single insemination:
36 – 40 hrs post – hCG
• double insemination:
within 12 & 48 hrs post - hCG
Variable protocol:
• TVS 36 h post hCG:- Ovulated → single IUI
- Not Ovulated→ IUI at once
→ IUI 24 hrs
later
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Bed rest
A 10 minutes
bed rest after IUI has a positive effect
on PR.
Intercourse within 12-18 hours of IUI.
Luteal phase support, OPTIONS:
- hCG: 1.500 IU hCG 3 & 6 days after 1st
hCG
- Duphastone 10 mg PO / 8 hourly after
IUI x 14 days
- Cyclogest 400 mg supp. PV or PR;
once daily after IUI x 14 days
Evidence based recommendations for
23
practicing IUI
Grade A recommendations*
NICE Guidance Feb. 2004
Couples with mild male factor fertility
problems, unexplained fertility
problems or minimal to mild
endometriosis should be offered up to
six cycles of intra-uterine insemination
because this increases the chance of
pregnancy.
* Grade A : based on randomised controlled trials
Evidence based recommendations for
24
practicing IUI
Grade A recommendations
NICE Guidance Feb. 2004
Where intra-uterine insemination is
used to manage male factor fertility
problems, ovarian stimulation should
not be offered because it is no more
clinically effective than unstimulated
intra-uterine insemination and it
carries a risk of multiple pregnancy.
Evidence based recommendations for
25
practicing IUI
Grade A recommendations
NICE Guidance Feb. 2004
Where intra-uterine insemination is
used to manage unexplained fertility
problems, both stimulated and
unstimulated intra-uterine
insemination are more effective than
no treatment. However, ovarian
stimulation should not be offered, even
though it is associated with higher
pregnancy rates than unstimulated
intra-uterine insemination, because it
Evidence based recommendations for
26
practicing IUI
Grade A recommendations
NICE Guidance Feb. 2004
Where intra-uterine insemination is
used to manage minimal or mild
endometriosis, couples should be
informed that ovarian stimulation
increases pregnancy rates compared
with no treatment, but that the
effectiveness of unstimulated intra-
uterine insemination is uncertain.
Evidence based recommendations for
27
practicing IUI
Grade A recommendations
NICE Guidance Feb. 2004
Where intra-uterine insemination is
undertaken, single rather than double
insemination should be offered.
Where intra-uterine insemination is
used to manage unexplained fertility
problems, fallopian sperm perfusion
for insemination (a large-volume
solution, 4 ml) should be offered
because it improves pregnancy rates
compared with standard insemination
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Measures to improve
results
Use of Aspirin in IUI Cycles Hsieh YY et al, 2000
RCT: Higher
pregnancy rate and better endometrial pattern
were achieved in patients with thin endometrium
after aspirin administration.
Type of catheter Smith et al, 2002, RCT :
No difference in PR when using softer Wallace
catheter or the less pliable Tomcat catheter
Vaginal misoprostol at the time IUI Brown et al.
2001 RCT :
200 - 400 μg of misoprostol vaginal insertion at
the time
of insemination is associated with higher PR.
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Measures to minimize
risk of
OHSS
Shalev E, et al, 1995 RCT :
Transvaginal aspiration of
supernumerary follicles (more than
three follicles sized > 14 mm) does
not reduce the PRs and reduce
multiple pregnancy rate.
What is the upper age limit
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for IUI ?
Most studies have suggested that
it is an effective treatment option
for women under the age of 40 yrs
Success of intrauterine insemination,
in women aged 40-42 years, Hawbe, et al,
Fertility and Sterility, Vol 78, No 1, July 2002
SUMMARY
IUI is relatively simple, non-invasive,
cheap & easily repeatable.
Careful selection of patient is important.
There is good evidence in the literature in
favor of IUI as a cost-effective treatment
for unexplained and mild, moderate male
factor sub fertility.
Although it may take relatively more
treatment cycles to achieve pregnancy,
there are considerable advantages to the
patient in terms of risk / benefit ratio and
financial cost as compared with other
ARTs.
Failure of 4 - 6 trials of Gn. stimulated IUI
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