Iui

BY Prof. Dr. Mohamed A. Emam Mansoura Faculty of Medicine Ob. & Gyn. Dept.

Mansoura integrated Fertility Center (MIFC)

Intrauterine Inseminations (IUI)

• Traditional: •

(widely used 0.2-0.5 ml washed sperm intraut).

• Modified ( Fallopian tube sperm perfusion):• Twice as effective (Trout and Kemmenn 1999). • 4ml of prepared semen over 4min (1ml each min). • Insemination performed before ovulation (Oocyte flushed out of the tube).

History of IUI As a technique: • Direct intrauterine insemination (neat semen) - Disadvantage: - PG cramps - Infection. • Split ejaculate • The advances in IVF, ET.

Abondoned (Stone et al, 1986) reviving IUI.

Reviving the interest in IUI

Advances in:• Progress in semen processing and sperm isolation methods.

+ • Improved ovarian stimulation protocols (developed primarily to meet IVF requirements) →↓ ↓side effects.

IUI progress is due to advances in IVF, ET.

Advantages of IUI • • • • •

Bypass (Vaginal acidity + cervical mucus hostility) Deposition of a well prepared sperms as close as possible to the oocytes (Short distance) Non invasive (like pap smear). Inexpensive. Antenatal & perinatal complications (like

Disadvantages 1. Multiple pregnancy (>IVF) number of follicles will grow or rupture can not precisely controlled. 2. Infection Iatrogenic infertility. 3. Psychological (guilt- anger- loss of self esteem)

IUI Steps • • • • • •

Selection

+

counseling

Protocol (spontaneous or stimulated cycle) Folliculometry&Endometrial thickness. Timing of insemination. Semen preparation. Procedure:

Selection and counselling • Complete work up of infertility: (Semenogram- midluteal progestrone - HSG + laparoscopy)

• Indications. • Adequate counseling

• Confidence of husband. • Religious • Cost • Failure & success • Complications.

Success of IUI The review of literature over the past 15 years • wide range of variation •0-26% pregnancy / cycle in different indications •MIFIC (22%).

Take home baby •Controversy No evidence- based infertility data.

Factors affecting success of IUI Couple: (age,duration of infertility,BMI).

infertility,cause

Therapies: • Semen processing technique.

• Protocol of COH. • Timing of insemination.

of

Timed intercourse versus IUI Probability of conception

• Natural cycles (IUI ↑) • COH cycles (IUI ↑ ↑ ↑) ( Cochrane database 2000)

Spontaneous cycle protocol • Cervical factor. • Sexual dysfunction. -D 10-11 monitor every 2 days. -Follicle 18-20 mm hcg 10,000 u. -Insemination 36 h after hcg. -Pregnancy test (hcg in serum 2w after insemination).

Ovarian Stimulation Protocol • Rationale for use COH -↑↑Number of oocytes available -↑Steroid production ↑( chance of implantation )

• Protocols commonly used • cc (2x50mg) day 2 to day 6 of menstruation + FSH or hmg (75 IU) daily from day 5 + HCG. • FSH only (75 IU) from day 3 + HCG.

Ov. Stim. Protocol

con..

• TVS monitoring of follicular growth and endometrial development -Baseline TVS (day 2 -3 of Menst.) -Serial TVS (day 7-8 of stimulation)

-Follicle 18-20 mm hcg 10,000 u. -Insemination 36 h after hcg. -Pregnancy test (hcg in serum 2w after insemination).

Timing of insemination • Rationale: viable sperms should be present at the time of ovulation.

• Detection of ovulation • serum or urinary LH • TVS (leading follicle > 18mm)

•

HCG 10.000 IU

Insemination: • one versus two (24 h & 48 h) from HCG

• or

TVS after 36 h : 1- Ovulate 2- Not Ovulate

IUI IUI at once IUI 24H later

Semen processing Rationale:• Concentration of progressively motile and morphologically normal spermatozoa into a small volume of culture fluid. • Elimination seminal plasma (PGlymphokines- cytokines - antigens - infectious matter). • Reduce the number of free oxygen radicals.

Procedure of IUI • Prior to insemination. • Cusco’s speculum. • Catheter (types)

• During insemination: • Utero cervical angle • Catheter insertion. • Insemination (catheter withdrawal)

• After insemination • Rest ?!

• Luteal phase support

Where IUI is done? • Ideally in a clinic with IVF facilities (all services under one floor) -OHSS -IVF choice. -Freezing extra embryos.

Where IUI is done?

IUI in the office setting • Benefits: 1. OB/Gyn extend their fertility care beyond the basic workup to provision of first-line therapies. 2. Maintaining the existing parent-OB/Gyn relationship for a longer period without referral.

Pre-Requisites for office IUI 1. Organization the practice to be extended in the week ends or holidays. 2. TVS probe ± Ovulation prediction kits. 3. Office semen processing or RSP service (Remote Semen preparation). 4. Familiarity about the optimal time for referral the case to an infertility specialist.

RSP • Prepare the semen for IUI (seven days/ week) • Assurance of quality control, semen analysis before and after IUI preparation. • Patient/ partner are able to safely transport processed semen & IUI kits.

Recent advances:

SIFT

(Sperm Intrafallopian transfer) • Speically designed catheters (JansenAnderson Catheter Sets) • The processed sperm can be injected into the tubes laparoscopically OR guided by ultrasound without anaesthesia or surgrey.

Conclusion While many gynecologists offer IUI office procedure, many of them are not specialized enough to provide a comprehensive service. This means that: 1. Patients need to run from gynecologist to ultrasound scan center to the lab. 2. Fragmented care because of poor coordination.

SO An ideal clinic is that which offers all the services under one roof.

T HANK YOU Prof. DR. MOHAMMAD EMAM Prof. OB& GYN, Mansoura Faculty of Medicine Member of Mansoura Integrated Fertility Center (MIFC) Telefax 0020502319922 & 0020502312299 Email. [email protected]